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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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Gagnon E, Girard A, Bourgault J, Abner E, Gill D, Thériault S, Vohl MC, Tchernof A, Esko T, Mathieu P, Arsenault BJ. Genetic assessment of efficacy and safety profiles of coagulation cascade proteins identifies Factors II and XI as actionable anticoagulant targets. EUROPEAN HEART JOURNAL OPEN 2024; 4:oeae043. [PMID: 38933427 PMCID: PMC11200102 DOI: 10.1093/ehjopen/oeae043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 06/28/2024]
Abstract
Aims Anticoagulants are routinely used by millions of patients worldwide to prevent blood clots. Yet, problems with anticoagulant therapy remain, including a persistent and cumulative bleeding risk in patients undergoing prolonged anticoagulation. New safer anticoagulant targets are needed. Methods and results To prioritize anticoagulant targets with the strongest efficacy [venous thromboembolism (VTE) prevention] and safety (low bleeding risk) profiles, we performed two-sample Mendelian randomization and genetic colocalization. We leveraged three large-scale plasma protein data sets (deCODE as discovery data set and Fenland and Atherosclerosis Risk in Communities as replication data sets] and one liver gene expression data set (Institut Universitaire de Cardiologie et de Pneumologie de Québec bariatric biobank) to evaluate evidence for a causal effect of 26 coagulation cascade proteins on VTE from a new genome-wide association meta-analysis of 44 232 VTE cases and 847 152 controls, stroke subtypes, bleeding outcomes, and parental lifespan as an overall measure of efficacy/safety ratio. A 1 SD genetically predicted reduction in F2 blood levels was associated with lower risk of VTE [odds ratio (OR) = 0.44, 95% confidence interval (CI) = 0.38-0.51, P = 2.6e-28] and cardioembolic stroke risk (OR = 0.55, 95% CI = 0.39-0.76, P = 4.2e-04) but not with bleeding (OR = 1.13, 95% CI = 0.93-1.36, P = 2.2e-01). Genetically predicted F11 reduction was associated with lower risk of VTE (OR = 0.61, 95% CI = 0.58-0.64, P = 4.1e-85) and cardioembolic stroke (OR = 0.77, 95% CI = 0.69-0.86, P = 4.1e-06) but not with bleeding (OR = 1.01, 95% CI = 0.95-1.08, P = 7.5e-01). These Mendelian randomization associations were concordant across the three blood protein data sets and the hepatic gene expression data set as well as colocalization analyses. Conclusion These results provide strong genetic evidence that F2 and F11 may represent safe and efficacious therapeutic targets to prevent VTE and cardioembolic strokes without substantially increasing bleeding risk.
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Affiliation(s)
- Eloi Gagnon
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
| | - Arnaud Girard
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
| | - Jérôme Bourgault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
| | - Erik Abner
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
| | - Dipender Gill
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Sébastien Thériault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
- Department of Molecular Biology, Medical Biochemistry and Pathology, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Marie-Claude Vohl
- School of Nutrition, Université Laval, Quebec, QC, Canada
- Centre Nutrition, Santé et société (NUTRISS), Institut sur la nutrition et les aliments fonctionnels (INAF), Université Laval, Quebec, QC, Canada
| | - André Tchernof
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
- School of Nutrition, Université Laval, Quebec, QC, Canada
| | - Tõnu Esko
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Patrick Mathieu
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
- Department of Surgery, Faculty of Medicine, Université Laval, Quebec, QC, Canada
| | - Benoit J Arsenault
- Centre de recherche de l’Institut universitaire de cardiologie et de pneumologie de Québec, Y-3106, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Quebec, QC, Canada, G1V 4G5
- Department of Medicine, Faculty of Medicine, 1050 Av. de la Médecine, Québec City, Quebec G1V 0A6, Canada
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3
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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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Baucom MR, Price AD, Weissman N, England L, Schuster RM, Pritts TA, Goodman MD. Desmopressin, Misoprostol, nor Carboprost Affect Platelet Aggregability Following Traumatic Brain Injury and Aspirin. J Surg Res 2024; 296:643-653. [PMID: 38359679 DOI: 10.1016/j.jss.2024.01.027] [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: 05/18/2023] [Revised: 12/26/2023] [Accepted: 01/16/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Desmopressin (DDAVP) has been utilized clinically in patients taking aspirin (ASA) to improve drug-induced platelet dysfunction. Misoprostol and carboprost, prostaglandin analogs commonly used for postpartum hemorrhage, may also induce platelet aggregation. The aim of this study was to determine the effects of DDAVP, misoprostol, and carboprost administration on platelet aggregability following traumatic brain injury (TBI) in mice treated with ASA. METHODS Male C57BL/6 mice were randomized into seven groups (n = 5 each): untouched, ASA only, Saline/TBI, ASA/TBI, ASA/TBI/DDAVP 0.4 μg/kg, ASA/TBI/misoprostol 1 mg/kg, and ASA/TBI/carboprost 100 μg/kg. TBI was induced via a weight drop model 4-h after ASA (50 mg/kg) gavage. Mice were given an intraperitoneal injection of DDAVP, misoprostol, or carboprost 10 minutes after TBI. In vivo testing was completed utilizing tail vein bleed. Mice were sacrificed 30-min posttreatment and blood was collected via cardiac puncture. Whole blood was analyzed via Multiplate impedance aggregometry, rotational thromboelastometry, and TEG6s. RESULTS Mice receiving misoprostol after ASA/TBI demonstrated decreased tail vein bleeding times compared to ASA only treated mice. However, mice treated with misoprostol following ASA and TBI demonstrated decreased platelet aggregability compared to untouched mice and TBI only mice within the arachidonic acid agonist pathway. By contrast, DDAVP and carboprost did not significantly change platelet aggregability via adenosine diphosphate or arachidonic acid following ASA and TBI. However, DDAVP did decrease the platelet contribution to clot via rotational thromboelastometry. CONCLUSIONS Reversal of medication-induced platelet inhibition has become increasingly controversial after TBI. Based on these results, DDAVP, misoprostol, nor carboprost consistently improve platelet aggregability following TBI in those also treated with ASA.
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Affiliation(s)
- Matthew R Baucom
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Adam D Price
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Lisa England
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | | | - Timothy A Pritts
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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5
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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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6
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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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7
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Mohammed BM, Sun MF, Cheng Q, Litvak M, McCrae KR, Emsley J, McCarty OJT, Gailani D. High molecular weight kininogen interactions with the homologs prekallikrein and factor XI: importance to surface-induced coagulation. J Thromb Haemost 2024; 22:225-237. [PMID: 37813198 PMCID: PMC10841474 DOI: 10.1016/j.jtha.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 10/11/2023]
Abstract
BACKGROUND In plasma, high molecular weight kininogen (HK) is either free or bound to prekallikrein (PK) or factor (F) XI (FXI). During contact activation, HK is thought to anchor PK and FXI to surfaces, facilitating their conversion to the proteases plasma kallikrein and FXIa. Mice lacking HK have normal hemostasis but are resistant to injury-induced arterial thrombosis. OBJECTIVES To identify amino acids on the HK-D6 domain involved in PK and FXI binding and study the importance of the HK-PK and HK-FXI interactions to coagulation. METHODS Twenty-four HK variants with alanine replacements spanning residues 542-613 were tested in PK/FXI binding and activated partial thromboplastin time clotting assays. Surface-induced FXI and PK activation in plasma were studied in the presence or absence of HK. Kng1-/- mice lacking HK were supplemented with human or murine HK and tested in an arterial thrombosis model. RESULTS Overlapping binding sites for PK and FXI were identified in the HK-D6 domain. HK variants with defects only in FXI binding corrected the activated partial thromboplastin time of HK-deficient plasma poorly compared to a variant defective only in PK-binding. In plasma, HK deficiency appeared to have a greater deleterious effect on FXI activation than PK activation. Human HK corrected the defect in arterial thrombus formation in HK-deficient mice poorly due to a specific defect in binding to mouse FXI. CONCLUSION Clinical observations indicate FXI is required for hemostasis, while HK is not. Yet, the HK-FXI interaction is required for contact activation-induced clotting in vitro and in vivo suggesting an important role in thrombosis and perhaps other FXI-related activities.
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Affiliation(s)
- Bassem M Mohammed
- Edward A. Doisy Research Center, Department of Biochemistry and Molecular Biology, St. Louis University School of Medicine, St. Louis, Missouri, USA.
| | - Mao-Fu Sun
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Maxim Litvak
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keith R McCrae
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonas Emsley
- Biodiscovery Institute, School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Owen J T McCarty
- Department of Biomedical Engineering, Division of Hematology/Medical Oncology, School of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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8
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Sun F, Wang W, Li Z, Li Y, Guo W, Kong Y. Design, expression and biological evaluation of DX-88mut as a novel selective factor XIa inhibitor for antithrombosis. Bioorg Chem 2024; 142:106951. [PMID: 37924755 DOI: 10.1016/j.bioorg.2023.106951] [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: 08/29/2023] [Revised: 10/21/2023] [Accepted: 10/28/2023] [Indexed: 11/06/2023]
Abstract
Thrombotic diseases, such as myocardial infarction, stroke, and deep vein thrombosis, severely threaten human health, and anticoagulation is an effective way to prevent such illnesses. However, most anticoagulant drugs in the clinic have different bleeding risks. Previous studies have shown that coagulation factor XI is an ideal target for safe anticoagulant drug development. Here, we designed the FXIa inhibitory peptide DX-88mut by replacing Loop1 (DGPCRAAHPR) and Loop2 (IYGGC) in DX-88, which is a clinical drug targeting PKa for the treatment of hereditary angioedema, using Loop1 (TGPCRAMISR) and Loop2 (FYGGC) in the FXIa inhibitory peptide PN2KPI, respectively. DX-88mut selectively inhibited FXIa against a panel of serine proteases with an IC50 value of 14.840 ± 0.453 nM, dose-dependently prolonged APTT in mouse, rat and human plasma, and potently inhibited FeCl3-induced carotid artery thrombosis in mice at a dose of 1 µmol/kg. Additionally, DX-88mut did not show a significant bleeding risk at a dose of 5 µmol/kg. Taken together, these results show that DX-88mut is a potential candidate for the development of a novel antithrombotic agent.
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Affiliation(s)
- Feilong Sun
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China
| | - Weihao Wang
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China
| | - Zhengyang Li
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China
| | - Yitong Li
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China
| | - Wei Guo
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China.
| | - Yi Kong
- School of Life Science and Technology, China Pharmaceutical University, Longmian Street 639, Nanjing 211198, China.
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9
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Santagata D, Donadini MP, Ageno W. Factor XI inhibitors for the prevention of cardiovascular disease: A new therapeutic approach on the horizon? Blood Rev 2023; 62:101119. [PMID: 37580207 DOI: 10.1016/j.blre.2023.101119] [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: 06/19/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
Anticoagulant drugs that are currently used to prevent and/or treat thrombosis have some limitations that hinder their ability to meet specific clinical requirements. While these drugs effectively reduce the rates of thrombotic events, they simultaneously increase the risk of bleeding. Moreover, their risk-to-benefit balance is problematic in some patients, such as those with severe chronic kidney disease or those at high bleeding risk. A novel anticoagulation method, FXI inhibition has emerged as a promising alternative. It demonstrates a strong rationale for the prevention and treatment of venous thromboembolism and the potential fulfillment of unmet clinical needs in the cardiovascular field. A number of FXI inhibitors are currently undergoing clinical investigation. The objective of this review is to provide an overview of early results of research on FXI inhibitors in the cardiovascular setting, offering valuable insights into their potential role in shaping the future of anticoagulation.
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Affiliation(s)
- D Santagata
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - M P Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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10
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Roehrig S, Ackerstaff J, Jiménez Núñez E, Teller H, Ellerbrock P, Meier K, Heitmeier S, Tersteegen A, Stampfuss J, Lang D, Schlemmer KH, Schaefer M, Gericke KM, Kinzel T, Meibom D, Schmidt M, Gerdes C, Follmann M, Hillisch A. Design and Preclinical Characterization Program toward Asundexian (BAY 2433334), an Oral Factor XIa Inhibitor for the Prevention and Treatment of Thromboembolic Disorders. J Med Chem 2023; 66:12203-12224. [PMID: 37669040 PMCID: PMC10510402 DOI: 10.1021/acs.jmedchem.3c00795] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Indexed: 09/06/2023]
Abstract
Activated coagulation factor XI (FXIa) is a highly attractive antithrombotic target as it contributes to the development and progression of thrombosis but is thought to play only a minor role in hemostasis so that its inhibition may allow for decoupling of antithrombotic efficacy and bleeding time prolongation. Herein, we report our major efforts to identify an orally bioavailable, reversible FXIa inhibitor. Using a protein structure-based de novo design approach, we identified a novel micromolar hit with attractive physicochemical properties. During lead modification, a critical problem was balancing potency and absorption by focusing on the most important interactions of the lead series with FXIa while simultaneously seeking to improve metabolic stability and the cytochrome P450 interaction profile. In clinical trials, the resulting compound from our extensive research program, asundexian (BAY 2433334), proved to possess the desired DMPK properties for once-daily oral dosing, and even more importantly, the initial pharmacological hypothesis was confirmed.
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Affiliation(s)
- Susanne Roehrig
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | | | | | | | | | | | - Stefan Heitmeier
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Adrian Tersteegen
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Jan Stampfuss
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Dieter Lang
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | | | | | - Kersten M. Gericke
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | | | - Daniel Meibom
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Martina Schmidt
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Christoph Gerdes
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
| | - Markus Follmann
- Pharmaceuticals, Research
and Development, Bayer AG, 42133 Wuppertal, Germany
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11
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Wichaiyo S, Parichatikanond W, Visansirikul S, Saengklub N, Rattanavipanon W. Determination of the Potential Clinical Benefits of Small Molecule Factor XIa Inhibitors in Arterial Thrombosis. ACS Pharmacol Transl Sci 2023; 6:970-981. [PMID: 37470020 PMCID: PMC10353063 DOI: 10.1021/acsptsci.3c00052] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Indexed: 07/21/2023]
Abstract
Anticoagulants are the mainstay for the prevention and treatment of thrombosis. However, bleeding complications remain a primary concern. Recent advances in understanding the contribution of activated factor XI (FXIa) in arterial thrombosis with a limited impact on hemostasis have led to the development of several FXIa-targeting modalities. Injectable agents including monoclonal antibodies and antisense oligonucleotides against FXIa have been primarily studied in venous thrombosis. The orally active small molecules that specifically inhibit the active site of FXIa are currently being investigated for their antithrombotic activity in both arteries and veins. This review focuses on a discussion of the potential clinical benefits of small molecule FXIa inhibitors, mainly asundexian and milvexian, in arterial thrombosis based on their pharmacological profiles and the compelling results of phase 2 clinical studies. The preclinical and epidemiological basis for the impact of FXIa in hemostasis and arterial thrombosis is also addressed. In recent clinical study results, asundexian appears to reduce ischemic events in patients with myocardial infarction and minor-to-moderate stroke, whereas milvexian possibly provides benefits in patients with minor stroke or high-risk transient ischemic attack (TIA). In addition, asundexian and milvexian had a minor impact on hemostasis even in combination with dual-antiplatelet therapy. Other orally active FXIa inhibitors also produce antithrombotic activity in vivo with low bleeding risk. Therefore, FXIa inhibitors might represent a new class of direct-acting oral anticoagulants (DOACs) for the treatment of thrombosis, although the explicit clinical positions of asundexian and milvexian in patients with ischemic stroke, high-risk TIA, and coronary artery disease require confirmation from the outcomes of ongoing phase 3 trials.
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Affiliation(s)
- Surasak Wichaiyo
- Department
of Pharmacology, Faculty of Pharmacy, Mahidol
University, Bangkok 10400, Thailand
- Centre
of Biopharmaceutical Science for Healthy Ageing, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Warisara Parichatikanond
- Department
of Pharmacology, Faculty of Pharmacy, Mahidol
University, Bangkok 10400, Thailand
- Centre
of Biopharmaceutical Science for Healthy Ageing, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Satsawat Visansirikul
- Department
of Pharmaceutical Chemistry, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
| | - Nakkawee Saengklub
- Centre
of Biopharmaceutical Science for Healthy Ageing, Faculty of Pharmacy, Mahidol University, Bangkok 10400, Thailand
- Department
of Physiology, Faculty of Pharmacy, Mahidol
University, Bangkok 10400, Thailand
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12
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Shamanaev A, Litvak M, Cheng Q, Ponczek M, Dickeson SK, Smith SA, Morrissey JH, Gailani D. A site on factor XII required for productive interactions with polyphosphate. J Thromb Haemost 2023; 21:1567-1579. [PMID: 36863563 PMCID: PMC10192085 DOI: 10.1016/j.jtha.2023.02.014] [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: 08/31/2022] [Revised: 02/07/2023] [Accepted: 02/22/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND During plasma contact activation, factor XII (FXII) binds to surfaces through its heavy chain and undergoes conversion to the protease FXIIa. FXIIa activates prekallikrein and factor XI (FXI). Recently, we showed that the FXII first epidermal growth factor-1 (EGF1) domain is required for normal activity when polyphosphate is used as a surface. OBJECTIVES The aim of this study was to identify amino acids in the FXII EGF1 domain required for polyphosphate-dependent FXII functions. METHODS FXII with alanine substitutions for basic residues in the EGF1 domain were expressed in HEK293 fibroblasts. Wild-type FXII (FXII-WT) and FXII containing the EGF1 domain from the related protein Pro-HGFA (FXII-EGF1) were positive and negative controls. Proteins were tested for their capacity to be activated, and to activate prekallikrein and FXI, with or without polyphosphate, and to replace FXII-WT in plasma clotting assays and a mouse thrombosis model. RESULTS FXII and all FXII variants were activated similarly by kallikrein in the absence of polyphosphate. However, FXII with alanine replacing Lys73, Lys74, and Lys76 (FXII-Ala73,74,76) or Lys76, His78, and Lys81 (FXII-Ala76,78,81) were activated poorly in the presence of polyphosphate. Both have <5% of normal FXII activity in silica-triggered plasma clotting assays and have reduced binding affinity for polyphosphate. Activated FXIIa-Ala73,74,76 displayed profound defects in surface-dependent FXI activation in purified and plasma systems. FXIIa-Ala73,74,76 reconstituted FXII-deficient mice poorly in an arterial thrombosis model. CONCLUSION FXII Lys73, Lys74, Lys76, and Lys81 form a binding site for polyanionic substances such as polyphosphate that is required for surface-dependent FXII function.
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Affiliation(s)
- Aleksandr Shamanaev
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA. https://twitter.com/Aleksan18944927
| | - Maxim Litvak
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michal Ponczek
- Department of General Biochemistry, Faculty of Biology and Environmental Protection, University of Lodz, Lodz, Poland
| | - S Kent Dickeson
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stephanie A Smith
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - James H Morrissey
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA.
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13
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Xie Z, Meng Z, Yang X, Duan Y, Wang Q, Liao C. Factor XIa Inhibitors in Anticoagulation Therapy: Recent Advances and Perspectives. J Med Chem 2023; 66:5332-5363. [PMID: 37037122 DOI: 10.1021/acs.jmedchem.2c02130] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
Factor XIa (FXIa) in the intrinsic pathway of the coagulation process has been proven to be an effective and safe target for anticoagulant discovery with limited or no bleeding. Numerous small-molecule FXIa inhibitors (SMFIs) with various scaffolds have been identified in the early stages of drug discovery. They have served as the foundation for the recent discovery of additional promising SMFIs with improved potency, selectivity, and pharmacokinetic profiles, some of which have entered clinical trials for the treatment of thrombosis. After reviewing the coagulation process and structure of FXIa, this perspective discusses the rational or structure-based design, discovery, structure-activity relationships, and development of SMFIs disclosed in recent years. Strategies for identifying more selective and druggable SMFIs are provided, paving the way for the design and discovery of more useful SMFIs for anticoagulation therapy.
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Affiliation(s)
- Zhouling Xie
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Zhiwei Meng
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Xiaoxiao Yang
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Yajun Duan
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
| | - Qin Wang
- Department of Otolaryngology-Head and Neck Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei 230022, P. R. China
| | - Chenzhong Liao
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P. R. China
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14
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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: 0] [Impact Index Per Article: 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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15
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Elsheikh S, Tidbury N, Lip GYH. A review of emerging factor XI inhibitors. Expert Opin Emerg Drugs 2023; 28:43-53. [PMID: 36927160 DOI: 10.1080/14728214.2023.2192923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
INTRODUCTION Whilst the introduction of direct oral anticoagulants (DOACs) has improved the prevention of thromboembolic events, there is still a need for safer anticoagulants. This is particularly so, for specific populations of patients, such as those with an increased bleeding risk or those with severely reduced kidney function. People with Factor XI (FXI) deficiency are at reduced risk of thromboembolic events, without an increased risk of spontaneous bleeding. FXI inhibition, therefore, presents the ideal target for novel anticoagulants. AREAS COVERED In this review, we provide an overview of the currently available anticoagulants and the emerging FXIa inhibitors in clinical trials. The need for availability of novel anticoagulants and the potential issues that will hinder the development and marketing of factor XIa inhibitors is also discussed. EXPERT OPINION Evidence suggests that FXI inhibition presents a promising drug target for novel anticoagulation therapies. The FXIa inhibitors in development have advantages over DOACs with lower renal clearance and long half-lives. Overall, FXI inhibition presents a promising target, it is likely that the clinical use of FXIa inhibitors is on the horizon.
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Affiliation(s)
- Sandra Elsheikh
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Cardiology Department, St Helens and Knowsley Teaching Hospitals NHS Trust, Whiston, UK
| | - Nicola Tidbury
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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16
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Wang Y, Jian C, Long Y, Xu X, Song Y, Yin Z. H 2O 2-triggered "off/on signal" nanoparticles target P-selectin for the non-invasive and contrast-enhanced theranostics for arterial thrombosis. Acta Biomater 2023; 158:769-781. [PMID: 36565786 DOI: 10.1016/j.actbio.2022.12.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/10/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
Pathological coagulation within an injured artery and the subsequent cardiovascular complications, such as stroke and heart attack, greatly threaten human life. Inspired by the biochemical features of acute arterial thrombosis, such as abundant activated platelets and hydrogen peroxide (H2O2), we constructed platelet-targeted theranostic nanoparticles (CyBA/PFM NPs) with H2O2-triggered photoacoustic contrast enhancement and antithrombotic capabilities. CyBA/PFM NPs were designed to target platelet-rich clots via fucoidan segment within the carrier, which could be activated by H2O2 to produce fluorescent "CyOH" molecules, thus turning on the photoacoustic signal. CyBA/PFM NPs showed obvious amplification of fluorescence following incubation with fresh clots, exhibiting efficient scavenging ability of intracellular reactive oxygen species (ROS). In a FeCl3-induced mouse model of carotid thrombosis, CyBA/PFM NPs significantly amplified the photoacoustic contrast in thrombogenic tissues, effectively eliminated ROS within the occlusion site, and suppressed the thrombus formation, accompanied by a normalization of the soluble CD40L level. Given their accurate imaging potential, potent antithrombotic activities and acceptable biosafety, CyBA/PFM NPs hold strong potential as nanoscale theranostics for H2O2-correlated cardiovascular diseases. STATEMENT OF SIGNIFICANCE: In this study, we developed a platelet-targeted and H2O2-triggered nanosystem self-assembled from phenylboronated fucoidan/maltodextrin polymers and responsive near-infrared probes. The fucoidan segment within the carrier could facilitate the specific delivery of the therapeutic polymers and probes to the platelet-rich arterial thrombus. In a mouse model of FeCl3-induced arterial thrombosis, the system could be activated by H2O2 to produce fluorescent "CyOH" molecules, thus turning on the photoacoustic signal and specifically imaging thrombosed tissues. Besides, CyBA/PFM NPs significantly effectively eliminated ROS within the occlusion site and suppressed the thrombus formation. Given their theranostic potential and acceptable biosafety, this system has great potential for H2O2-correlated cardiovascular diseases.
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Affiliation(s)
- Ying Wang
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China; School of Pharmacy, Chengdu University, Chengdu, 610106, China
| | - Chuanjiang Jian
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
| | - Yiqing Long
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
| | - Xiaowen Xu
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China
| | - Yang Song
- Cooperative Institute for Great Lakes Research, School for Environment and Sustainability, University of Michigan, Ann Arbor, MI 48109, United States
| | - Zongning Yin
- Key Laboratory of Drug-Targeting and Drug Delivery System of the Education Ministry, Sichuan Engineering Laboratory for Plant-Sourced Drug and Sichuan Research Center for Drug Precision Industrial Technology, West China School of Pharmacy, Sichuan University, Chengdu, 610041, China.
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17
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Pandey A, Verma R, Eikelboom J, Verma S. Factor XI inhibitors: what should clinicians know. Curr Opin Cardiol 2023; 38:88-93. [PMID: 36718618 DOI: 10.1097/hco.0000000000001015] [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] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Factor XI (FXI) inhibitors were developed to address unmet needs and limitations of current anticoagulants and are currently being studied in several indications. In this paper, we review the rationale for the development of these agents and summarize what clinicians should know about drugs that target FXI. RECENT FINDINGS Patients with FXI deficiency may have a lower risk of venous thromboembolism and cardiovascular events and have a variable but generally mild bleeding diathesis. FXI has been proposed as a target for anticoagulants due to the potential for reduction in thrombosis with a lower risk of bleeding than current anticoagulant agents. Several classes of drugs that target FXI are under development, of which three classes (small molecule inhibitors, antisense oligonucleotides and monoclonal antibodies) have been studied in Phase II trials. At least three large Phase III trial programs are planned or are underway, and will study the efficacy and safety of FXI inhibitors in tens of thousands of patients across a variety of indications including atrial fibrillation, stroke and cancer-associated venous thromboembolism. SUMMARY FXI inhibitors were developed with the hope of attenuating thrombosis with reduced bleeding/impairment of haemostasis. These agents have shown promise in preliminary trials with a low rate of bleeding. Ongoing Phase III investigations will inform the utility of these agents in clinical practice.
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Affiliation(s)
| | - Raj Verma
- Royal College of Surgeons in Ireland, Dublin, Ireland
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18
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Harrington J, Piccini JP, Alexander JH, Granger CB, Patel MR. Clinical Evaluation of Factor XIa Inhibitor Drugs: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:771-779. [PMID: 36813377 DOI: 10.1016/j.jacc.2022.11.057] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/15/2022] [Accepted: 11/21/2022] [Indexed: 02/22/2023]
Abstract
Factor XI/XIa (FXI/FXIa) represents a potential target for improved precision in anticoagulation because it is involved primarily in thrombus formation and plays a much smaller role in clotting and hemostasis. This suggests that the inhibition of FXI/XIa could prevent pathologic thrombi from forming, but largely preserve a patient's ability to clot in response to bleeding or trauma. This theory is supported by observational data showing that patients with congenital FXI deficiency have lower rates of embolic events without an increase in spontaneous bleeding. Small phase 2 trials of FXI/XIa inhibitors have offered encouraging data with regard to bleeding and safety and evidence of efficacy for the prevention of venous thromboembolism. However, larger clinical trials across multiple patient groups are needed for this emerging class of anticoagulants to understand their possible role in clinical use. Here we review the potential clinical indications for FXI/XIa inhibitors, data available to date, and consider future trials.
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Affiliation(s)
- Josephine Harrington
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA. https://twitter.com/JLHarrington_MD
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA. https://twitter.com/JonPicciniSr
| | - John H Alexander
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Manesh R Patel
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.
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He X, Zhang J, Du Y, Liu X, Hu D, Cao B, Gao H, Wu Y, Zhou T, Wu Q, Huang Q, Yang C, Liao C, Zhang L, Shen C, Wang L. BJTJ-1837, a novel FXI activation-blocking antibody. Res Pract Thromb Haemost 2023; 7:100067. [PMID: 36936858 PMCID: PMC10017418 DOI: 10.1016/j.rpth.2023.100067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 12/22/2022] [Accepted: 01/02/2023] [Indexed: 02/10/2023] Open
Abstract
Background Factor (F)XI contributes to thrombosis development while it plays a limited role in normal hemostasis. FXI targeting has the potential for preventing and treating thrombosis with little bleeding risk. Objectives The aim of this study was to develop novel antibody therapeutics against FXI for the treatment of thrombosis-related diseases. Methods Mouse hybridoma technology was applied to screen for anti-FXI antibodies. Surface plasma resonance, enzyme inhibition, activated partial thromboplastin time, and prothrombin time assays were conducted to characterize the binding affinity and activity of antibodies. A cynomolgus monkey arterial venous shunt model was applied to validate the antithrombotic activities. Results A humanized antibody, BJTJ-1837, reported here bound to the protease domain of FXI and activated FXI with high affinity. BJTJ-1837 fully inhibited the activation of FXI by activated FXII and thrombin. BJTJ-1837 also demonstrated strong anticoagulant activity in human and cynomolgus monkey plasma as measured by activated partial thromboplastin time. Moreover, BJTJ-1837 showed favorable antithrombotic activity with a dose-dependent protection in an arterial venous shunt thrombosis model in cynomolgus monkeys without the bleeding adverse effect. Furthermore, BJTJ-1837 displayed favorable pharmacokinetic and pharmacodynamic properties and good developability. Conclusion As a potential antithrombotic therapeutic agent with a safe profile, BJTJ-1837 is a very promising FXI activation-blocking antibody candidate.
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Affiliation(s)
- Xugang He
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
| | - Jin Zhang
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
| | - Yanping Du
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
| | - Xiao Liu
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
| | - Dongmei Hu
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
| | - Baohua Cao
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
| | - Hong Gao
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
| | - Yongguang Wu
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
| | - Tianlin Zhou
- Jiangsu Hengrui Pharmaceuticals Co Ltd, Lianyungang, Jiangsu, China
| | - Qimei Wu
- Jiangsu Hengrui Pharmaceuticals Co Ltd, Lianyungang, Jiangsu, China
| | - Qi Huang
- Jiangsu Hengrui Pharmaceuticals Co Ltd, Lianyungang, Jiangsu, China
| | - Changyong Yang
- Jiangsu Hengrui Pharmaceuticals Co Ltd, Lianyungang, Jiangsu, China
| | - Cheng Liao
- Jiangsu Hengrui Pharmaceuticals Co Ltd, Lianyungang, Jiangsu, China
| | - Lianshan Zhang
- Shanghai Hengrui Pharmaceutical Co Ltd, Shanghai, China
- Correspondence Lianshan Zhang, Shanghai Hengrui Pharmaceutical Co Ltd, 279 Wenjing Road, Shanghai 200245, China.
| | - Chenxi Shen
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
- Chenxi Shen and Lei Wang, Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China, Level 7, Building 4, No.9 Yi Ke Road, ZGC Life Science Park, Changping District, Beijing, 102206, China.
| | - Lei Wang
- Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China
- Chenxi Shen and Lei Wang, Beijing TUO JIE Biopharmaceutical Co Ltd, Beijing, China, Level 7, Building 4, No.9 Yi Ke Road, ZGC Life Science Park, Changping District, Beijing, 102206, China.
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20
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De Caterina R, Prisco D, Eikelboom JW. Factor XI inhibitors: cardiovascular perspectives. Eur Heart J 2023; 44:280-292. [PMID: 36263776 DOI: 10.1093/eurheartj/ehac464] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/15/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Anticoagulants are the cornerstone for prevention and treatment of thrombosis but are not completely effective, and concerns about the risk of bleeding continue to limit their uptake. Animal studies and experience from patients with genetic coagulation factor XI deficiency suggesting that this factor is more important for thrombosis than for haemostasis raises the potential for drugs that target factor XI to provide safer anticoagulation. Multiple factor XI inhibitors are currently under evaluation in clinical trials, including parenterally administered antisense oligonucleotides, monoclonal antibodies, and orally active small-molecule inhibitors. Promising results of phase 2 trials in patients undergoing major orthopaedic surgery, and in those with end-stage kidney disease, atrial fibrillation and acute coronary syndromes have led to large phase 3 trials that are currently ongoing. We here review premises for the use of these agents, results so far accrued, ongoing studies, and perspectives for future patient care.
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Affiliation(s)
- Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Division of Cardiology, Pisa University Hospital, Pisa, Italy
| | - Domenico Prisco
- Chair of Internal Medicine, Department of Experimental and Clinical Medicine, University of Florence and Careggi University Hospital, Florence, Italy
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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21
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Bifunctional fusion protein targeting both FXIIa and FXIa displays potent anticoagulation effects. Life Sci 2022; 309:121021. [DOI: 10.1016/j.lfs.2022.121021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/21/2022]
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22
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A Factor XIa Inhibitor Engineered from Banded Krait Venom Toxin: Efficacy and Safety in Rodent Models of Arterial and Venous Thrombosis. Biomedicines 2022; 10:biomedicines10071679. [PMID: 35884984 PMCID: PMC9312835 DOI: 10.3390/biomedicines10071679] [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] [Received: 06/20/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022] Open
Abstract
Activated factor XI (FXIa) is an important antithrombotic drug target. Clinical and pre-clinical data have demonstrated that its inhibition attenuates thrombosis with minimal risk of excessive bleeding. We isolated Fasxiator from the venom of banded krait Bungarus fasciatus and subsequently engineered FasxiatorN17R,L19E, with improved affinity (Ki = 0.9 nM) and selectivity towards FXIa. Here, we assess the in vivo efficacy and bleeding risk of rFasxiatorN17R, L19E in pre-clinical animal models. Rats injected intravenously (i.v.) with bolus rFasxiatorN17R, L19E showed the specific in vivo attenuation of the intrinsic coagulation pathway, lasting for at least 60 min. We performed the in vivo dose-ranging experiments for rFasxiatorN17R, L19E as follows: FeCl3-induced carotid artery occlusion in rats (arterial thrombosis); inferior vena cava ligation in mice (venous thrombosis); tail bleeding time in both rats and mice (bleeding risk). Head-to-head comparisons were made using therapeutic dosages of unfractionated heparin (UFH) and low-molecular-weight heparin (LMWH) for arterial and venous thrombosis, respectively. In the arterial thrombosis model, 2 mg/kg i.v. rFasxiatorN17R,L19E achieved a similar antithrombotic efficacy to that of UFH, with >3-fold lower bleeding time. In the venous thrombosis model, the 10 mg/kg subcutaneous (s.c.) injection of rFasxiatorN17R,L19E achieved similar efficacy and bleeding levels to those of LMWH enoxaparin. Overall, rFasxiatorN17R,L19E represents a promising molecule for the development of FXIa-targeting anticoagulants.
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Heitmeier S, Visser M, Tersteegen A, Dietze‐Torres J, Glunz J, Gerdes C, Laux V, Stampfuss J, Roehrig S. Pharmacological profile of asundexian, a novel, orally bioavailable inhibitor of factor XIa. J Thromb Haemost 2022; 20:1400-1411. [PMID: 35289054 PMCID: PMC9313898 DOI: 10.1111/jth.15700] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Activated coagulation factor XI (FXIa) contributes to the development and propagation of thrombosis but plays only a minor role in hemostasis; therefore, it is an attractive antithrombotic target. OBJECTIVES To evaluate the pharmacology of asundexian (BAY 2433334), a small molecule inhibitor targeting FXIa, in vitro and in various rabbit models. METHODS The effects of asundexian on FXIa activity, selectivity versus other proteases, plasma thrombin generation, and clotting assays were evaluated. Antithrombotic effects were determined in FeCl2 - and arterio-venous (AV) shunt models. Asundexian was administered intravenously or orally, before or during thrombus formation, and with or without antiplatelet drugs (aspirin and ticagrelor). Potential effects of asundexian on bleeding were evaluated in ear-, gum-, and liver injury models. RESULTS Asundexian inhibited human FXIa with high potency and selectivity. It reduced FXIa activity, thrombin generation triggered by contact activation or low concentrations of tissue factor, and prolonged activated partial thromboplastin time in human, rabbit, and various other species, but not in rodents. In the FeCl2 -injury models, asundexian reduced thrombus weight versus control, and in the arterial model when added to aspirin and ticagrelor. In the AV shunt model, asundexian reduced thrombus weight when administered before or during thrombus formation. Asundexian alone or in combination with antiplatelet drugs did not increase bleeding times or blood loss in any of the models studied. CONCLUSIONS Asundexian is a potent oral FXIa inhibitor with antithrombotic efficacy in arterial and venous thrombosis models in prevention and intervention settings, without increasing bleeding.
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Affiliation(s)
- Stefan Heitmeier
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Mayken Visser
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | | | | | - Julia Glunz
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Christoph Gerdes
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Volker Laux
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Jan Stampfuss
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Susanne Roehrig
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
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24
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Nopp S, Kraemmer D, Ay C. Factor XI Inhibitors for Prevention and Treatment of Venous Thromboembolism: A Review on the Rationale and Update on Current Evidence. Front Cardiovasc Med 2022; 9:903029. [PMID: 35647061 PMCID: PMC9133368 DOI: 10.3389/fcvm.2022.903029] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022] Open
Abstract
Although anticoagulation therapy has evolved from non-specific drugs (i.e., heparins and vitamin K antagonists) to agents that directly target specific coagulation factors (i.e., direct oral anticoagulants, argatroban, fondaparinux), thrombosis remains a leading cause of death worldwide. Direct oral anticoagulants (i.e., factor IIa- and factor Xa-inhibitors) now dominate clinical practice because of their favorable pharmacological profile and ease of use, particularly in venous thromboembolism (VTE) treatment and stroke prevention in atrial fibrillation. However, despite having a better safety profile than vitamin K antagonists, their bleeding risk is not insignificant. This is true for all currently available anticoagulants, and a high bleeding risk is considered a contraindication to anticoagulation. As a result, ongoing research focuses on developing future anticoagulants with an improved safety profile. Several promising approaches to reduce the bleeding risk involve targeting the intrinsic (or contact activation) pathway of coagulation, with the ultimate goal of preventing thrombosis without impairing hemostasis. Based on epidemiological data on hereditary factor deficiencies and preclinical studies factor XI (FXI) emerged as the most promising candidate target. In this review, we highlight unmet clinical needs of anticoagulation therapy, outlay the rationale and evidence for inhibiting FXI, discuss FXI inhibitors in current clinical trials, conduct an exploratory meta-analysis on their efficacy and safety, and provide an outlook on the potential clinical application of these novel anticoagulants.
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Affiliation(s)
| | | | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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25
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Heithoff DM, Pimienta G, Mahan SP, Yang WH, Le DT, House JK, Marth JD, Smith JW, Mahan MJ. Coagulation factor protein abundance in the pre-septic state predicts coagulopathic activities that arise during late-stage murine sepsis. EBioMedicine 2022; 78:103965. [PMID: 35349828 PMCID: PMC8965145 DOI: 10.1016/j.ebiom.2022.103965] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/21/2022] [Accepted: 03/10/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although sepsis accounts for 1 in 5 deaths globally, few molecular therapies exist for this condition. The development of effective biomarkers and treatments for sepsis requires a more complete understanding of host responses and pathogenic mechanisms at early stages of disease to minimize host-driven pathology. METHODS An alternative to the current symptom-based approach used to diagnose sepsis is a precise assessment of blood proteomic changes during the onset and progression of Salmonella Typhimurium (ST) murine sepsis. FINDINGS A distinct pattern of coagulation factor protein abundance was identified in the pre-septic state- prior to overt disease symptoms or bacteremia- that was predictive of the dysregulation of fibrinolytic and anti-coagulant activities and resultant consumptive coagulopathy during ST murine sepsis. Moreover, the changes in protein abundance observed generally have the same directionality (increased or decreased abundance) reported for human sepsis. Significant overlap of ST coagulopathic activities was observed in Gram-negative Escherichia coli- but not in Gram-positive staphylococcal or pneumococcal murine sepsis models. Treatment with matrix metalloprotease inhibitors prevented aberrant inflammatory and coagulopathic activities post-ST infection and increased survival. Antibiotic treatment regimens initiated after specific changes arise in the plasma proteome post-ST infection were predictive of an increase in disease relapse and death after cessation of antibiotic treatment. INTERPRETATION Altered blood proteomics provides a platform to develop rapid and easy-to-perform tests to predict sepsis for early intervention via biomarker incorporation into existing blood tests prompted by patient presentation with general malaise, and to stratify Gram-negative and Gram-positive infections for appropriate treatment. Antibiotics are less effective in microbial clearance when initiated after the onset of altered blood proteomics as evidenced by increased disease relapse and death after termination of antibiotic therapy. Treatment failure is potentially due to altered bacterial / host-responses and associated increased host-driven pathology, providing insight into why delays in antibiotic administration in human sepsis are associated with increased risk for death. Delayed treatment may thus require prolonged therapy for microbial clearance despite the prevailing notion of antibiotic de-escalation and shortened courses of antibiotics to improve drug stewardship. FUNDING National Institutes of Health, U.S. Army.
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Affiliation(s)
- Douglas M. Heithoff
- Department of Molecular, Cellular, and Developmental Biology, University of California, Santa Barbara CA 93106, USA,Institute for Collaborative Biotechnologies, University of California, Santa Barbara, CA 93106, USA
| | - Genaro Pimienta
- Cancer Metabolism and Signaling Networks Program, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Scott P. Mahan
- Department of Molecular, Cellular, and Developmental Biology, University of California, Santa Barbara CA 93106, USA,Institute for Collaborative Biotechnologies, University of California, Santa Barbara, CA 93106, USA,Department of Medical Microbiology and Immunology, School of Medicine, University of California, Davis CA 95616, USA
| | - Won Ho Yang
- Department of Molecular, Cellular, and Developmental Biology, University of California, Santa Barbara CA 93106, USA,Glycosylation Network Research Center and Department of Systems Biology, College of Life Science and Biotechnology, Yonsei University, Seoul 03722, Republic of Korea,Infectious and Inflammatory Diseases Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Dzung T. Le
- Department of Pathology, University of California, La Jolla, San Diego, CA 92093, USA
| | - John K. House
- Faculty of Science, Sydney School of Veterinary Science, The University of Sydney, Camden, New South Wales 2570, Australia
| | - Jamey D. Marth
- Department of Molecular, Cellular, and Developmental Biology, University of California, Santa Barbara CA 93106, USA,Infectious and Inflammatory Diseases Research Center, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Jeffrey W. Smith
- Cancer Metabolism and Signaling Networks Program, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA 92037, USA
| | - Michael J. Mahan
- Department of Molecular, Cellular, and Developmental Biology, University of California, Santa Barbara CA 93106, USA,Institute for Collaborative Biotechnologies, University of California, Santa Barbara, CA 93106, USA,Corresponding author at: Department of Molecular, Cellular, and Developmental Biology, University of California, Santa Barbara CA 93106, USA.
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26
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Marar TT, Matzko CN, Wu J, Esmon CT, Sinno T, Brass LF, Stalker TJ, Tomaiuolo M. Thrombin spatial distribution determines protein C activation during hemostasis and thrombosis. Blood 2022; 139:1892-1902. [PMID: 34890454 PMCID: PMC8952187 DOI: 10.1182/blood.2021014338] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022] Open
Abstract
Rebalancing the hemostatic system by targeting endogenous anticoagulant pathways, like the protein C (PC) system, is being tested as a means of improving hemostasis in patients with hemophilia. Recent intravital studies of hemostasis demonstrated that, in some vascular contexts, thrombin activity is sequestered in the extravascular compartment. These findings raise important questions about the context-dependent contribution of activated PC (APC) to the hemostatic response, because PC activation occurs on the surface of endothelial cells. We used a combination of pharmacologic, genetic, imaging, and computational approaches to examine the relationships among thrombin spatial distribution, PC activation, and APC anticoagulant function. We found that inhibition of APC activity, in mice either harboring the factor V Leiden mutation or infused with an APC-blocking antibody, significantly enhanced fibrin formation and platelet activation in a microvascular injury model, consistent with the role of APC as an anticoagulant. In contrast, inhibition of APC activity had no effect on hemostasis after penetrating injury of the mouse jugular vein. Computational studies showed that differences in blood velocity, injury size, and vessel geometry determine the localization of thrombin generation and, consequently, the extent of PC activation. Computational predictions were tested in vivo and showed that when thrombin generation occurred intravascularly, without penetration of the vessel wall, inhibition of APC significantly increased fibrin formation in the jugular vein. Together, these studies show the importance of thrombin spatial distribution in determining PC activation during hemostasis and thrombosis.
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Affiliation(s)
- Tanya T Marar
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Thomas Jefferson University, Philadelphia, PA
| | - Chelsea N Matzko
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jie Wu
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Talid Sinno
- Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia, PA; and
| | - Lawrence F Brass
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Timothy J Stalker
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Thomas Jefferson University, Philadelphia, PA
| | - Maurizio Tomaiuolo
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
- Vickie and Jack Farber Vision Research Center, Wills Eye Hospital, Philadelphia, PA
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27
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Gailani D. Factor XI as a target for preventing venous thromboembolism. J Thromb Haemost 2022; 20:550-555. [PMID: 35023278 PMCID: PMC9540353 DOI: 10.1111/jth.15628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 01/10/2023]
Affiliation(s)
- David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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28
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Yao N, Jia Z, Tian Y, Hou S, Yang X, Han J, Duan Y, Liao C, Kong Y, Xie Z. Targeting the S2 Subsite Enables the Structure-Based Discovery of Novel Highly Selective Factor XIa Inhibitors. J Med Chem 2022; 65:4318-4334. [DOI: 10.1021/acs.jmedchem.1c02153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ningning Yao
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Zhiping Jia
- School of Life Science & Technology, China Pharmaceutical University, Nanjing 210009, P.R. China
| | - Yongbin Tian
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Shuzeng Hou
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Xiaoxiao Yang
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Jihong Han
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Yajun Duan
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Chenzhong Liao
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
| | - Yi Kong
- School of Life Science & Technology, China Pharmaceutical University, Nanjing 210009, P.R. China
| | - Zhouling Xie
- Department of Pharmaceutical Sciences and Engineering, School of Food and Biological Engineering, Hefei University of Technology, Hefei 230009, P.R. China
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29
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Kubitza D, Heckmann M, Distler J, Koechel A, Schwers S, Kanefendt F. Pharmacokinetics, pharmacodynamics and safety of BAY 2433334, a novel activated factor XI inhibitor, in healthy volunteers: A randomized phase 1 multiple-dose study. Br J Clin Pharmacol 2022; 88:3447-3462. [PMID: 35014061 PMCID: PMC9311154 DOI: 10.1111/bcp.15230] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022] Open
Abstract
Aim To evaluate BAY 2433334, an oral activated factor XI (FXIa) inhibitor, in volunteers. Methods Phase 1 study of healthy men at a German centre. Part A: randomized, single‐blind, multiple dose‐escalation study of BAY 2433334 (25/50/100 mg once daily [OD]) vs. placebo. Part B: similar design to Part A; evaluated BAY 2433334 25 mg twice daily. Part C: nonrandomized, open‐label study; evaluated potential interactions between BAY 2433334 (25/75 mg OD) and midazolam (7.5 mg), a CYP3A4 index substrate. Primary variables: treatment‐emergent adverse events (TEAEs; Parts A and B); area under the plasma concentration–time curve (AUC) and maximum plasma concentration of midazolam and α‐hydroxymidazolam (Part C). Study period: 18 days plus follow‐up visit. Results Parts A and B: 36 participants randomized to BAY 2433334; 12 to placebo. Part C: 48 participants assigned to BAY 2433334 plus midazolam. BAY 2433334 was well tolerated in all study parts. AUC and maximum plasma concentration of BAY 2433334 in plasma appeared dose proportional over 25–100 mg OD, with low‐to‐moderate variability in pharmacokinetic parameters. Multiple dosing caused minor‐to‐moderate accumulation and a mean terminal half‐life (15.8–17.8 h) supporting once‐daily dosing. Dose‐dependent FXIa activity inhibition and activated partial thromboplastin time prolongation were observed. BAY 2433334 appeared to have a minor effect on AUC for midazolam (ratio [90% confidence interval]: 1.1736 [1.0963–1.2564]) and α‐hydroxymidazolam (0.9864 [0.9169–1.0612]) only for BAY 2433334 75 mg OD on day 10. Conclusion Multiple dosing of BAY 2433334 in healthy volunteers was well tolerated, with a predictable pharmacokinetic/pharmacodynamic profile and no clinically relevant CYP3A4 induction or inhibition.
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Affiliation(s)
| | | | | | - Annemone Koechel
- CRS Clinical Research Services Wuppertal GmbH, Wuppertal, Germany
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30
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Mohammed BM, Cheng Q, Ivanov IS, Gailani D. Murine Models in the Evaluation of Heparan Sulfate-Based Anticoagulants. Methods Mol Biol 2022; 2303:789-805. [PMID: 34626423 PMCID: PMC8552346 DOI: 10.1007/978-1-0716-1398-6_59] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Evaluating prospective anticoagulant therapies in animal thrombosis and bleeding models are standard pre-clinical approaches. Mice are frequently used for initial evaluations because a variety of models have been developed in this well-characterized species, and mice are relatively inexpensive to maintain. Because mice seem to be resistant to forming "spontaneous" thrombosis, vessel injury is used to induce intravascular clot formation. For the purpose of testing heparin-based drugs, we adapted a well-established model in which thrombus formation in the carotid artery is induced by exposing the vessel to ferric chloride. For studying anticoagulant effects on venous thrombosis, we use a model in which the inferior vena cava is ligated and the size of the resulting clots are measured. The most common adverse effect of anticoagulation therapy is bleeding. We describe a simple tail bleeding time that has been used for many years to study the effects of anticoagulants on hemostasis. We also describe a more reproducible, but more technically challenging, saphenous vein bleeding model that is also used for this purpose.
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Affiliation(s)
- Bassem M Mohammed
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, Doisy Research Center, St. Louis, MO, USA
| | - Qiufang Cheng
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Ivan S Ivanov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, USA.
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31
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Salomon O, Gailani D. A proposal for managing bleeding in patients on therapeutic factor XI(a) inhibitors. J Thromb Haemost 2022; 20:32-38. [PMID: 34735741 PMCID: PMC9540351 DOI: 10.1111/jth.15579] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/27/2021] [Accepted: 11/01/2021] [Indexed: 12/16/2022]
Abstract
Several drugs that reduce functional levels of the plasma protease zymogen factor XI (FXI), or that inhibit its activated form (FXIa), are being evaluated as treatments to prevent thrombosis. Based on the observation that individuals with inherited FXI deficiency have a relatively mild bleeding disorder, it is anticipated that therapeutic FXI(a) inhibitors will have a smaller impact on hemostasis than anticoagulants targeting thrombin or factor Xa. However, even if FXI(a) inhibitors are determined to be safer than currently used anticoagulants, some patients on these drugs will experience abnormal bleeding or require emergent surgery. Strategies for dealing with such situations are required. Treatment with antifibrinolytic agents and low doses of recombinant factor VIIa effectively prevent abnormal bleeding in FXI-deficient patients with alloantibody inhibitors to FXI who undergo surgery. We propose that a similar strategy can be used for patients on therapeutic FXI(a) inhibitors who are bleeding or require invasive procedures.
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Affiliation(s)
- Ophira Salomon
- Thrombosis Unit Sheba Medical Center, Tel Hashomer, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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32
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WPK5, a Novel Kunitz-Type Peptide from the Leech Whitmania pigra Inhibiting Factor XIa, and Its Loop-Replaced Mutant to Improve Potency. Biomedicines 2021; 9:biomedicines9121745. [PMID: 34944561 PMCID: PMC8698482 DOI: 10.3390/biomedicines9121745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022] Open
Abstract
Kunitz-type proteins or peptides have been found in many blood-sucking animals, but the identity of them in leeches remained elusive. In the present study, five Kunitz-type peptides named WPK1-WPK5 were identified from the leech Whitmania pigra. Recombinant WPK1-WPK5 were expressed in Pichia pastoris GS115, and their inhibitory activity against Factor XIa (FXIa) was tested. WPK5 showed inhibitory activity against FXIa with an IC50 value of 978.20 nM. To improve its potency, the loop replacement strategy was used. The loop 1 (TGPCRSNLER) and loop 2 (QYGGC) in WPK5 were replaced by loop 1 (TGPCRAMISR) and loop 2 (FYGGC) in PN2KPI, respectively, and the resulting peptide named WPK5-Mut showed an IC50 value of 8.34 nM to FXIa, which is about 100-fold the potency of FXIa compared to that of WPK5. WPK5-Mut was further evaluated for its extensive bioactivity in vitro and in vivo. It dose-dependently prolonged APTT on both murine plasma and human plasma, and potently inhibited FeCl3-induced carotid artery thrombosis in mice at a dose of 1.5 mg/kg. Additionally, WPK5-Mut did not show significant bleeding risk at a dose of 6 mg/kg. Together, these results showed that WPK5-Mut is a promising candidate for the development of an antithrombotic drug.
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33
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Thomas D, Kanefendt F, Schwers S, Unger S, Yassen A, Boxnick S. First evaluation of the safety, pharmacokinetics, and pharmacodynamics of BAY 2433334, a small molecule targeting coagulation factor XIa. J Thromb Haemost 2021; 19:2407-2416. [PMID: 34192419 PMCID: PMC8518835 DOI: 10.1111/jth.15439] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Coagulation factor XI (FXI) contributes to the development of thrombosis but appears to play a minor role in hemostasis and is, therefore, an attractive anticoagulant drug target. OBJECTIVES To evaluate the safety, pharmacokinetic, and pharmacodynamic properties of BAY 2433334, an orally administered small molecule targeting activated FXI (FXIa), in healthy men. PATIENTS/METHODS This phase 1 study was conducted in two parts. In part 1, 70 volunteers were randomized 4:1 to receive a single oral dose of BAY 2433334 (5-150 mg as oral solution or immediate-release tablets) or placebo. In part 2, 16 volunteers received a single oral dose of five BAY 2433334 5-mg tablets with or without a high-calorie breakfast in a randomized crossover study design. Adverse events, pharmacokinetic parameters, and pharmacodynamic parameters were assessed up to 72 h after drug administration. Volunteers were followed up after 7 to 14 days. RESULTS BAY 2433334 demonstrated favorable safety and tolerability with a dose-dependent increase in exposure and a terminal half-life of 14.2 to 17.4 h. A high-calorie breakfast reduced mean maximum plasma concentration and exposure by 31% and 12.4%, respectively. AY 2433334 was associated with a dose-dependent inhibition of FXIa activity and an increase in activated partial thromboplastin time. Bleeding times in volunteers who had received BAY 2433334 were similar to those in volunteers who had received placebo. CONCLUSIONS These data indicate that BAY 2433334 is a promising development candidate for once-daily oral anticoagulation; it is being evaluated in phase 2 dose-finding studies in patients at risk of thrombosis.
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Affiliation(s)
- Dirk Thomas
- Research and Development PharmaceuticalsBayer AGWuppertalGermany
| | | | - Stephan Schwers
- Research and Development PharmaceuticalsBayer AGWuppertalGermany
| | - Sigrun Unger
- Research and Development PharmaceuticalsBayer AGWuppertalGermany
| | - Ashraf Yassen
- Research and Development PharmaceuticalsBayer AGWuppertalGermany
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Jia Z, Liu Y, Ji X, Zheng Y, Li Z, Jiang S, Li H, Kong Y. DAKS1, a Kunitz Scaffold Peptide from the Venom Gland of Deinagkistrodon acutus Prevents Carotid-Artery and Middle-Cerebral-Artery Thrombosis via Targeting Factor XIa. Pharmaceuticals (Basel) 2021; 14:ph14100966. [PMID: 34681191 PMCID: PMC8539665 DOI: 10.3390/ph14100966] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 02/07/2023] Open
Abstract
Scaffold-based peptides (SBPs) are fragments of large proteins that are characterized by potent bioactivity, high thermostability, and low immunogenicity. Some SBPs have been approved by the FDA for human use. In the present study, we developed SBPs from the venom gland of Deinagkistrodon acutus (D. acutus) by combining transcriptome sequencing and Pfam annotation. To that end, 10 Kunitz peptides were discovered from the venom gland of D. acutus, and most of which peptides exhibited Factor XIa (FXIa) inhibitory activity. One of those, DAKS1, exhibiting strongest inhibitory activity against FXIa, was further evaluated for its anticoagulant and antithrombotic activity. DAKS1 prolonged twofold APTT at a concentration of 15 μM in vitro. DAKS1 potently inhibited thrombosis in a ferric chloride-induced carotid-artery injury model in mice at a dose of 1.3 mg/kg. Furthermore, DAKS1 prevented stroke in a transient middle cerebral-artery occlusion (tMCAO) model in mice at a dose of 2.6 mg/kg. Additionally, DAKS1 did not show significant bleeding risk at a dose of 6.5 mg/kg. Together, our results indicated that DAKS1 is a promising candidate for drug development for the treatment of thrombosis and stroke disorders.
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Affiliation(s)
| | | | | | | | | | | | | | - Yi Kong
- Correspondence: ; Tel.: +86-025-832-712-82
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Hsu C, Hutt E, Bloomfield DM, Gailani D, Weitz JI. Factor XI Inhibition to Uncouple Thrombosis From Hemostasis: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 78:625-631. [PMID: 34353538 DOI: 10.1016/j.jacc.2021.06.010] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/07/2021] [Accepted: 06/08/2021] [Indexed: 11/29/2022]
Abstract
Hemostasis and thrombosis are believed to be so intricately linked that any strategies that reduce thrombosis will have an inevitable impact on hemostasis. Consequently, bleeding is viewed as an unavoidable side effect of anticoagulant therapy. Emerging evidence suggests that factor XI is important for thrombosis but has a minor role in hemostasis. This information raises the possibility that anticoagulants that target factor XI will be safer than currently available agents. The authors provide a visual representation of the coagulation pathways that distinguishes between the steps involved in thrombosis and hemostasis to explain why factor XI inhibitors may serve as hemostasis-sparing anticoagulants. A safer class of anticoagulants would provide opportunities for treatment of a wider range of patients, including those at high risk for bleeding. Ongoing clinical studies will determine the extent to which factor XI inhibitors attenuate thrombosis without disruption of hemostasis.
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Affiliation(s)
- Charles Hsu
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.
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Carle V, Wu Y, Mukherjee R, Kong XD, Rogg C, Laurent Q, Cecere E, Villequey C, Konakalla MS, Maric T, Lamers C, Díaz-Perlas C, Butler K, Goto J, Stegmayr B, Heinis C. Development of Selective FXIa Inhibitors Based on Cyclic Peptides and Their Application for Safe Anticoagulation. J Med Chem 2021; 64:6802-6813. [PMID: 33974422 DOI: 10.1021/acs.jmedchem.1c00056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Coagulation factor XI (FXI) has emerged as a promising target for the development of safer anticoagulation drugs that limit the risk of severe and life-threatening bleeding. Herein, we report the first cyclic peptide-based FXI inhibitor that selectively and potently inhibits activated FXI (FXIa) in human and animal blood. The cyclic peptide inhibitor (Ki = 2.8 ± 0.5 nM) achieved anticoagulation effects that are comparable to that of the gold standard heparin applied at a therapeutic dose (0.3-0.7 IU/mL in plasma) but with a substantially broader estimated therapeutic range. We extended the plasma half-life of the peptide via PEGylation and demonstrated effective FXIa inhibition over extended periods in vivo. We validated the anticoagulant effects of the PEGylated inhibitor in an ex vivo hemodialysis model with human blood. Our work shows that FXI can be selectively targeted with peptides and provides a promising candidate for the development of a safe anticoagulation therapy.
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Affiliation(s)
- Vanessa Carle
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Yuteng Wu
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Rakesh Mukherjee
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Xu-Dong Kong
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Chloé Rogg
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Quentin Laurent
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Enza Cecere
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Camille Villequey
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Madhuree S Konakalla
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Tamara Maric
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Christina Lamers
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Cristina Díaz-Perlas
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Kaycie Butler
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
| | - Junko Goto
- Department of Public Health and Clinical Medicine, University of Umeå, SE-901 87 Umeå, Sweden
| | - Bernd Stegmayr
- Department of Public Health and Clinical Medicine, University of Umeå, SE-901 87 Umeå, Sweden
| | - Christian Heinis
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015 Lausanne, Switzerland
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Lei Y, Zhang B, Zhang Y, Dai X, Duan Y, Mao Q, Gao J, Yang Y, Bao Z, Fu X, Ping K, Yan C, Mou Y, Wang S. Design, synthesis and biological evaluation of novel FXIa inhibitors with 2-phenyl-1H-imidazole-5-carboxamide moiety as P1 fragment. Eur J Med Chem 2021; 220:113437. [PMID: 33894565 DOI: 10.1016/j.ejmech.2021.113437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 03/05/2021] [Accepted: 03/30/2021] [Indexed: 12/17/2022]
Abstract
Factor XIa, as a blood coagulation enzyme, amplifies the generation of the last enzyme thrombin in the blood coagulation cascade. It was proved that direct inhibition of factor XIa could reduce pathologic thrombus formation without an enhanced risk of bleeding. WSJ-557, a nonpurine imidazole-based xanthine oxidase inhibitor in our previous reports, could delay blood coagulation during its animal experiments, which prompted us to investigate its action mechanism. Subsequently, during the exploration of the action mechanism, it was found that WSJ-557 exhibited weak in vitro factor XIa binding affinity. Under the guide of molecular modeling, we adopted molecular hybridization strategy to develop novel factor XIa inhibitors with WSJ-557 as an initial compound. This led to the identification of the most potent compound 44g with a Ki value of 0.009 μM, which was close to that of BMS-724296 (Ki = 0.0015 μM). Additionally, serine protease selectivity study indicated that compound 44g display a desired selectivity, more 400-fold than those of thrombin, factor VIIa and factor Xa in coagulation cascade. Moreover, enzyme kinetics studies suggested that the representative compound 44g acted as a competitive-type inhibitor for FXIa, and molecular modeling revealed that it could tightly bind to the S1, S1' and S2' pockets of factor XIa. Furthermore, in vivo efficacy in the rabbit arteriovenous shunt model suggested that compound 44g demonstrated dose-dependent antithrombotic efficacy. Therefore, these results supported that compound 44g could be a potential and efficacious agent for the treatment of thrombotic diseases.
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Affiliation(s)
- Yu Lei
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Bing Zhang
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Yan Zhang
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Xiwen Dai
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Yulin Duan
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Qing Mao
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Jun Gao
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Yuwei Yang
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Ziyang Bao
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Xuefeng Fu
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Kunqi Ping
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China
| | - Chengda Yan
- Department of Pharmacy, The First Hospital of China Medical University, 155 Nanjing North Street, Shenyang, 110001, Liaoning, China
| | - Yanhua Mou
- Department of Pharmacology, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China.
| | - Shaojie Wang
- Key Laboratory of Structure-Based Drugs Design & Discovery of Ministry of Education, School of Pharmaceutical Engineering, Shenyang Pharmaceutical University, 103 Culture Road, Shenhe District, Shenyang, 110016, China.
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Ngo ATP, Jordan KR, Mueller PA, Hagen MW, Reitsma SE, Puy C, Revenko AS, Lorentz CU, Tucker EI, Cheng Q, Hinds MT, Fazio S, Monia BP, Gailani D, Gruber A, Tavori H, McCarty OJT. Pharmacological targeting of coagulation factor XI mitigates the development of experimental atherosclerosis in low-density lipoprotein receptor-deficient mice. J Thromb Haemost 2021; 19:1001-1017. [PMID: 33421301 PMCID: PMC8549080 DOI: 10.1111/jth.15236] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 12/21/2020] [Accepted: 01/04/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Human coagulation factor (F) XI deficiency, a defect of the contact activation system, protects against venous thrombosis, stroke, and heart attack, whereas FXII, plasma prekallikrein, or kininogen deficiencies are asymptomatic. FXI deficiency, inhibition of FXI production, activated FXI (FXIa) inhibitors, and antibodies to FXI that interfere with FXI/FXII interactions reduce experimental thrombosis and inflammation. FXI inhibitors are antithrombotic in patients, and FXI and FXII deficiencies are atheroprotective in apolipoprotein E-deficient mice. OBJECTIVES Investigate the effects of pharmacological targeting of FXI in experimental models of atherogenesis and established atherosclerosis. METHODS AND RESULTS Low-density lipoprotein receptor-knockout (Ldlr-/- ) mice were administered high-fat diet (HFD) for 8 weeks; concomitantly, FXI was targeted with anti-FXI antibody (14E11) or FXI antisense oligonucleotide (ASO). 14E11 and FXI-ASO reduced atherosclerotic lesion area in proximal aortas when compared with controls, and 14E11 also reduced aortic sinus lesions. In an established disease model, in which therapy was given after atherosclerosis had developed, Ldlr-/- mice were fed HFD for 8 weeks and then administered 14E11 or FXI-ASO weekly until 16 weeks on HFD. In this established disease model, 14E11 and FXI-ASO reduced atherosclerotic lesion area in proximal aortas, but not in aortic sinus. In cultures of human endothelium, FXIa exposure disrupted VE-Cadherin expression and increased endothelial lipoprotein permeability. Strikingly, we found that 14E11 prevented the disruption of VE-Cadherin expression in aortic sinus lesions observed in the atherogenesis mouse model. CONCLUSION Pharmacological targeting of FXI reduced atherogenesis in Ldlr-/- mice. Interference with the contact activation system may safely reduce development or progression of atherosclerosis.
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Affiliation(s)
- Anh T. P. Ngo
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Kelley R. Jordan
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Paul A. Mueller
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Matthew W. Hagen
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Stéphanie E. Reitsma
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Cristina Puy
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | | | - Christina U. Lorentz
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
- Aronora Inc, Portland, OR, USA
| | - Erik I. Tucker
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
- Aronora Inc, Portland, OR, USA
| | - Quifang Cheng
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN, USA
| | - Monica T. Hinds
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Sergio Fazio
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | | | - David Gailani
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University, Nashville, TN, USA
| | - András Gruber
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
- Aronora Inc, Portland, OR, USA
| | - Hagai Tavori
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Owen J. T. McCarty
- Department of Biomedical Engineering, School of Medicine, Oregon Health and Science University, Portland, OR, USA
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Barrachina MN, Izquierdo I, Hermida-Nogueira L, Morán LA, Pérez A, Arroyo AB, García-Barberá N, González-Conejero R, Troitiño S, Eble JA, Rivera J, Martínez C, Loza MI, Domínguez E, García Á. The PI3Kδ Inhibitor Idelalisib Diminishes Platelet Function and Shows Antithrombotic Potential. Int J Mol Sci 2021; 22:ijms22073304. [PMID: 33804911 PMCID: PMC8037016 DOI: 10.3390/ijms22073304] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/16/2021] [Accepted: 03/19/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Clinical management of ischemic events and prevention of vascular disease is based on antiplatelet drugs. Given the relevance of phosphatidylinositol-4,5-bisphosphate 3-kinase (PI3K) as a candidate target in thrombosis, the main goal of the present study was to identify novel antiplatelet agents within the existing inhibitors blocking PI3K isoforms. Methods: We performed a biological evaluation of the pharmacological activity of PI3K inhibitors in platelets. The effect of the inhibitors was evaluated in intracellular calcium release and platelet functional assays, the latter including aggregation, adhesion, and viability assays. The in vivo drug antithrombotic potential was assessed in mice undergoing chemically induced arterial occlusion, and the associated hemorrhagic risk evaluated by measuring the tail bleeding time. Results: We show that PI3K Class IA inhibitors potently block calcium mobilization in human platelets. The PI3K p110δ inhibitor Idelalisib inhibits platelet aggregation mediated by ITAM receptors GPVI and CLEC-2, preferentially by the former. Moreover, Idelalisib also inhibits platelet adhesion and aggregation under shear and adhesion to collagen. Interestingly, an antithrombotic effect was observed in mice treated with Idelalisib, with mild bleeding effects at high doses of the drug. Conclusion: Idelalisib may have antiplatelet effects with minor bleeding effects, which provides a rationale to evaluate its antithrombotic efficacy in humans.
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Affiliation(s)
- María N. Barrachina
- Platelet Proteomics Group, Center for Research in Molecular Medicine and Chronic Diseases, Universidade Santiago de Compostela and Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain; (M.N.B.); (I.I.); (L.H.-N.); (L.A.M.); (S.T.)
| | - Irene Izquierdo
- Platelet Proteomics Group, Center for Research in Molecular Medicine and Chronic Diseases, Universidade Santiago de Compostela and Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain; (M.N.B.); (I.I.); (L.H.-N.); (L.A.M.); (S.T.)
| | - Lidia Hermida-Nogueira
- Platelet Proteomics Group, Center for Research in Molecular Medicine and Chronic Diseases, Universidade Santiago de Compostela and Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain; (M.N.B.); (I.I.); (L.H.-N.); (L.A.M.); (S.T.)
| | - Luis A. Morán
- Platelet Proteomics Group, Center for Research in Molecular Medicine and Chronic Diseases, Universidade Santiago de Compostela and Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain; (M.N.B.); (I.I.); (L.H.-N.); (L.A.M.); (S.T.)
| | - Amparo Pérez
- Pharmacology Applied to Drug Discovery Group, Centro Singular de Investigación en Medicina Molecular y Enfermedades Crónicas, Universidade Santiago de Compostela, 15705 Santiago de Compostela, Spain; (A.P.); (M.I.L.); (E.D.)
- Grupo Biofarma, Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain
| | - Ana B. Arroyo
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30003 Murcia, Spain; (A.B.A.); (N.G.-B.); (R.G.-C.); (J.R.); (C.M.)
| | - Nuria García-Barberá
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30003 Murcia, Spain; (A.B.A.); (N.G.-B.); (R.G.-C.); (J.R.); (C.M.)
| | - Rocío González-Conejero
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30003 Murcia, Spain; (A.B.A.); (N.G.-B.); (R.G.-C.); (J.R.); (C.M.)
| | - Sara Troitiño
- Platelet Proteomics Group, Center for Research in Molecular Medicine and Chronic Diseases, Universidade Santiago de Compostela and Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain; (M.N.B.); (I.I.); (L.H.-N.); (L.A.M.); (S.T.)
| | - Johannes A. Eble
- Institute of Physiological Chemistry and Pathobiochemistry, University of Münster, 48149 Münster, Germany;
| | - José Rivera
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30003 Murcia, Spain; (A.B.A.); (N.G.-B.); (R.G.-C.); (J.R.); (C.M.)
| | - Constantino Martínez
- Servicio de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Centro Regional de Hemodonación, Universidad de Murcia, IMIB-Arrixaca, CIBERER-U765, 30003 Murcia, Spain; (A.B.A.); (N.G.-B.); (R.G.-C.); (J.R.); (C.M.)
| | - María I. Loza
- Pharmacology Applied to Drug Discovery Group, Centro Singular de Investigación en Medicina Molecular y Enfermedades Crónicas, Universidade Santiago de Compostela, 15705 Santiago de Compostela, Spain; (A.P.); (M.I.L.); (E.D.)
- Grupo Biofarma, Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain
| | - Eduardo Domínguez
- Pharmacology Applied to Drug Discovery Group, Centro Singular de Investigación en Medicina Molecular y Enfermedades Crónicas, Universidade Santiago de Compostela, 15705 Santiago de Compostela, Spain; (A.P.); (M.I.L.); (E.D.)
- Grupo Biofarma, Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain
| | - Ángel García
- Platelet Proteomics Group, Center for Research in Molecular Medicine and Chronic Diseases, Universidade Santiago de Compostela and Instituto de Investigación Sanitaria de Santiago, 15706 Santiago de Compostela, Spain; (M.N.B.); (I.I.); (L.H.-N.); (L.A.M.); (S.T.)
- Correspondence: ; Tel.: +34-881-815429
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Hamada M, Bhakta V, Andres SN, Sheffield WP. Stepwise Reversion of Multiply Mutated Recombinant Antitrypsin Reveals a Selective Inhibitor of Coagulation Factor XIa as Active as the M358R Variant. Front Cardiovasc Med 2021; 8:647405. [PMID: 33816577 PMCID: PMC8017132 DOI: 10.3389/fcvm.2021.647405] [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] [Received: 12/29/2020] [Accepted: 02/16/2021] [Indexed: 11/13/2022] Open
Abstract
Alpha-1 antitrypsin (AAT, also known as alpha-1 proteinase inhibitor or SERPINA1) is the most abundant member of the serpin superfamily found in human plasma. The naturally occurring variant AAT M358R, altered at the P1 position of the critical reactive center loop (RCL), is re-directed away from inhibition of AAT's chief natural target, neutrophil elastase, and toward accelerated inhibition of thrombin (FIIa), kallikrein (Kal), and other proteases such as factor XIa (FXIa). FXIa is an emerging target for the development of antithrombotic agents, since patients with FXI deficiency are protected from thromboembolic disease and do not exhibit a strong bleeding tendency. Previously, we used phage display, bacterial lysate screening, and combinatorial mutagenesis to identify AAT-RC, an engineered AAT M358R with additional changes between RCL positions P7-P3', CLEVEPR-STE [with changes bolded and the P1-P1' (R358-S359) reactive center shown as R-S]. AAT-RC was 279- and 16-fold more selective for FXIa/IIa or FXIa/Kal than AAT M358R; the increased selectivity came at a cost of a 2.3-fold decrease in the rate of FXIa inhibition and a 3.3-fold increase in the stoichiometry of inhibition (SI). Here, we asked which alterations in AAT-RC were most important for the observed increases in selectivity for FXIa inhibition. We back-mutated AAT-RC to AAT-RC-1 (P7-P3' FLEVEPRSTE), AAT-RC-2 (P7-P3' FLEAEPRSTE), and AAT RC-3 (P7-P3' FLEAIPR-STE). Proteins were expressed as cleavable, hexahistidine-tagged glutathione sulfotransferase fusion proteins in E. coli and purified by proteolytic elution from glutathione agarose, with polishing on nickel chelate agarose. Selectivity for FXIa over Kal of AAT-RC-1, −2, and −3 was 14, 21, and 2.3, respectively. AAT-RC-2 inhibited FXIa 31% more rapidly than AAT M358R, with the same SI, and enhanced selectivity for FXIa over Kal, FXa, FXIIa, activated protein C, and FIIa of 25-, 130-, 420-, 440-, and 470-fold, respectively. Structural modeling of the AAT-RC-2/FXIa encounter complex suggested that both E (Glu) substitutions at P3 and P3' may promote FXIa binding via hydrogen bonding to K192 in FXIa. AAT-RC-2 is the most selective and active AAT variant reported to date for FXIa inhibition and will be tested in animal models of thrombosis and bleeding.
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Affiliation(s)
- Mostafa Hamada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Varsha Bhakta
- Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada
| | - Sara N Andres
- Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
| | - William P Sheffield
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.,Centre for Innovation, Canadian Blood Services, Hamilton, ON, Canada
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Abstract
PURPOSE OF REVIEW Anticoagulation with vitamin-K antagonists or direct oral anticoagulants is associated with a significant risk of bleeding. There is a major effort underway to develop antithrombotic drugs that have a smaller impact on hemostasis. The plasma contact proteins factor XI (FXI) and factor XII (FXII) have drawn considerable interest because they contribute to thrombosis but have limited roles in hemostasis. Here, we discuss results of preclinical and clinical trials supporting the hypothesis that the contact system contributes to thromboembolic disease. RECENT FINDINGS Numerous compounds targeting FXI or FXII have shown antithrombotic properties in preclinical studies. In phase 2 studies, drugs-targeting FXI or its protease form FXIa compared favorably with standard care for venous thrombosis prophylaxis in patients undergoing knee replacement. While less work has been done with FXII inhibitors, they may be particularly useful for limiting thrombosis in situations where blood comes into contact with artificial surfaces of medical devices. SUMMARY Inhibitors of contact activation, and particularly of FXI, are showing promise for prevention of thromboembolic disease. Larger studies are required to establish their efficacy, and to establish that they are safer than current therapy from a bleeding standpoint.
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Identification of an alpha-1 antitrypsin variant with enhanced specificity for factor XIa by phage display, bacterial expression, and combinatorial mutagenesis. Sci Rep 2021; 11:5565. [PMID: 33692375 PMCID: PMC7946950 DOI: 10.1038/s41598-021-84618-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/15/2021] [Indexed: 01/20/2023] Open
Abstract
Coagulation Factor XIa (FXIa) is an emerging target for antithrombotic agent development. The M358R variant of the serpin alpha-1 antitrypsin (AAT) inhibits both FXIa and other proteases. Our aim was to enhance the specificity of AAT M358R for FXIa. We randomized two AAT M358R phage display libraries at reactive centre loop positions P13-P8 and P7-P3 and biopanned them with FXIa. A bacterial expression library randomized at P2′-P3′ was also probed. Resulting novel variants were expressed as recombinant proteins in E. coli and their kinetics of FXIa inhibition determined. The most potent FXIa-inhibitory motifs were: P13-P8, HASTGQ; P7-P3, CLEVE; and P2-P3′, PRSTE (respectively, novel residues bolded). Selectivity for FXIa over thrombin was increased up to 34-fold versus AAT M358R for these single motif variants. Combining CLEVE and PRSTE motifs in AAT-RC increased FXIa selectivity for thrombin, factors XIIa, Xa, activated protein C, and kallikrein by 279-, 143-, 63-, 58-, and 36-fold, respectively, versus AAT M358R. AAT-RC lengthened human plasma clotting times less than AAT M358R. AAT-RC rapidly and selectively inhibits FXIa and is worthy of testing in vivo. AAT specificity can be focused on one target protease by selection in phage and bacterial systems coupled with combinatorial mutagenesis.
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Functionalized polymeric hybrid micelles as an efficient nanotheranostic agent for thrombus imaging and thrombolysis. Acta Biomater 2021; 122:278-290. [PMID: 33359293 DOI: 10.1016/j.actbio.2020.10.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/24/2020] [Accepted: 10/09/2020] [Indexed: 12/11/2022]
Abstract
Pathological thrombosis within a vessel hampers blood flow and is the mainspring of numerous fatal cardiovascular complications. In order to specifically image and dissolve a thrombus, we rationally designed a functionalized polymeric hybrid micelle (PHM) system self-assembled from amphiphilic polycaprolactone-polyethylenimine (PCL-PEI) and polycaprolactone-polyethylene glycol (PCL-PEG). Based on a biological component of thrombi, activated coagulation factor XIII (FXIIIa), which is responsible for fibrin crosslinking, we further developed FXIIIa-targeted near infrared imaging and thrombolytic nanoparticles, termed IR780/FPHM/LK NPs, through chemical conjugation of peptides to the system. In a ferric chloride (FeCl3)-induced mouse carotid thrombosis model, IR780/FPHM/LK NPs specifically targeted the thrombus and significantly enhanced the photoacoustic signal for an accurate diagnosis. When loaded with the fibrinolytic drug lumbrokinase (LK), FPHM remarkably dissociated the thrombus accompanied by an increase in the d-dimer level, a fibrin degradation product, and alleviation of fatal nonspecific hemorrhagic risk. Given its thrombus-specific imaging along with potent therapeutic activities, IR780/FPHM/LK NPs hold promise for developing nanotheranostic agents in preclinical thrombotic vascular disease models.
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Stevens H, McFadyen J, Chan N. Advances in the Management of Acute Venous Thromboembolism and New Therapeutic Agents. Semin Respir Crit Care Med 2021; 42:218-232. [PMID: 33601429 DOI: 10.1055/s-0041-1723953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Important advances in the understanding and management of venous thromboembolism (VTE) have enhanced our ability to diagnose, prevent, and treat VTE. In this narrative review, we discuss how recent advances in the understanding and management of VTE are changing practice, highlight ongoing unmet needs in VTE management, and outline how novel therapeutic targets with little or no influence on hemostasis may help address these unmet needs.
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Affiliation(s)
- Hannah Stevens
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - James McFadyen
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Clinical Haematology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Noel Chan
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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45
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A novel rationale for targeting FXI: Insights from the hemostatic microRNA targetome for emerging anticoagulant strategies. Pharmacol Ther 2021; 218:107676. [DOI: 10.1016/j.pharmthera.2020.107676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
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46
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Van Doren L, Nguyen N, Garzia C, Fletcher EK, Stevenson R, Jaramillo D, Kuliopulos A, Covic L. Lipid Receptor GPR31 (G-Protein-Coupled Receptor 31) Regulates Platelet Reactivity and Thrombosis Without Affecting Hemostasis. Arterioscler Thromb Vasc Biol 2021; 41:e33-e45. [PMID: 33267659 PMCID: PMC8108540 DOI: 10.1161/atvbaha.120.315154] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE 12-LOX (12-lipoxygenase) produces a number of bioactive lipids including 12(S)-HETE that are involved in inflammation and platelet reactivity. The GPR31 (G-protein-coupled receptor 31) is the proposed receptor of 12(S)-HETE; however, it is not known whether the 12(S)-HETE-GPR31 signaling axis serves to enhance or inhibit platelet activity. Approach and Results: Using pepducin technology and biochemical approaches, we provide evidence that 12(S)-HETE-GPR31 signals through Gi to enhance PAR (protease-activated receptor)-4-mediated platelet activation and arterial thrombosis using both human platelets and mouse carotid artery injury models. 12(S)-HETE suppressed AC (adenylyl cyclase) activity through GPR31 and resulted in Rap1 (Ras-related protein 1) and p38 activation and low but detectable calcium flux but did not induce platelet aggregation. A GPR31 third intracellular (i3) loop-derived pepducin, GPR310 (G-protein-coupled receptor 310), significantly inhibited platelet aggregation in response to thrombin, collagen, and PAR4 agonist, AYPGKF, in human and mouse platelets but relative sparing of PAR1 agonist SFLLRN in human platelets. GPR310 treatment gave a highly significant 80% protection (P=0.0018) against ferric chloride-induced carotid artery injury in mice by extending occlusion time, without any effect on tail bleeding. PAR4-mediated dense granule secretion and calcium flux were both attenuated by GPR310. Consistent with these results, GPR310 inhibited 12(S)-HETE-mediated and PAR4-mediated Rap1-GTP and RASA3 translocation to the plasma membrane and attenuated PAR4-Akt and ERK activation. GPR310 caused a right shift in thrombin-mediated human platelet aggregation, comparable to the effects of inhibition of the Gi-coupled P2Y12 receptor. Co-immunoprecipitation studies revealed that GPR31 and PAR4 form a heterodimeric complex in recombinant systems. CONCLUSIONS The 12-LOX product 12(S)-HETE stimulates GPR31-Gi-signaling pathways, which enhance thrombin-PAR4 platelet activation and arterial thrombosis in human platelets and mouse models. Suppression of this bioactive lipid pathway, as exemplified by a GPR31 pepducin antagonist, may provide beneficial protective effects against platelet aggregation and arterial thrombosis with minimal effect on hemostasis.
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Affiliation(s)
- Layla Van Doren
- Division of Hematology/Oncology, Center for Hemostasis and Thrombosis Research, Tufts Medical Center, Boston, MA (L.V.D., N.N., C.G., E.K.F., R.S., L.C., A.K.)
| | - Nga Nguyen
- Division of Hematology/Oncology, Center for Hemostasis and Thrombosis Research, Tufts Medical Center, Boston, MA (L.V.D., N.N., C.G., E.K.F., R.S., L.C., A.K.)
| | - Christopher Garzia
- Division of Hematology/Oncology, Center for Hemostasis and Thrombosis Research, Tufts Medical Center, Boston, MA (L.V.D., N.N., C.G., E.K.F., R.S., L.C., A.K.)
| | - Elizabeth K Fletcher
- Division of Hematology/Oncology, Center for Hemostasis and Thrombosis Research, Tufts Medical Center, Boston, MA (L.V.D., N.N., C.G., E.K.F., R.S., L.C., A.K.)
| | - Ryan Stevenson
- Division of Hematology/Oncology, Center for Hemostasis and Thrombosis Research, Tufts Medical Center, Boston, MA (L.V.D., N.N., C.G., E.K.F., R.S., L.C., A.K.)
| | | | - Athan Kuliopulos
- Division of Hematology/Oncology, Center for Hemostasis and Thrombosis Research, Tufts Medical Center, Boston, MA (L.V.D., N.N., C.G., E.K.F., R.S., L.C., A.K.)
- Departments of Medicine (L.C., A.K.), Tufts University School of Medicine, Boston, MA
- Biochemistry (L.C., A.K.), Tufts University School of Medicine, Boston, MA
| | - Lidija Covic
- Division of Hematology/Oncology, Center for Hemostasis and Thrombosis Research, Tufts Medical Center, Boston, MA (L.V.D., N.N., C.G., E.K.F., R.S., L.C., A.K.)
- Departments of Medicine (L.C., A.K.), Tufts University School of Medicine, Boston, MA
- Biochemistry (L.C., A.K.), Tufts University School of Medicine, Boston, MA
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47
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Enhancing therapeutic efficacy of in vivo platelet-targeted gene therapy in hemophilia A mice. Blood Adv 2020; 4:5722-5734. [PMID: 33216891 DOI: 10.1182/bloodadvances.2020002479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/15/2020] [Indexed: 11/20/2022] Open
Abstract
Our previous studies demonstrated that intraosseous (IO) infusion of lentiviral vectors (LVs) carrying a modified B domain-deleted factor VIII (FVIII) transgene driven by a megakaryocyte-specific promoter (GP1Bα promoter; G-F8/N6-LV) successfully transduced hematopoietic stem cells (HSCs) to produce FVIII stored in the platelet α-granules. Platelet FVIII corrected the bleeding phenotype with limited efficacy in hemophilia A (HemA) mice with and without preexisting anti-FVIII inhibitors. The present study sought to further enhance the therapeutic efficacy of this treatment protocol by increasing both the efficiency of LV transduction and the functional activity of platelet FVIII. A combined drug regimen of dexamethasone and anti-CD8α monoclonal antibody enhanced the percentage of transduced bone marrow and HSCs over time. In G-F8/N6-LV-treated HemA mice, significant improvement in phenotypic correction was observed on day 84. To improve platelet FVIII functionality, genes encoding FVIII variant F8X10K12 with increased expression or F8N6K12RH with increased functional activity compared with F8/N6 were incorporated into LVs. Treatment with G-F8X10K12-LV in HemA mice produced a higher level of platelet FVIII but induced anti-FVIII inhibitors. After treatment with combined drugs and IO infusion of G-F8/N6K12RH-LV, HemA mice showed significant phenotypic correction without anti-FVIII inhibitor formation. These results indicate that new human FVIII variant F8/N6K12RH combined with immune suppression could significantly enhance the therapeutic efficacy of in vivo platelet-targeted gene therapy for murine HemA via IO delivery. This protocol provides a safe and effective treatment for hemophilia that may be translatable to and particularly beneficial for patients with preexisting inhibitory antibodies to FVIII.
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Xu Y, Liang Y, Parunov L, Despres D, Eckhaus M, Scott D, Ovanesov M, Struble EB. Combined thrombogenic effects of vessel injury, pregnancy and procoagulant immune globulin administration in mice. Thromb J 2020; 18:32. [PMID: 33292285 PMCID: PMC7648396 DOI: 10.1186/s12959-020-00245-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/26/2020] [Indexed: 11/25/2022] Open
Abstract
Background Pregnant women are at increased risk of thrombotic adverse events. Plasma derived immune globulin (IG) products, which are used in pregnancy for various indications, may contain procoagulant impurity activated coagulation factor XI (FXIa). Procoagulant IG products have been associated with increased thrombogenicity but their effect in pregnancy is unknown. Methods Late pregnant (gestation days 17–20) or early lactation (days 1–3) and control female mice were treated with IGs supplemented with human FXIa then subjected to ferric chloride (FeCl3) vessel injury. Occlusion of blood vessel was assessed by recording blood velocity in the femoral vein for 20 min using doppler ultrasound laser imaging. FXIa dose was selected by the ability to increase thrombin generation in mouse plasma in vitro. Results FXIa produced robust thrombin generation in mouse plasma ex vivo. Following FeCl3 injury, pregnant and non-pregnant mice receiving IG + FXIa exhibited faster reduction of blood velocity in femoral vein compared to IG alone or untreated controls. In vitro, thrombin generation in plasma samples collected after thrombosis in FXIa-treated animals was elevated and could be reduced by anti-FXI antibody. Conclusions Our results suggest that intravenously-administered FXIa may contribute to thrombosis at the site of vascular injury in both pregnant and non-pregnant animals. Supplementary Information Supplementary information accompanies this paper at 10.1186/s12959-020-00245-8.
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Affiliation(s)
- Yanqun Xu
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA
| | - Yideng Liang
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA
| | - Leonid Parunov
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA
| | - Daryl Despres
- Mouse Imaging Facility, National Institutes of Health, Bethesda, MD, USA
| | - Michael Eckhaus
- Pathology Service, Division of Veterinary Resources, National Institutes of Health, Bethesda, MD, USA
| | - Dorothy Scott
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA
| | - Mikhail Ovanesov
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA.
| | - Evi B Struble
- Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, 10903 New Hampshire Ave, Silver Spring, MD, 20993-0002, USA.
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49
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Patel P, Shaik NF, Zhou Y, Golla K, McKenzie SE, Naik UP. Apoptosis signal-regulating kinase 1 regulates immune-mediated thrombocytopenia, thrombosis, and systemic shock. J Thromb Haemost 2020; 18:3013-3028. [PMID: 32767736 PMCID: PMC7831975 DOI: 10.1111/jth.15049] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/07/2020] [Accepted: 07/31/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Immune complexes (ICs) bind to and activate platelets via FcγRIIA, causing patients to experience thrombocytopenia, as well as an increased risk of forming occlusive thrombi. Although platelets have been shown to mediate IC-induced pathologies, the mechanisms involved have yet to be fully elucidated. We identified that apoptosis signal-regulating kinase 1 (ASK1) is present in both human and mouse platelets and potentiates many platelet functions. OBJECTIVES Here we set out to study ASK1's role in regulating IC-mediated platelet functions in vitro and IC-induced pathologies using an in vivo mouse model. METHODS Using human platelets treated with an ASK1-specific inhibitor and platelets from FCGR2A/Ask1-/- transgenic mice, we examined various platelet functions induced by model ICs in vitro and in vivo. RESULTS We found that ASK1 was activated in human platelets following cross-linking of FcγRIIA using either anti-hCD9 or IV.3 + goat-anti-mouse. Although genetic deletion or inhibition of ASK1 significantly attenuated anti-CD9-induced platelet aggregation, activation of the canonical FcγRIIA signaling targets Syk and PLCγ2 was unaffected. We further found that anti-mCD9-induced cPla2 phosphorylation and TxA2 generation is delayed in Ask1 null transgenic mouse platelets leading to diminished δ-granule secretion. In vivo, absence of Ask1 protected FCGR2A transgenic mice from thrombocytopenia, thrombosis, and systemic shock following injection of anti-mCD9. In whole blood microfluidics, platelet adhesion and thrombus formation on fibrinogen was enhanced by Ask1. CONCLUSIONS These findings suggest that ASK1 inhibition may be a potential target for the treatment of IC-induced shock and other immune-mediated thrombotic disorders.
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Affiliation(s)
- Pravin Patel
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Department of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Noor F. Shaik
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Department of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Yuhang Zhou
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Department of Medicine, Thomas Jefferson University, Philadelphia, PA
- Dell Children’s Hospital, University of Texas, Austin, TX
| | - Kalyan Golla
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Department of Medicine, Thomas Jefferson University, Philadelphia, PA
- Center for Blood Research, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Steven E. McKenzie
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Department of Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Ulhas P. Naik
- Cardeza Center for Hemostasis, Thrombosis, and Vascular Biology, Cardeza Foundation for Hematologic Research, Department of Medicine, Thomas Jefferson University, Philadelphia, PA
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50
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Wilbs J, Kong XD, Middendorp SJ, Prince R, Cooke A, Demarest CT, Abdelhafez MM, Roberts K, Umei N, Gonschorek P, Lamers C, Deyle K, Rieben R, Cook KE, Angelillo-Scherrer A, Heinis C. Cyclic peptide FXII inhibitor provides safe anticoagulation in a thrombosis model and in artificial lungs. Nat Commun 2020; 11:3890. [PMID: 32753636 PMCID: PMC7403315 DOI: 10.1038/s41467-020-17648-w] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 07/08/2020] [Indexed: 01/06/2023] Open
Abstract
Inhibiting thrombosis without generating bleeding risks is a major challenge in medicine. A promising solution may be the inhibition of coagulation factor XII (FXII), because its knock-out or inhibition in animals reduced thrombosis without causing abnormal bleeding. Herein, we have engineered a macrocyclic peptide inhibitor of activated FXII (FXIIa) with sub-nanomolar activity (Ki = 370 ± 40 pM) and a high stability (t1/2 > 5 days in plasma), allowing for the preclinical evaluation of a first synthetic FXIIa inhibitor. This 1899 Da molecule, termed FXII900, efficiently blocks FXIIa in mice, rabbits, and pigs. We found that it reduces ferric-chloride-induced experimental thrombosis in mice and suppresses blood coagulation in an extracorporeal membrane oxygenation (ECMO) setting in rabbits, all without increasing the bleeding risk. This shows that FXIIa activity is controllable in vivo with a synthetic inhibitor, and that the inhibitor FXII900 is a promising candidate for safe thromboprotection in acute medical conditions.
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Affiliation(s)
- Jonas Wilbs
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015, Lausanne, Switzerland
| | - Xu-Dong Kong
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015, Lausanne, Switzerland
| | - Simon J Middendorp
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015, Lausanne, Switzerland
| | - Raja Prince
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.,Department of Clinical Research, University of Bern, CH-3008, Bern, Switzerland
| | - Alida Cooke
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15213, USA
| | - Caitlin T Demarest
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15213, USA
| | - Mai M Abdelhafez
- Department of Clinical Research, University of Bern, CH-3008, Bern, Switzerland
| | - Kalliope Roberts
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15213, USA
| | - Nao Umei
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15213, USA
| | - Patrick Gonschorek
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015, Lausanne, Switzerland
| | - Christina Lamers
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015, Lausanne, Switzerland
| | - Kaycie Deyle
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015, Lausanne, Switzerland
| | - Robert Rieben
- Department of Clinical Research, University of Bern, CH-3008, Bern, Switzerland
| | - Keith E Cook
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA, 15213, USA
| | - Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, CH-3010, Bern, Switzerland.,Department of Clinical Research, University of Bern, CH-3008, Bern, Switzerland
| | - Christian Heinis
- Institute of Chemical Sciences and Engineering, Ecole Polytechnique Fédérale de Lausanne (EPFL), CH-1015, Lausanne, Switzerland.
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