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Husain A, Monga J, Narwal S, Singh G, Rashid M, Afzal O, Alatawi A, Almadani NM. Prodrug Rewards in Medicinal Chemistry: An Advance and Challenges Approach for Drug Designing. Chem Biodivers 2023; 20:e202301169. [PMID: 37833241 DOI: 10.1002/cbdv.202301169] [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: 08/04/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 10/15/2023]
Abstract
This article emphasizes the importance of prodrugs and their diverse spectrum of effects in the field of developing novel drugs for a variety of biological applications. Prodrugs are chemicals that are supplied inactively, but then go through enzymatic and chemical transformation in vivo to release the active parent medication that can have the desired pharmacological effect. By adding an inactive chemical moiety, prodrugs are improved in a number of ways that contribute to their potency and durability. For the purpose of illustrating the usefulness of the prodrug approach, this review covers examples of prodrugs that have been made available or are now undergoing human trials. Additionally, it included lists of the most common functional groups, carrier linkers, and reactive chemicals that can be used to create prodrugs. The current study also provides a brief introduction, several chemical methods and modifications for creating prodrugs and mutual prodrugs, as well as an explanation of recent advancements and difficulties in the field of prodrug design. The primary chemical carriers employed in the creation of prodrugs, such as esters, amides, imides, NH-acidic carriers, amines, alcohols, carbonyl, carboxylic, and azo-linkages, are also discussed. This review also discusses glycosidic and triglyceride mutually activated prodrugs, which aim to deliver the drugs after bioconversion at the intended site of action. The article also discusses the extensive chemistry and wide variety of applications of recently approved prodrugs, such as antibacterial, anti-inflammatory, cardiovascular, antiplatelet, antihypertensive, atherosclerotic, antiviral, etc. In order to illustrate the prodrug and mutual drug concept's various applications and highlight its many triumphs in overcoming the formulation and delivery of problematic pharmaceuticals, this work represents a thorough guide that includes the synthetic moiety for the reader.
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Affiliation(s)
- Asif Husain
- Department of Pharmaceutical Chemistry, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, 110064, India
| | - Jyoti Monga
- Ch. Devi Lal College of Pharmacy, Jagadhri, 135003, Haryana, India
| | - Smita Narwal
- Global Research Institute of Pharmacy, Nachraun, Radaur, 135133, Haryana, India
| | - Gurvirender Singh
- Institute of Pharmaceutical Sciences, Kurukshetra University Kurukshetra-136119, Haryana, India
| | - Mohammad Rashid
- Department of Pharmacognosy and Pharmaceutical Chemistry, College of Dentistry and Pharmacy, Buraydah Private Colleges, Buraydah, 51418, Saudi Arabia
| | - Obaid Afzal
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al Kharj, 11942, Saudi Arabia
| | - Abdurahhman Alatawi
- Clinical Pharmacist, Pharmaceutical Care Department, King Fahad Specialized Hospital, Tabuk, 47717, Saudi Arabia
| | - Norah M Almadani
- Biochemistry Department, Faculty of Science, University of Tabuk, Tabuk, 47914, Saudi Arabia
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Wang X, Li Q, Du F, Shukla N, Nawrocki AR, Chintala M. Antithrombotic Effects of the Novel Small-Molecule Factor XIa Inhibitor Milvexian in a Rabbit Arteriovenous Shunt Model of Venous Thrombosis. TH OPEN 2023; 7:e97-e104. [PMID: 37101592 PMCID: PMC10125780 DOI: 10.1055/a-2061-3311] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/20/2023] [Indexed: 04/28/2023] Open
Abstract
Background Factor XIa (FXIa) is an emerging therapeutic target, and FXIa inhibition is a promising mechanism to improve therapeutic index over current anticoagulants. Milvexian (BMS-986177/JNJ-70033093) is an oral small-molecule FXIa inhibitor. Objective Milvexian's antithrombotic efficacy was characterized in a rabbit arteriovenous (AV) shunt model of venous thrombosis and compared with the factor Xa inhibitor apixaban and the direct thrombin inhibitor dabigatran. Methods The AV shunt model of thrombosis was conducted in anesthetized rabbits. Vehicle or drugs were administered as intravenous bolus plus a continuous infusion. Thrombus weight was the primary efficacy endpoint. Ex vivo activated partial thromboplastin time (aPTT), prothrombin time (PT), and thrombin time (TT) were measured as the pharmacodynamic responses. Results Milvexian dose dependently reduced thrombus weights by 34.3 ± 7.9, 51.6 ± 6.8 ( p < 0.01; n = 5), and 66.9 ± 4.8% ( p < 0.001; n = 6) versus vehicle at 0.25 + 0.17, 1.0 + 0.67, and 4.0 ± 2.68 mg/kg bolus + mg/kg/h infusion, respectively. Ex vivo clotting data supported a dose-dependent prolongation of aPTT (with 1.54-, 2.23-, and 3.12-fold increases from baseline upon the AV shunt start), but no changes in PT and TT. Dose-dependent inhibition in thrombus weight and clotting assays was also demonstrated for both apixaban and dabigatran as the references for the model validation. Conclusion Results demonstrate that milvexian is an effective anticoagulant for prevention of venous thrombosis in the rabbit model, which supports the utility of milvexian in venous thrombosis, as seen in the phase 2 clinical study.
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Affiliation(s)
- Xinkang Wang
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
- Address for correspondence Xinkang Wang, PhD Janssen Research & Development, LLC1400 McKean Road, 42-2522, Spring House, PA 19002United States
| | - Qiu Li
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
| | - Fuyong Du
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
| | - Neetu Shukla
- Formulation, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
| | - Andrea R. Nawrocki
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
| | - Madhu Chintala
- Cardiovascular & Metabolism Therapeutic Area, Janssen Research & Development, LLC, Spring House, Pennsylvania, United States
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Brent MB. Pharmaceutical treatment of bone loss: From animal models and drug development to future treatment strategies. Pharmacol Ther 2023; 244:108383. [PMID: 36933702 DOI: 10.1016/j.pharmthera.2023.108383] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/18/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023]
Abstract
Animal models are fundamental to advance our knowledge of the underlying pathophysiology of bone loss and to study pharmaceutical countermeasures against it. The animal model of post-menopausal osteoporosis from ovariectomy is the most widely used preclinical approach to study skeletal deterioration. However, several other animal models exist, each with unique characteristics such as bone loss from disuse, lactation, glucocorticoid excess, or exposure to hypobaric hypoxia. The present review aimed to provide a comprehensive overview of these animal models to emphasize the importance and significance of investigating bone loss and pharmaceutical countermeasures from perspectives other than post-menopausal osteoporosis only. Hence, the pathophysiology and underlying cellular mechanisms involved in the various types of bone loss are different, and this might influence which prevention and treatment strategies are the most effective. In addition, the review sought to map the current landscape of pharmaceutical countermeasures against osteoporosis with an emphasis on how drug development has changed from being driven by clinical observations and enhancement or repurposing of existing drugs to today's use of targeted anti-bodies that are the result of advanced insights into the underlying molecular mechanisms of bone formation and resorption. Moreover, new treatment combinations or repurposing opportunities of already approved drugs with a focus on dabigatran, parathyroid hormone and abaloparatide, growth hormone, inhibitors of the activin signaling pathway, acetazolamide, zoledronate, and romosozumab are discussed. Despite the considerable progress in drug development, there is still a clear need to improve treatment strategies and develop new pharmaceuticals against various types of osteoporosis. The review also highlights that new treatment indications should be explored using multiple animal models of bone loss in order to ensure a broad representation of different types of skeletal deterioration instead of mainly focusing on primary osteoporosis from post-menopausal estrogen deficiency.
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Affiliation(s)
- Mikkel Bo Brent
- Department of Biomedicine, Aarhus University, Denmark, Wilhelm Meyers Allé 3, 8000 Aarhus C, Denmark.
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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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Yin L, Qi Y, Ge Z, Li J. Effects of direct oral anticoagulants dabigatran and rivaroxaban on the blood coagulation function in rabbits. Open Life Sci 2022; 17:1-9. [PMID: 35128064 PMCID: PMC8800383 DOI: 10.1515/biol-2022-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to explore the effects of dabigatran and rivaroxaban on the activities of various coagulation factors. To achieve that, 60 rabbits were randomly divided into experimental groups that received different doses of dabigatran or rivaroxaban. The effects of dabigatran and rivaroxaban on the activities of FII, FV, FVIII, FX, and activated protein C (APC) were analyzed. In the dabigatran groups, activated partial thromboplastin time and thromboplastin time (TT) were prolonged after drug administration, and the activities of FII, FV, FVIII, and FX were inhibited as the drug concentration increased. Low doses of dabigatran inhibited APC activity. In the rivaroxaban groups, APTT and TT were not significantly prolonged after drug administration. In contrast, the high-dose rivaroxaban group exhibited prolonged PT, and the degree of inhibition of the activities of FII, FV, FVIII, and FX increased as the drug concentration increased. Rivaroxaban had no significant effect on APC activity regardless of dosage. As the drug concentration increased, both NOACs had more significant inhibitory effects on the activities of FII, FV, FVIII, and FX. Low concentrations of dabigatran generated an inhibitory effect on APC activity, while high concentrations of dabigatran had no significant effect. Rivaroxaban had no significant effect on APC activity.
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Affiliation(s)
- Lu Yin
- Department of Cardiology, Gongli Hospital of Shanghai Pudong New Area, Shanghai 200000, China
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yuan Qi
- Department of Cardiology, Gongli Hospital of Shanghai Pudong New Area, Shanghai 200000, China
| | - Zhiru Ge
- Department of Cardiology, Gongli Hospital of Shanghai Pudong New Area, Shanghai 200000, China
| | - Jiajin Li
- Department of Nuclear Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai 200127, China
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Lerche CJ, Schwartz F, Theut M, Fosbøl EL, Iversen K, Bundgaard H, Høiby N, Moser C. Anti-biofilm Approach in Infective Endocarditis Exposes New Treatment Strategies for Improved Outcome. Front Cell Dev Biol 2021; 9:643335. [PMID: 34222225 PMCID: PMC8249808 DOI: 10.3389/fcell.2021.643335] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/04/2021] [Indexed: 12/13/2022] Open
Abstract
Infective endocarditis (IE) is a life-threatening infective disease with increasing incidence worldwide. From early on, in the antibiotic era, it was recognized that high-dose and long-term antibiotic therapy was correlated to improved outcome. In addition, for several of the common microbial IE etiologies, the use of combination antibiotic therapy further improves outcome. IE vegetations on affected heart valves from patients and experimental animal models resemble biofilm infections. Besides the recalcitrant nature of IE, the microorganisms often present in an aggregated form, and gradients of bacterial activity in the vegetations can be observed. Even after appropriate antibiotic therapy, such microbial formations can often be identified in surgically removed, infected heart valves. Therefore, persistent or recurrent cases of IE, after apparent initial infection control, can be related to biofilm formation in the heart valve vegetations. On this background, the present review will describe potentially novel non-antibiotic, antimicrobial approaches in IE, with special focus on anti-thrombotic strategies and hyperbaric oxygen therapy targeting the biofilm formation of the infected heart valves caused by Staphylococcus aureus. The format is translational from preclinical models to actual clinical treatment strategies.
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Affiliation(s)
- Christian Johann Lerche
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Franziska Schwartz
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marie Theut
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Loldrup Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
- Department of Emergency Medicine, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Shah R, Sheikh N, Mangwani J, Morgan N, Khairandish H. Direct oral anticoagulants (DOACs) and neck of femur fractures: Standardising the perioperative management and time to surgery. J Clin Orthop Trauma 2021; 12:138-147. [PMID: 33716439 PMCID: PMC7920209 DOI: 10.1016/j.jcot.2020.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/09/2020] [Indexed: 01/17/2023] Open
Abstract
Demographic projections for hip fragility fractures indicate a rising annual incidence by virtue of a multimorbid, ageing population with more noncommunicable diseases (NCDs). NCDs are characterised by slow progression and long duration ranging from ischaemic cardiovascular disease, cerebrovascular disease, diabetes, chronic obstructive pulmonary disease to various cancers. Management of this disease burden often involves commencing patients on oral anticoagulants to reduce the risk of thromboembolic events. The use of direct oral anticoagulants (DOACs) in clinical practice has increased due to their rapid onset of action, short half-life and predictable anticoagulant effects, without the need for routine monitoring. Safe and timely surgical intervention relies on reversal of anticoagulants. However, the lack of specific evidence-based guidelines for the perioperative management of patients on DOACs with hip fractures has proved challenging; in particular, the accessibility of DOAC-specific assays, justification of the cost-benefit ratio of targeted reversal agents and indications for neuraxial anaesthesia. This has led to potentially avoidable delays in surgical intervention. Following a literature review of the pharmacokinetic and pharmacodynamics of commonly used DOACs in our region including the role of surrogate markers, we propose a systematic, evidence-based guideline to the perioperative management of hip fractures DOACs. We believe this standardised protocol can be easily replicated between hospitals. We recommend that if patients are deemed suitable for a general anaesthesia, with satisfactory renal function, optimal surgical time should be 24 h following the last ingested dose of DOAC.
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Affiliation(s)
- Rohi Shah
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Road, Kettering, NN16 8UZ, UK,Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK,Corresponding author. Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Road, Kettering, NN16 8UZ, UK.
| | - Nomaan Sheikh
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Road, Kettering, NN16 8UZ, UK
| | - Jitendra Mangwani
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Nicolette Morgan
- Department of Trauma and Orthopaedics, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK
| | - Hamidreza Khairandish
- Department of Trauma and Orthopaedics, Kettering General Hospital, Rothwell Road, Kettering, NN16 8UZ, UK
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Zhang C, Zhang P, Li H, Han L, Zhang L, Zhang L, Yang X. The effect of dabigatran on thrombin generation and coagulation assays in rabbit and human plasma. Thromb Res 2018; 165:38-43. [DOI: 10.1016/j.thromres.2018.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 03/10/2018] [Accepted: 03/14/2018] [Indexed: 10/17/2022]
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Yau JW, Liao P, Fredenburgh JC, Roberts RS, Weitz JI. Only high levels of dabigatran attenuate catheter thrombosis in vitro and in rabbits. Thromb Haemost 2017; 112:79-86. [DOI: 10.1160/th13-12-1047] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 02/08/2014] [Indexed: 11/05/2022]
Abstract
SummaryIn patients with mechanical heart valves, thromboembolic events were more frequent with dabigatran, an oral thrombin inhibitor, than with warfarin. This observation raises the possibility that dabigatran may be less effective than conventional anticoagulants in patients with other blood-contacting devices, such as catheters. To address this, we compared the capacity of dabigatran and/or heparin to inhibit catheter-induced thrombin generation in vitro and to attenuate catheter occlusion in rabbits. Using a catheter-induced thrombin generation assay, concentrations of dabigatran over 100 ng/ml prolonged the lag time and time to peak thrombin, and reduced the peak thrombin concentration and endogenous thrombin potential in a concentration-dependent fashion. Compared with saline in a rabbit model of catheter thrombosis, dabigatran prolonged the mean time to catheter occlusion by 2.9– and 1.9-fold when plasma levels were 173 and 140 ng/ml, respectively; values comparable to median peak levels in humans given dabigatran 150 mg twice daily. In contrast, low-dose dabigatran, which produced a level of 60 ng/ml; a value comparable to the trough level of dabigatran in humans, did not prolong the time to occlusion. Whereas a 70 U/kg bolus of heparin prolonged the mean time to occlusion by 3.4-fold, a 15 U/kg bolus had no effect. When low-dose dabigatran was given in combination with 15 U/kg heparin, the mean time to occlusion was prolonged by 2.7-fold. These findings suggest that only peak levels of dabigatran are sufficient to prevent catheter-induced clotting unless supplemented heparin is given.
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Jagadeeswaran P, Cooley BC, Gross PL, Mackman N. Animal Models of Thrombosis From Zebrafish to Nonhuman Primates: Use in the Elucidation of New Pathologic Pathways and the Development of Antithrombotic Drugs. Circ Res 2017; 118:1363-79. [PMID: 27126647 DOI: 10.1161/circresaha.115.306823] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/30/2015] [Indexed: 12/23/2022]
Abstract
Thrombosis is a leading cause of morbidity and mortality worldwide. Animal models are used to understand the pathological pathways involved in thrombosis and to test the efficacy and safety of new antithrombotic drugs. In this review, we will first describe the central role a variety of animal models of thrombosis and hemostasis has played in the development of new antiplatelet and anticoagulant drugs. These include the widely used P2Y12 antagonists and the recently developed orally available anticoagulants that directly target factor Xa or thrombin. Next, we will describe the new players, such as polyphosphate, neutrophil extracellular traps, and microparticles, which have been shown to contribute to thrombosis in mouse models, particularly venous thrombosis models. Other mouse studies have demonstrated roles for the factor XIIa and factor XIa in thrombosis. This has spurred the development of strategies to reduce their levels or activities as a new approach for preventing thrombosis. Finally, we will discuss the emergence of zebrafish as a model to study thrombosis and its potential use in the discovery of novel factors involved in thrombosis and hemostasis. Animal models of thrombosis from zebrafish to nonhuman primates are vital in identifying pathological pathways of thrombosis that can be safely targeted with a minimal effect on hemostasis. Future studies should focus on understanding the different triggers of thrombosis and the best drugs to prevent each type of thrombotic event.
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Affiliation(s)
- Pudur Jagadeeswaran
- From the Department of Biological Sciences, University of North Texas, Denton (P.J.); Department of Pathology and Laboratory Medicine (B.C.C.), and Department of Medicine (N.M.), University of North Carolina, Chapel Hill; and Department of Medicine, McMaster University, Hamilton, Ontario, Canada (P.L.G.).
| | - Brian C Cooley
- From the Department of Biological Sciences, University of North Texas, Denton (P.J.); Department of Pathology and Laboratory Medicine (B.C.C.), and Department of Medicine (N.M.), University of North Carolina, Chapel Hill; and Department of Medicine, McMaster University, Hamilton, Ontario, Canada (P.L.G.)
| | - Peter L Gross
- From the Department of Biological Sciences, University of North Texas, Denton (P.J.); Department of Pathology and Laboratory Medicine (B.C.C.), and Department of Medicine (N.M.), University of North Carolina, Chapel Hill; and Department of Medicine, McMaster University, Hamilton, Ontario, Canada (P.L.G.)
| | - Nigel Mackman
- From the Department of Biological Sciences, University of North Texas, Denton (P.J.); Department of Pathology and Laboratory Medicine (B.C.C.), and Department of Medicine (N.M.), University of North Carolina, Chapel Hill; and Department of Medicine, McMaster University, Hamilton, Ontario, Canada (P.L.G.)
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Aminocaproic Acid and Tranexamic Acid Fail to Reverse Dabigatran-Induced Coagulopathy. Am J Ther 2016; 23:e1619-e1622. [DOI: 10.1097/mjt.0000000000000216] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hale SL, Kloner RA. Dabigatran treatment: effects on infarct size and the no-reflow phenomenon in a model of acute myocardial ischemia/reperfusion. J Thromb Thrombolysis 2015; 39:50-4. [PMID: 25017632 DOI: 10.1007/s11239-014-1098-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The no-reflow phenomenon occurs when an epicardial coronary artery is reopened following myocardial infarction, but portions of the intramural microvasculature fail to reperfuse. One potential mechanism for this is the presence of fibrin tactoids. In addition, some recent studies have suggested that dabigatran treatment may be associated with increased incidence of myocardial infarction. Our aim was to investigate the effect on myocardial infarct size and no-reflow in an acute model of ischemia/reperfusion. Anesthetized, open-chest rabbits were randomly assigned to receive dabigatran (Dab, 0.5 mg/kg bolus + infusion, 0.15 mg/kg/h, IV, n = 11) or vehicle (Veh, n = 11) 15 m before a 30-m coronary artery occlusion and during 2.5 h of the 3 h reperfusion procedure. At the end of the reperfusion period, infarct size (% risk zone) and no-reflow defect were measured. The ischemic risk zone (% of left ventricle) was similar in groups, 24 % in Dab and 25 % in Veh. Necrosis was neither reduced nor increased by Dab treatment; expressed as a percentage of the risk region, infarct size was 30 ± 4 % in Dab and 28 ± 5 % in Veh, p = 0.76. The extent of no-reflow was comparable, expressed either as a percent of the risk region (19 ± 3 %, Dab and 18 ± 3 %, Veh) or as a percent of the necrotic zone (67 ± 8 % Dab and 65 ± 10 % Veh). Dab treatment had no effect on heart rate or blood pressure. Dabigatran treatment did not prevent or ameliorate the no-reflow phenomenon, suggesting that fibrin does not play a major role in the development of microvascular obstruction. Dabigatran did not exacerbate myocardial infarct size.
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Affiliation(s)
- Sharon L Hale
- The Heart Institute of Good Samaritan Hospital, 1225 Wilshire Blvd, Los Angeles, CA, 90017, USA,
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13
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Development and validation of a liquid chromatography/tandem mass spectrometry assay for the simultaneous determination of dabigatran etexilate, intermediate metabolite and dabigatran in 50μL rat plasma and its application to pharmacokinetic study. J Chromatogr B Analyt Technol Biomed Life Sci 2014; 973C:110-119. [DOI: 10.1016/j.jchromb.2014.09.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/15/2014] [Accepted: 09/19/2014] [Indexed: 12/17/2022]
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Herzog E, Kaspereit FJ, Krege W, Doerr B, van Ryn J, Dickneite G, Pragst I. Thrombotic safety of prothrombin complex concentrate (Beriplex P/N) for dabigatran reversal in a rabbit model. Thromb Res 2014; 134:729-36. [DOI: 10.1016/j.thromres.2014.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 07/03/2014] [Accepted: 07/05/2014] [Indexed: 01/23/2023]
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Veloso TR, Que YA, Chaouch A, Giddey M, Vouillamoz J, Rousson V, Moreillon P, Entenza JM. Prophylaxis of Experimental Endocarditis With Antiplatelet and Antithrombin Agents: A Role for Long-term Prevention of Infective Endocarditis in Humans? J Infect Dis 2014; 211:72-9. [DOI: 10.1093/infdis/jiu426] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Weigand A, Boos AM, Ringwald J, Mieth M, Kneser U, Arkudas A, Bleiziffer O, Klumpp D, Horch RE, Beier JP. New aspects on efficient anticoagulation and antiplatelet strategies in sheep. BMC Vet Res 2013; 9:192. [PMID: 24088206 PMCID: PMC3851128 DOI: 10.1186/1746-6148-9-192] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 09/26/2013] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND After addressing fundamental questions in preclinical models in vitro or in small animals in vivo, the translation into large animal models has become a prerequisite before transferring new findings to human medicine. Especially in cardiovascular, orthopaedic and reconstructive surgery, the sheep is an important in vivo model for testing innovative therapies or medical devices prior to clinical application. For a wide variety of sheep model based research projects, an optimal anticoagulation and antiplatelet therapy is mandatory. However, no standardised scheme for this model has been developed so far. Thus the efficacy of antiplatelet (acetylsalicylic acid, clopidogrel, ticagrelor) and anticoagulant (sodium enoxaparin, dabigatran etexilate) strategies was evaluated through aggregometry, anti-factor Xa activity and plasma thrombin inhibitor levels in sheep of different ages. RESULTS Responses to antiplatelet and anticoagulant drugs in different concentrations were studied in the sheep. First, a baseline for the measurement of platelet aggregation was assessed in 20 sheep. The effectiveness of 225 mg clopidogrel twice daily (bid) in 2/5 sheep and 150 mg bid in 3/5 lambs could be demonstrated, while clopidogrel and its metabolite carboxylic acid were detected in every plasma sample. High dose ticagrelor (375 mg bid) resulted in sufficient inhibition of platelet aggregation in 1/5 sheep, while acetylsalicylic acid did not show any antiplatelet effect. Therapeutic anti-factor Xa levels were achieved with age-dependent dosages of sodium enoxaparin (sheep 3 mg/kg bid, lambs 5 mg/kg bid). Administration of dabigatran etexilate resulted in plasma concentrations similar to human ranges in 2/5 sheep, despite receiving quadruple dosages (600 mg bid). CONCLUSION High dosages of clopidogrel inhibited platelet aggregation merely in a low number of sheep despite sufficient absorption. Ticagrelor and acetylsalicylic acid cannot be recommended for platelet inhibition in sheep. Efficient anticoagulation can be ensured using sodium enoxaparin rather than dabigatran etexilate in age-dependent dosages. The findings of this study significantly contribute to the improvement of a safe and reliable prophylaxis for thromboembolic events in sheep. Applying these results in future translational experimental studies may help to avoid early dropouts due to thromboembolic events and associated unnecessary high animal numbers.
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Affiliation(s)
- Annika Weigand
- Department of Plastic and Hand Surgery, University Hospital of Erlangen Friedrich-Alexander University of Erlangen-Nürnberg, Krankenhausstr, 12, Erlangen D-91054, Germany.
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Scaglione F. New oral anticoagulants: comparative pharmacology with vitamin K antagonists. Clin Pharmacokinet 2013; 52:69-82. [PMID: 23292752 DOI: 10.1007/s40262-012-0030-9] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
New oral anticoagulants (OACs) that directly inhibit Factor Xa (FXa) or thrombin have been developed for the long-term prevention of thromboembolic disorders. These novel agents provide numerous benefits over older vitamin K antagonists (VKAs) due to major pharmacological differences. VKAs are economical and very well characterized, but have important limitations that can outweigh these advantages, such as slow onset of action, narrow therapeutic window and unpredictable anticoagulant effect. VKA-associated dietary precautions, monitoring and dosing adjustments to maintain international normalized ratio (INR) within therapeutic range, and bridging therapy, are inconvenient for patients, expensive, and may result in inappropriate use of VKA therapy. This may lead to increased bleeding risk or reduced anticoagulation and increased risk of thrombotic events. The new OACs have rapid onset of action, low potential for food and drug interactions, and predictable anticoagulant effect that removes the need for routine monitoring. FXa inhibitors, e.g. rivaroxaban and apixaban, are potent, oral direct inhibitors of prothrombinase-bound, clot-associated or free FXa. Both agents have a rapid onset of action, a wide therapeutic window, little or no interaction with food and other drugs, minimal inter-patient variability, and display similar pharmacokinetics in different patient populations. Since both are substrates, co-administration of rivaroxaban and apixaban with strong cytochrome P450 (CYP) 3A4 and permeability glycoprotein (P-gp) inhibitors and inducers can result in substantial changes in plasma concentrations due to altered clearance rates; consequently, their concomitant use is contraindicated and caution is required when used concomitantly with strong CYP3A4 and P-gp inducers. Although parenteral oral direct thrombin inhibitors (DTIs), such as argatroban and bivalirudin, have been on the market for years, DTIs such as dabigatran are novel synthetic thrombin antagonists. Dabigatran etexilate is a low-molecular-weight non-active pro-drug that is administered orally and converted rapidly to its active form, dabigatran--a potent, competitive and reversible DTI. Dabigatran has an advantage over the indirect thrombin inhibitors, unfractionated heparin and low-molecular-weight heparin, in that it inhibits free and fibrin-bound thrombin. The reversible binding of dabigatran may provide safer and more predictable anticoagulant treatment than seen with irreversible, non-covalent thrombin inhibitors, e.g. hirudin. Dabigatran shows a very low potential for drug-drug interactions. However, co-administration of dabigatran etexilate with other anticoagulants and antiplatelet agents can increase the bleeding risk. Although the new agents are pharmacologically better than VKAs--particularly in terms of fixed dosing, rapid onset of action, no INR monitoring and lower risk of drug interactions--there are some differences between them: the bioavailability of dabigatran is lower than rivaroxaban and apixaban, and so the dabigatran dosage required is higher; lower protein binding of dabigatran reduces the variability related to albuminaemia. The risk of metabolic drug-drug interactions also appears to differ between OACs: VKAs > rivaroxaban > apixaban > dabigatran. The convenience of the new OACs has translated into improvements in efficacy and safety as shown in phase III randomized trials. The new anticoagulants so far offer the greatest promise and opportunity for the replacement of VKAs.
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Affiliation(s)
- Francesco Scaglione
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milano, Italy.
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Antithrombotic activity of HY023016, a novel Dabigatran prodrug evaluated in animal thrombosis models. Thromb Res 2013; 131:425-35. [DOI: 10.1016/j.thromres.2013.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 02/15/2013] [Accepted: 03/01/2013] [Indexed: 11/23/2022]
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van Ryn J, Goss A, Hauel N, Wienen W, Priepke H, Nar H, Clemens A. The discovery of dabigatran etexilate. Front Pharmacol 2013; 4:12. [PMID: 23408233 PMCID: PMC3569592 DOI: 10.3389/fphar.2013.00012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 01/23/2013] [Indexed: 01/18/2023] Open
Abstract
Thromboembolic disease is a major cause of mortality and morbidity in the developed world and is caused by an excessive stimulation of coagulation. Thrombin is a key serine protease in the coagulation cascade and numerous efforts have been made to develop safe and effective orally active direct thrombin inhibitors (DTIs). Current anticoagulant therapy includes the use of indirect thrombin inhibitors (e.g., heparins, low-molecular-weight-heparins) and vitamin K antagonists such as warfarin. However there are several caveats in the clinical use of these agents including narrow therapeutic window, parenteral delivery, and food- and drug-drug interactions. Dabigatran is a synthetic, reversible DTI with high affinity and specificity for its target binding both free and clot-bound thrombin, and offers a favorable pharmacokinetic profile. Large randomized clinical trials have demonstrated that dabigatran provides comparable or superior thromboprophylaxis in multiple thromboembolic disease indications compared to standard of care. This minireview will highlight the discovery and development of dabigatran, the first in a class of new oral anticoagulant agents to be licensed worldwide for the prevention of thromboembolism in the setting of orthopedic surgery and stroke prevent in atrial fibrillation.
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Affiliation(s)
- Joanne van Ryn
- Department of CardioMetabolic Disease Research, Boehringer Ingelheim Pharma GmbH & Co. KGBiberach an der Riss, Baden-Württemberg, Germany
| | - Ashley Goss
- Department of CardioMetabolic Disease Research, Boehringer Ingelheim Pharmaceuticals Inc.Ridgefield, CT, USA
| | - Norbert Hauel
- Department of Medicinal Chemistry, Boehringer Ingelheim Pharma GmbH & Co. KGBiberach an der Riss, Baden-Württemberg, Germany
| | - Wolfgang Wienen
- Department of Respiratory Diseases Research, Boehringer Ingelheim Pharma GmbH & Co. KGBiberach an der Riss, Baden-Württemberg, Germany
| | - Henning Priepke
- Department of Medicinal Chemistry, Boehringer Ingelheim Pharma GmbH & Co. KGBiberach an der Riss, Baden-Württemberg, Germany
| | - Herbert Nar
- Department of Lead Identification and Optimization Support, Boehringer Ingelheim Pharma GmbH & Co. KGBiberach an der Riss, Baden-Württemberg, Germany
| | - Andreas Clemens
- Global Clinical Development and Medical Affairs, Boehringer Ingelheim Pharma GmbH & Co. KGIngelheim, Baden-Württemberg, Germany
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Pragst I, Zeitler SH, Doerr B, Kaspereit FJ, Herzog E, Dickneite G, van Ryn J. Reversal of dabigatran anticoagulation by prothrombin complex concentrate (Beriplex P/N) in a rabbit model. J Thromb Haemost 2012; 10:1841-8. [PMID: 22812619 DOI: 10.1111/j.1538-7836.2012.04859.x] [Citation(s) in RCA: 137] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND One limitation of the direct thrombin inhibitor dabigatran is the lack of specific antidotes that allow acute bleeding events to be managed or urgent interventional procedures performed. Prothrombin complex concentrates (PCCs) have served as a standard treatment for the reversal of coumarin anticoagulation. OBJECTIVES This study was designed to determine in an animal model whether a PCC (Beriplex P/N) can effectively reverse the effects of dabigatran. An additional objective was to evaluate markers of dabigatran-associated bleeding diathesis. METHODS Anesthetized rabbits were treated with 0.4 mg kg(-1) dabigatran followed by PCC doses of 20, 35 or 50 IU kg(-1) or placebo. After a standardized kidney incision, volume of blood loss and time to hemostasis were determined. RESULTS From an initial mean of 29 mL, blood loss progressively declined by 5.44 mL with a 95% confidence interval (CI) of 2.21-8.67 mL per 10 IU kg(-1) increment in PCC dose (P = 0.002). At a PCC dose of 50 IU kg(-1) blood loss was fully normalized. Increasing PCC doses shortened the median time to hemostasis from 20.0 to 5.7 min (P < 0.001). The rate of hemostasis was nearly trebled with each 10 IU kg(-1) increment in PCC dose (rate ratio, 2.89; CI, 1.64-5.09). CONCLUSIONS In this animal study, PCC showed potential as an agent for reversing the effects of dabigatran. Further investigation is warranted.
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Affiliation(s)
- I Pragst
- CSL Behring GmbH, Marburg Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany.
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Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e44S-e88S. [PMID: 22315269 PMCID: PMC3278051 DOI: 10.1378/chest.11-2292] [Citation(s) in RCA: 1026] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The objective of this article is to summarize the published literature concerning the pharmacokinetics and pharmacodynamics of oral anticoagulant drugs that are currently available for clinical use and other aspects related to their management. METHODS We carried out a standard review of published articles focusing on the laboratory and clinical characteristics of the vitamin K antagonists; the direct thrombin inhibitor, dabigatran etexilate; and the direct factor Xa inhibitor, rivaroxaban RESULTS The antithrombotic effect of each oral anticoagulant drug, the interactions, and the monitoring of anticoagulation intensity are described in detail and discussed without providing specific recommendations. Moreover, we describe and discuss the clinical applications and optimal dosages of oral anticoagulant therapies, practical issues related to their initiation and monitoring, adverse events such as bleeding and other potential side effects, and available strategies for reversal. CONCLUSIONS There is a large amount of evidence on laboratory and clinical characteristics of vitamin K antagonists. A growing body of evidence is becoming available on the first new oral anticoagulant drugs available for clinical use, dabigatran and rivaroxaban.
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Affiliation(s)
| | | | | | - Mark Crowther
- McMaster University, St. Joseph's Hospital, Hamilton, ON, Canada
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Zhou W, Schwarting S, Illanes S, Liesz A, Middelhoff M, Zorn M, Bendszus M, Heiland S, van Ryn J, Veltkamp R. Hemostatic Therapy in Experimental Intracerebral Hemorrhage Associated With the Direct Thrombin Inhibitor Dabigatran. Stroke 2011; 42:3594-9. [DOI: 10.1161/strokeaha.111.624650] [Citation(s) in RCA: 277] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background and Purpose—
Dabigatran-etexilate (DE) recently has been approved for stroke prevention in atrial fibrillation. However, lack of effective antagonists represents a major concern in the event of intracerebral hemorrhage (ICH). The aims of the present study were to establish a murine model of ICH associated with dabigatran, and to test the efficacy of different hemostatic factors in preventing hematoma growth.
Methods—
In C57BL/6 mice receiving DE (4.5 or 9.0 mg/kg), in vivo and in vitro coagulation assays and dabigatran plasma levels were measured repeatedly. Thirty minutes after inducing ICH by striatal collagenase injection, mice received an intravenous injection of saline, prothrombin complex concentrate (PCC; 100 U/kg), murine fresh-frozen plasma (200 μL), or recombinant human factor VIIa (8.0 mg/kg). ICH volume was quantified on brain cryosections 24 hours later.
Results—
DE substantially prolonged tail vein bleeding time and ecarin clotting time for 4 hours corresponding to dabigatran plasma levels. Intracerebral hematoma expansion was observed mainly during the first 3 hours on serial T2* MRI. Anticoagulation with high doses of DE increased the hematoma volume significantly. PCC and, less consistently, fresh-frozen plasma prevented excess hematoma expansion caused by DE, whereas recombinant human factor VIIa was ineffective. Prevention of hematoma growth and reversal of tail vein bleeding time by PCC were dose-dependent.
Conclusions—
The study provides strong evidence that PCC and, less consistently, fresh-frozen plasma prevent excess intracerebral hematoma expansion in a murine ICH model associated with dabigatran. The efficacy and safety of this strategy must be further evaluated in clinical studies.
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Affiliation(s)
- Wei Zhou
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Sönke Schwarting
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Sergio Illanes
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Arthur Liesz
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Moritz Middelhoff
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Markus Zorn
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Martin Bendszus
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Sabine Heiland
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Joanne van Ryn
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Roland Veltkamp
- From the Departments of Neurology (W.Z., S.S., S.I., A.L., M.M., R.V.), Internal Medicine-I (M.Z.), and Neuroradiology (M.B., S.H.), University Heidelberg, Germany; Boehringer Ingelheim Pharmaceuticals (J.v.R.), Ridgefield, CT; UTAC (S.I.), Hospital Clínico Universidad de Chile, Santiago, Chile
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Guay DRP. Dabigatran etexilate: a possible replacement for heparinoids and vitamin K antagonists? Hosp Pract (1995) 2011; 39:105-125. [PMID: 21441766 DOI: 10.3810/hp.2011.02.381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Dabigatran etexilate is the first oral anticoagulant to be approved in the United States in decades. It works directly by inhibiting clot-bound and free factor IIa (ie, thrombin) and indirectly by inhibiting platelet aggregation induced by thrombin. It is approved in the United States for stroke prophylaxis in nonvalvular atrial fibrillation. There is evidence to suggest that it is also effective for the treatment of acute venous thromboembolism and venous thromboembolism prophylaxis after knee and hip replacement surgery. Dabigatran etexilate therapy does not require laboratory monitoring, an advantage over warfarin. Unlike the earlier direct thrombin inhibitor, ximelagatran, it has demonstrated no potential for serious hepatotoxicity. It is also subject to a much lower degree of interpatient variability in dose response, has no diet-drug interactions, and has fewer clinically significant drug-drug interactions compared with warfarin. Dabigatran etexilate appears to be a valuable addition to our anticoagulant armamentarium.
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Affiliation(s)
- David R P Guay
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, Minneapolis, MN 55455, USA.
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Eisert WG, Hauel N, Stangier J, Wienen W, Clemens A, van Ryn J. Dabigatran: An Oral Novel Potent Reversible Nonpeptide Inhibitor of Thrombin. Arterioscler Thromb Vasc Biol 2010; 30:1885-9. [DOI: 10.1161/atvbaha.110.203604] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Dabigatran is a highly selective, reversible, and potent thrombin inhibitor and is orally available as the prodrug, dabigatran etexilate. It has shown antithrombotic efficacy in animal models of thrombosis, with a rapid onset of action and predictable pharmacodynamic response. Peak plasma concentrations of dabigatran occur 1 to 2 hours after ingestion of the prodrug. The terminal half-life of dabigatran is 12 to 14 hours in elderly volunteers. Dabigatran is not metabolized by cytochrome P450 isoenzymes and does not interact with food. Dabigatran has a low potential for drug-drug interactions and is predominantly renally excreted. Dabigatran etexilate as chronic therapy effectively prevents the recurrence of venous thromboembolism and cardioembolic stroke. For the first time, it has been demonstrated clinically that there may be an effective and safe alternative to warfarin.
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Affiliation(s)
- Wolfgang G. Eisert
- From the Clinical Development and Medical Affairs, Boehringer Ingelheim GmbH, Ingelheim, Germany (W.G.E., A.C.); Departments of Medicinal Chemistry (N.H.), Drug Metabolism and Pharmacokinetics (J.S.), Pulmonary Research (W.W.), Drug Discovery Support (J.v.R.), Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Norbert Hauel
- From the Clinical Development and Medical Affairs, Boehringer Ingelheim GmbH, Ingelheim, Germany (W.G.E., A.C.); Departments of Medicinal Chemistry (N.H.), Drug Metabolism and Pharmacokinetics (J.S.), Pulmonary Research (W.W.), Drug Discovery Support (J.v.R.), Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Joachim Stangier
- From the Clinical Development and Medical Affairs, Boehringer Ingelheim GmbH, Ingelheim, Germany (W.G.E., A.C.); Departments of Medicinal Chemistry (N.H.), Drug Metabolism and Pharmacokinetics (J.S.), Pulmonary Research (W.W.), Drug Discovery Support (J.v.R.), Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Wolfgang Wienen
- From the Clinical Development and Medical Affairs, Boehringer Ingelheim GmbH, Ingelheim, Germany (W.G.E., A.C.); Departments of Medicinal Chemistry (N.H.), Drug Metabolism and Pharmacokinetics (J.S.), Pulmonary Research (W.W.), Drug Discovery Support (J.v.R.), Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Andreas Clemens
- From the Clinical Development and Medical Affairs, Boehringer Ingelheim GmbH, Ingelheim, Germany (W.G.E., A.C.); Departments of Medicinal Chemistry (N.H.), Drug Metabolism and Pharmacokinetics (J.S.), Pulmonary Research (W.W.), Drug Discovery Support (J.v.R.), Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Joanne van Ryn
- From the Clinical Development and Medical Affairs, Boehringer Ingelheim GmbH, Ingelheim, Germany (W.G.E., A.C.); Departments of Medicinal Chemistry (N.H.), Drug Metabolism and Pharmacokinetics (J.S.), Pulmonary Research (W.W.), Drug Discovery Support (J.v.R.), Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
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Maegdefessel L, Spin JM, Azuma J, Tsao PS. New options with dabigatran etexilate in anticoagulant therapy. Vasc Health Risk Manag 2010; 6:339-49. [PMID: 20531953 PMCID: PMC2879296 DOI: 10.2147/vhrm.s8942] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Indexed: 02/01/2023] Open
Abstract
Thrombosis, the localized clotting of blood, occurs in both the arterial and venous circulation, and has a major impact on health outcomes. The primary etiology of myocardial infarctions, and approximately 80% of strokes, is acute arterial thrombosis. In combination this represents the most common cause of death in the Western world, while the third leading cause of cardiovascular-associated death is venous thromboembolism. An understanding of the pathogenic changes in the vessel wall and the blood that result in thrombosis is crucial for developing safer and more effective antithrombotic drugs. Dabigatran etexilate belongs to a new class of direct thrombin inhibitors. Following oral administration, dabigatran reaches peak plasma concentrations within 2 hours, shows linear pharmacokinetics, and a limited (but important) amount of direct drug interactions. Given once daily at 150 mg or 220 mg, it has proven to be competitive with enoxaparin in the prevention of venous thromboembolism after major orthopedic surgery, with a comparable safety profile. For stroke prevention in patients suffering from atrial fibrillation, dabigatran administered at a dose of 110 mg twice daily was associated with rates of stroke and systemic embolism that were similar to those associated with warfarin, as well as lower rates of hemorrhage. Dabigatran given at a dose of 150 mg twice daily, as compared with warfarin, was associated with lower rates of stroke and systemic embolism but similar rates of major hemorrhage. Oral bioavailability of dabigatran, together with a rapid onset and offset of action and predictable anticoagulation response, makes this newly available antithrombotic drug an attractive alternative to traditional anticoagulant therapies for numerous thrombosis-related indications.
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Affiliation(s)
- Lars Maegdefessel
- Department of Cardiovascular Medicine, Stanford University - School of Medicine, Stanford, CA 94305-5406, USA.
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Ammollo CT, Semeraro F, Incampo F, Semeraro N, Colucci M. Dabigatran enhances clot susceptibility to fibrinolysis by mechanisms dependent on and independent of thrombin-activatable fibrinolysis inhibitor. J Thromb Haemost 2010; 8:790-8. [PMID: 20088944 DOI: 10.1111/j.1538-7836.2010.03739.x] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anticoagulants are expected to promote fibrinolysis by counteracting the antifibrinolytic effects of thrombin, which include thrombin-activatable fibrinolysis inhibitor (TAFI) activation and clot structure enhancement. However, the efficiency of anticoagulants may vary remarkably, and the ability of direct thrombin inhibitors to facilitate clot lysis remains controversial. OBJECTIVE To evaluate the profibrinolytic effect of dabigatran, a new, direct thrombin inhibitor, using different in vitro models. METHODS AND RESULTS The resistance of tissue factor-induced plasma clots to fibrinolysis by exogenous tissue-type plasminogen activator (t-PA) (turbidimetric method) was reduced by dabigatran in a concentration-dependent manner, with > or = 50% shortening of lysis time at clinically relevant concentrations (1-2 microm). A similar effect was observed in the presence of low (0.1 and 1 nm) but not high (10 nm) concentrations of thrombomodulin. Acceleration of clot lysis by dabigatran was associated with a reduction in TAFI activation and thrombin generation, and was largely, although not completely, negated by an inhibitor of activated TAFI, potato tuber carboxypeptidase inhibitor. The assessment of the viscoelastic properties of clots showed that those generated in the presence of dabigatran were more permeable, were less rigid, and consisted of thicker fibers. The impact of these physical changes on fibrinolysis was investigated using a model under flow conditions, which demonstrated that dabigatran made the clots markedly more susceptible to flowing t-PA, by a mechanism that was largely TAFI-independent. CONCLUSIONS Dabigatran, at clinically relevant concentrations, enhances the susceptibility of plasma clots to t-PA-induced lysis by reducing TAFI activation and by altering the clot structure. These mechanisms might contribute to the antithrombotic activity of the drug.
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Affiliation(s)
- C T Ammollo
- Department of Biomedical Sciences and Human Oncology, Section of General and Experimental Pathology, University of Bari, Bari, Italy
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Cohen M. The thrombin hypothesis in ACS: a disappointing disconnect between bench data and bedside clinical trials. Am J Med 2010; 123:103-10. [PMID: 20103015 DOI: 10.1016/j.amjmed.2009.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Studies have demonstrated the efficacy and safety of unfractionated heparin and low-molecular-weight heparin in the management of patients with acute coronary syndrome. However, a common limitation of unfractionated heparin and low-molecular-weight heparin is that neither can neutralize clot-bound thrombin. To overcome this limitation of the broad heparin-based anticoagulants, novel anticoagulants targeted for both the free and clot-bound forms of thrombin (direct thrombin inhibitors), or other individual components of the coagulation cascade (eg, direct and indirect factor Xa inhibitors), were developed. These targeted anticoagulation agents showed promising results in preclinical testing and have been evaluated in large-scale clinical acute coronary syndrome trials. This review discusses the disconnect between the excellent preclinical findings obtained with these novel, targeted agents and the efficacy and safety data observed in patients with acute coronary syndrome, compared with the broader-range heparin-based anticoagulants.
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Affiliation(s)
- Marc Cohen
- Division of Cardiology, Newark Beth Israel Medical Center, Newark, NJ; Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA.
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Wong PC, Crain EJ, Watson CA, Xin B. Favorable therapeutic index of the direct factor Xa inhibitors, apixaban and rivaroxaban, compared with the thrombin inhibitor dabigatran in rabbits. J Thromb Haemost 2009; 7:1313-20. [PMID: 19500242 DOI: 10.1111/j.1538-7836.2009.03503.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Apixaban is an oral, direct factor Xa (FXa) inhibitor in late-stage clinical development. This study assessed effects of the direct FXa inhibitors, apixaban and rivaroxaban, vs. the direct thrombin inhibitor, dabigatran, on venous thrombosis (VT), bleeding time (BT) and clotting times in rabbits. METHODS We induced the formation of non-occlusive thrombus in VT models by placing threads in the vena cava, and induced bleeding by the incision of cuticles in anesthetized rabbits. Apixaban, rivaroxaban and dabigatran were infused IV to achieve a stable plasma level. Clotting times, including the activated partial thromboplastin time (aPTT), prothrombin time (PT), modified PT (mPT) and thrombin time (TT), were measured. RESULTS Apixaban, rivaroxaban and dabigatran exhibited dose-related efficacy in preventing VT with EC(50) of 65, 33 and 194 nm, respectively. At doses for 80% reduction of control thrombus, apixaban, rivaroxaban and dabigatran prolonged BT by 1.13 +/- 0.02-, 1.9 +/- 0.1-* and 4.4 +/- 0.4-fold*, respectively (*P < 0.05, vs. apixaban). In the treatment model, these inhibitors equally prevented growth of a preformed thrombus. Antithrombotic doses of apixaban and rivaroxaban prolonged aPTT and PT by <3-fold with no effect on TT. Dabigatran was > or = 50-fold more potent in prolonging TT than aPTT and PT. Of the clotting assays studied, apixaban, rivaroxaban and dabigatran responded the best to mPT. CONCLUSION Comparable antithrombotic efficacy was observed between apixaban, rivaroxaban and dabigatran in the prevention and treatment of VT in rabbits. Apixaban and rivaroxaban exhibited lower BT compared with dabigatran at equivalent antithrombotic doses. The clinical significance of these findings remains to be determined.
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Affiliation(s)
- P C Wong
- Thrombosis Research, Bristol-Myers Squibb Company, Pennington, NJ 08534, USA.
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Eriksson BI, Quinlan DJ, Weitz JI. Comparative Pharmacodynamics and Pharmacokinetics of Oral Direct Thrombin and Factor Xa Inhibitors in Development. Clin Pharmacokinet 2009; 48:1-22. [PMID: 19071881 DOI: 10.2165/0003088-200948010-00001] [Citation(s) in RCA: 363] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Bengt I Eriksson
- Orthopaedics Department, University Hospital Sahlgrenska/Ostra, Gothenburg, Sweden.
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Stangier J. Clinical pharmacokinetics and pharmacodynamics of the oral direct thrombin inhibitor dabigatran etexilate. Clin Pharmacokinet 2008; 47:285-95. [PMID: 18399711 DOI: 10.2165/00003088-200847050-00001] [Citation(s) in RCA: 455] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The direct thrombin inhibitor dabigatran etexilate is currently in phase III of development for the prophylaxis and treatment of thromboembolic disorders, with three trials completed in primary venous thromboembolism (VTE) prevention. Dabigatran etexilate is an orally administered prodrug, which is rapidly absorbed and converted to the active form, dabigatran. Dabigatran has been shown to specifically and reversibly inhibit thrombin, the key enzyme in the coagulation cascade. Studies in healthy volunteers and in patients undergoing orthopaedic surgery have indicated that dabigatran has a predictable pharmacokinetic/pharmacodynamic profile, allowing for a fixed-dose regimen. Peak plasma concentrations of dabigatran are reached approximately 2 hours after oral administration in healthy volunteers, with no unexpected accumulation of drug concentrations upon multiple dosing. Excretion is predominantly via the renal route as unchanged drug. Dabigatran is not metabolized by cytochrome P450 isoenzymes. The small differences in dabigatran pharmacokinetics associated with age and gender are attributed to variations in renal function. Additional studies have shown that the pharmacokinetic/pharmacodynamic profile of dabigatran is consistent across a range of patient populations, with no effect of moderate hepatic impairment being observed. Drug-drug interactions are not observed with concomitant administration of atorvastatin, diclofenac or digoxin. The pharmacodynamic profile of dabigatran demonstrates effective anticoagulation combined with a low risk of bleeding. Further phase III studies are ongoing, including acute VTE treatment and stroke prevention in atrial fibrillation; the results obtained so far show that dabigatran etexilate is well tolerated and effective in the treatment and prevention of thromboembolic events.
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New oral Xa and IIa inhibitors: updates on clinical trial results. J Thromb Thrombolysis 2007; 25:52-60. [PMID: 17965837 DOI: 10.1007/s11239-007-0108-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Accepted: 08/30/2007] [Indexed: 10/22/2022]
Abstract
Heparins and VKAs have been the cornerstones of anticoagulation therapy for several decades and these agents have become most important drugs in the primary and secondary prevention of venous and arterial thromboembolic disease. Although effective, their use has been hampered by numerous limitations. In the search for new agents matching the 'ideal' anticoagulant profile, a number of different steps in the coagulation cascade have been targeted, including direct thrombin inhibition, and direct inhibition of Factor Xa. There are currently a host of promising new agents at various stages of development and clinical evaluation. With potential benefits including predictable efficacy, rapid onset of action, ability to bind clot-bound coagulation factors and no requirement for therapeutic monitoring, these new agents are set to improve the management of thromboembolic disorders.
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