1
|
Jiang Y, Liu P, Qiu Z, Zhou M, Cheng M, Yang T. The U.S. FDA approved cardiovascular drugs from 2011 to 2023: A medicinal chemistry perspective. Eur J Med Chem 2024; 275:116593. [PMID: 38889609 DOI: 10.1016/j.ejmech.2024.116593] [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: 04/21/2024] [Revised: 06/01/2024] [Accepted: 06/09/2024] [Indexed: 06/20/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide. A total of 28 new molecular entities (NMEs) were approved by the U.S. Food and Drug Administration (FDA) for the treatment of cardiovascular diseases from 2011 to 2023. Approximately 25 % of the medications were sanctioned for the management of diverse vascular disorders. The other major therapeutic areas of focus included antilipemic agents (15 %), blood pressure disease (11 %), heart failure, hyperkalemia, and cardiomyopathy (7-8% each). Among all the approved drugs, there are a total of 22 new chemical entities (NCEs), including inhibitors, agonists, polymers, and inorganic compounds. In addition to NCEs, 6 biological agents (BLAs), including monoclonal antibodies, small interfering RNAs (siRNAs), and antisense oligonucleotides, have also obtained approval for the treatment of cardiovascular diseases. From this perspective, approved NCEs are itemized and discussed based on their disease, targets, chemical classes, major drug metabolites, and biochemical and pharmacological properties. Systematic analysis has been conducted to examine the binding modes of these approved drugs with their targets using cocrystal structure information or docking studies to provide valuable insights for designing next-generation agents. Furthermore, the synthetic approaches employed in the creation of these drug molecules have been emphasized, aiming to inspire the development of novel, efficient, and applicable synthetic methodologies. Generally, the primary objective of this review is to provide a comprehensive examination of the clinical applications, pharmacology, binding modes, and synthetic methodologies employed in small-molecule drugs approved for treating CVD. This will facilitate the development of more potent and innovative therapeutics for effectively managing cardiovascular diseases.
Collapse
Affiliation(s)
- Yunhan Jiang
- Laboratory of Human Diseases and Immunotherapy, West China Hospital, Sichuan University, Chengdu 610041, China; Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China; Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Pingxian Liu
- Laboratory of Human Diseases and Immunotherapy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Zhiqiang Qiu
- State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Meng Zhou
- Laboratory of Human Diseases and Immunotherapy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Mengdi Cheng
- Laboratory of Human Diseases and Immunotherapy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Tao Yang
- Laboratory of Human Diseases and Immunotherapy, West China Hospital, Sichuan University, Chengdu 610041, China; State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, Sichuan University, Chengdu, 610041, China.
| |
Collapse
|
2
|
Jannati S, Patnaik R, Banerjee Y. Beyond Anticoagulation: A Comprehensive Review of Non-Vitamin K Oral Anticoagulants (NOACs) in Inflammation and Protease-Activated Receptor Signaling. Int J Mol Sci 2024; 25:8727. [PMID: 39201414 PMCID: PMC11355043 DOI: 10.3390/ijms25168727] [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: 06/16/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 09/02/2024] Open
Abstract
Non-vitamin K oral anticoagulants (NOACs) have revolutionized anticoagulant therapy, offering improved safety and efficacy over traditional agents like warfarin. This review comprehensively examines the dual roles of NOACs-apixaban, rivaroxaban, edoxaban, and dabigatran-not only as anticoagulants, but also as modulators of inflammation via protease-activated receptor (PAR) signaling. We highlight the unique pharmacotherapeutic properties of each NOAC, supported by key clinical trials demonstrating their effectiveness in preventing thromboembolic events. Beyond their established anticoagulant roles, emerging research suggests that NOACs influence inflammation through PAR signaling pathways, implicating factors such as factor Xa (FXa) and thrombin in the modulation of inflammatory responses. This review synthesizes current evidence on the anti-inflammatory potential of NOACs, exploring their impact on inflammatory markers and conditions like atherosclerosis and diabetes. By delineating the mechanisms by which NOACs mediate anti-inflammatory effects, this work aims to expand their therapeutic utility, offering new perspectives for managing inflammatory diseases. Our findings underscore the broader clinical implications of NOACs, advocating for their consideration in therapeutic strategies aimed at addressing inflammation-related pathologies. This comprehensive synthesis not only enhances understanding of NOACs' multifaceted roles, but also paves the way for future research and clinical applications in inflammation and cardiovascular health.
Collapse
Affiliation(s)
- Shirin Jannati
- Yajnavalkaa Banerrji Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai Health, Dubai P.O. Box 505055, United Arab Emirates; (S.J.); (R.P.)
| | - Rajashree Patnaik
- Yajnavalkaa Banerrji Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai Health, Dubai P.O. Box 505055, United Arab Emirates; (S.J.); (R.P.)
| | - Yajnavalka Banerjee
- Yajnavalkaa Banerrji Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai Health, Dubai P.O. Box 505055, United Arab Emirates; (S.J.); (R.P.)
- Centre for Medical Education, University of Dundee, Dundee DD1 4HN, UK
| |
Collapse
|
3
|
Baradaran Bagheri A, Dehghani MJ, Aghajanian S. Safety and efficacy of apixaban vs. enoxaparin in thromboprophylaxis after spinal stenosis and degenerative spine surgery. Clin Neurol Neurosurg 2024; 239:108205. [PMID: 38471196 DOI: 10.1016/j.clineuro.2024.108205] [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: 12/01/2023] [Revised: 02/18/2024] [Accepted: 02/24/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Degenerative spine surgeries often require postoperative immobilization or reduced mobility, predisposing patients to the formation of thrombosis and higher risk of thromboembolic complications. Despite the significance of this issue, there remains a lack of consensus on the optimal anticoagulant agent for postoperative thromboprophylaxis in spinal stenosis and degenerative spine surgeries. Low molecular weight heparins and direct Xa inhibitors represent two anticoagulant groups with high chemoprophylactic potential. METHODS This study included a prospective cohort of patients undergoing posterior decompressive surgery with or without instrumentation for degenerative spine disease and/or spinal stenosis. Patients receiving postoperative prophylactic Enoxaparin and Apixaban were selected to evaluate the rate of complications, as assessed by Clavien-Dindo classification, thromboembolic events, and 30-day mortality, readmission, and reoperation rate between the two anticoagulants. RESULTS 130 patients were included in the analysis. 65 patients received Apixaban and Enoxaparin in each group. Mean age of the participants was 57.6±11.0. 83.1% underwent laminectomy and posterior spinal fusion, while 22 patients underwent decompressive surgery only. The incidence of venous thromboembolism (P-value=0.403), deep vein thrombosis (p-value=0.999), hematoma formation (p-value=0.403), surgical site infection (p-value=0.901), readmission (p-value=0.545), reoperation (p=0.510), mortality (p=0.648), and complications rate (p-value=0.232) were not statistically different between Enoxaparin and Apixaban. DISCUSSION Both Apixaban and Enoxaparin may be viable options for postoperative thromboprophylaxis in spine surgeries with comparable efficacy and safety profile. Future research endeavors should investigate the efficacy of these agents in comparison to placebo in a randomized setting.
Collapse
Affiliation(s)
- Ali Baradaran Bagheri
- Department of Neurosurgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran.
| | - Mohammad Javad Dehghani
- Department of Orthopedic Surgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran
| | - Sepehr Aghajanian
- Department of Neurosurgery, Shahid Madani Hospital, Alborz University of Medical Sciences, Karaj, Iran; Neuroscience Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
4
|
Kumano O, Suzuki S, Yamazaki M, An Y, Yasaka M, Ieko M. Age-related variation in coagulation factors in non-valvular atrial fibrillation patients receiving direct oral anticoagulants. Int J Hematol 2024; 119:407-415. [PMID: 38334914 DOI: 10.1007/s12185-024-03712-4] [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: 06/22/2023] [Revised: 01/07/2024] [Accepted: 01/11/2024] [Indexed: 02/10/2024]
Abstract
Age is a significant risk factor for ischemic stroke. However, the influence of aging on coagulation parameters in non-valvular atrial fibrillation (NVAF) patients treated with direct oral anticoagulants (DOACs) remains unclear. A total of 775 samples were collected from 224 NVAF patients receiving apixaban, edoxaban or rivaroxaban. The samples were categorized into three age groups: (i) ≤ 64 years, (ii) 65-74 years, and (iii) ≥ 75 years (apixaban: N = 48, 108, 119; edoxaban: N = 63, 68, 126; rivaroxaban: N = 115, 90, 38, respectively). Coagulation parameters including fibrinogen (Fbg), factor II, factor V, factor VII, factor X, and D-dimer, were compared between the three age groups for each drug. The slopes in the correlation between drug concentrations and modified diluted prothrombin time (mdPT) were also assessed. Fbg and factor V increased with age, while factor II and factor X decreased. Factor VII and D-dimer showed no significant differences across age categories. The slope in response to drug concentrations was similar between the age groups. In NVAF patients treated with apixaban, edoxaban and rivaroxaban, some coagulation parameters exhibited age-related variation. However, the response of mdPT to drug concentration was consistent across age categories.
Collapse
Affiliation(s)
- Osamu Kumano
- Sysmex Corporation, Kobe, Japan
- Health and Medical Research Institute, National Institute of Advanced Industrial Science and Technology (AIST), Takamatsu, Japan
| | - Shinya Suzuki
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Masako Yamazaki
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
- Department of Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yoshimori An
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Cardiology, Saiseikai Noe Hospital, Osaka, Japan
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
- Fukuoka Neurosurgical Hospital, Fukuoka, Japan
| | - Masahiro Ieko
- Department of Internal Medicine, School of Dentistry, Health Sciences University of Hokkaido, Ishikari-Tobetsu, Japan.
- Department of Nursing, Sapporo University of Health Sciences, 1-15, Nakanuma Nishi-4-2, Higashi-ku, Sapporo, Hokkaido, 007-0894, Japan.
| |
Collapse
|
5
|
Renda G, Bucciarelli V, Barbieri G, Lanuti P, Berteotti M, Malatesta G, Cesari F, Salvatore T, Giusti B, Gori AM, Marcucci R, De Caterina R. Ex Vivo Antiplatelet Effects of Oral Anticoagulants. J Cardiovasc Dev Dis 2024; 11:111. [PMID: 38667729 PMCID: PMC11049965 DOI: 10.3390/jcdd11040111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/27/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The impact of non-vitamin K antagonist oral anticoagulants (NOACs) on platelet function is still unclear. We conducted a comprehensive ex vivo study aimed at assessing the effect of the four currently marketed NOACs on platelet function. METHODS We incubated blood samples from healthy donors with concentrations of NOACs (50, 150 and 250 ng/mL), in the range of those achieved in the plasma of patients during therapy. We evaluated generation of thrombin; light transmittance platelet aggregation (LTA) in response to adenosine diphosphate (ADP), thrombin receptor-activating peptide (TRAP), human γ-thrombin (THR) and tissue factor (TF); generation of thromboxane (TX)B2; and expression of protease-activated receptor (PAR)-1 and P-selectin on the platelet surface. RESULTS All NOACs concentration-dependently reduced thrombin generation compared with control. THR-induced LTA was suppressed by the addition of dabigatran at any concentration, while TF-induced LTA was reduced by factor-Xa inhibitors. ADP- and TRAP-induced LTA was not modified by NOACs. TXB2 generation was reduced by all NOACs, particularly at the highest concentrations. We found a concentration-dependent increase in PAR-1 expression after incubation with dabigatran, mainly at the highest concentrations, but not with FXa inhibitors; P-selectin expression was not changed by any drugs. CONCLUSIONS Treatment with the NOACs is associated with measurable ex vivo changes in platelet function, arguing for antiplatelet effects beyond the well-known anticoagulant activities of these drugs. There are differences, however, among the NOACs, especially between dabigatran and the FXa inhibitors.
Collapse
Affiliation(s)
- Giulia Renda
- Department of Neuroscience, Imaging and Clinical Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Valentina Bucciarelli
- Cardiovascular Sciences Department, Azienda Ospedaliero-Universitaria delle Marche, 60121 Ancona, Italy;
| | - Giulia Barbieri
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Paola Lanuti
- Department of Medicine and Aging Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Martina Berteotti
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Gelsomina Malatesta
- Cardiology Unit, National Institute of Health and Science on Aging (INRCA), 64125 Ancona, Italy;
| | - Francesca Cesari
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Tanya Salvatore
- Department of Neuroscience, Imaging and Clinical Sciences and Center for Advanced Studies and Technology, G. d’Annunzio University Chieti-Pescara, 66100 Chieti, Italy;
| | - Betti Giusti
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Anna Maria Gori
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, 50121 Florence, Italy; (G.B.); (M.B.); (F.C.); (B.G.); (A.M.G.); (R.M.)
| | - Raffaele De Caterina
- Cardiology Division 1-Pisa University Hospital, University of Pisa, 56124 Pisa, Italy;
- Fondazione Villa Serena per la Ricerca, 37011 Città Sant’Angelo, Italy
| |
Collapse
|
6
|
Romagnoli A, Santoleri F, Costantini A, Di Risio A. Adherence, persistence and switching rates of apixaban, dabigatran and rivaroxaban in non-valvular atrial fibrillation: a multicentre real-life analysis at 3 years. Eur J Hosp Pharm 2024; 31:156-161. [PMID: 35961767 PMCID: PMC10895192 DOI: 10.1136/ejhpharm-2022-003338] [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: 04/04/2022] [Accepted: 08/02/2022] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Adherence to and persistence with long-term treatment with oral anticoagulants play a significant role in preventing adverse events and mortality in patients with cardiac conditions. The aim of this study was to evaluate the adherence, persistence and switching rate at 3 years in real-life patients with non-valvular atrial fibrillation receiving treatment with first-line new oral anticoagulants. METHODS The study assessed all patients treated with drugs with the ATC codes B01AA, B01AE, B01AF and dispensed in pharmacies in the Lanciano-Vasto-Chieti and Pescara Local Health Units from 1 January 2011 to 30 September 2021. Adherence was calculated as the proportion of days covered; persistence was calculated as the difference in days between the start and end of treatment; and the switching rate was calculated as the difference in days between the start of treatment and the switch. RESULTS A total of 4270 patients were analysed. The absolute adherence figure at 3 years was 0.85. The lowest adherence levels were found in patients treated with dabigatran with an absolute value of 0.72, while the highest levels were found in patients treated with rivaroxaban with an absolute value at 3 years of 0.88. The persistence curves at 3 years of treatment with dabigatran showed a statistically significant difference (p<0.0001) compared with those of rivaroxaban and apixaban. CONCLUSIONS The data collected over a 3-year period showed that adherence and persistence levels and switch data were optimal and comparable in patients with non-valvular atrial fibrillation receiving treatment with either rivaroxaban or apixaban. In contrast, patients treated with dabigatran had worrying adherence and persistence levels.
Collapse
Affiliation(s)
- Alessia Romagnoli
- Territorial Pharmaceutical Service, Local Health Unit Lanciano Vasto Chieti, Chieti, Italy
| | | | | | - Angelora Di Risio
- Territorial Pharmaceutical Service, Local Health Unit Lanciano Vasto Chieti, Chieti, Italy
| |
Collapse
|
7
|
Gaspar F, Terrier J, Favre S, Gosselin P, Fontana P, Daali Y, Lenoir C, Samer CF, Rollason V, Reny J, Csajka C, Guidi M. Population pharmacokinetics of apixaban in a real-life hospitalized population from the OptimAT study. CPT Pharmacometrics Syst Pharmacol 2023; 12:1541-1552. [PMID: 37723920 PMCID: PMC10583248 DOI: 10.1002/psp4.13032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 07/19/2023] [Accepted: 08/09/2023] [Indexed: 09/20/2023] Open
Abstract
This study aimed to characterize apixaban pharmacokinetics (PKs) and its variability in a real-world clinical setting of hospitalized patients using a population PK (PopPK) approach. Model-based simulations helped to identify factors that affect apixaban exposure and their clinical significance. A classic stepwise strategy was applied to determine the best PopPK model for describing typical apixaban PKs in hospitalized patients from the OptimAT study (n = 100) and evaluating the associated variability and influencing factors. Apixaban exposure under specific conditions was assessed using the final model. A two-compartment model with first-order absorption and elimination best described the data. The developed PopPK model revealed a major role of renal function and a minor role of P-glycoprotein phenotypic (P-gp) activity in explaining apixaban variability. The final model indicated that a patient with stage 4 chronic kidney disease (creatinine clearance [CLcr] = 15-29 mL/min) would have a 45% higher drug exposure than a patient with normal renal function (CLcr >90 mL/min), with a further 12% increase if the patient was also a poor metabolizer of P-gp. A high interindividual variability in apixaban PKs was observed in a real-life setting, which was partially explained by renal function and by P-gp phenotypic activity. Target apixaban concentrations are reached under standard dosage regimens, but overexposure can rapidly occur in the presence of cumulative factors warranting the development of a predictive tool for tailoring apixaban exposure and its clinical utility in at-risk patients.
Collapse
Affiliation(s)
- Frédéric Gaspar
- Center for Research and Innovation in Clinical Pharmaceutical SciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
- School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland
- Institute of Pharmaceutical Sciences of Western SwitzerlandUniversity of Geneva, University of LausanneGeneva, LausanneSwitzerland
| | - Jean Terrier
- Division of General Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
- Division of Clinical Pharmacology and Toxicology, Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine DepartmentGeneva University HospitalsGenevaSwitzerland
| | - Samantha Favre
- Center for Research and Innovation in Clinical Pharmaceutical SciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
- School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland
- Institute of Pharmaceutical Sciences of Western SwitzerlandUniversity of Geneva, University of LausanneGeneva, LausanneSwitzerland
| | - Pauline Gosselin
- Division of General Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Pierre Fontana
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
- Division of Angiology and HaemostasisGeneva University HospitalsGenevaSwitzerland
| | - Youssef Daali
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
- Division of Clinical Pharmacology and Toxicology, Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine DepartmentGeneva University HospitalsGenevaSwitzerland
| | - Camille Lenoir
- Division of Clinical Pharmacology and Toxicology, Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine DepartmentGeneva University HospitalsGenevaSwitzerland
| | - Caroline Flora Samer
- Division of Clinical Pharmacology and Toxicology, Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine DepartmentGeneva University HospitalsGenevaSwitzerland
- Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Victoria Rollason
- Division of Clinical Pharmacology and Toxicology, Anesthesiology, Pharmacology, Intensive Care, and Emergency Medicine DepartmentGeneva University HospitalsGenevaSwitzerland
- Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Jean‐Luc Reny
- Division of General Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Geneva Platelet Group, Faculty of MedicineUniversity of GenevaGenevaSwitzerland
| | - Chantal Csajka
- Center for Research and Innovation in Clinical Pharmaceutical SciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
- School of Pharmaceutical SciencesUniversity of GenevaGenevaSwitzerland
- Institute of Pharmaceutical Sciences of Western SwitzerlandUniversity of Geneva, University of LausanneGeneva, LausanneSwitzerland
| | - Monia Guidi
- Center for Research and Innovation in Clinical Pharmaceutical SciencesLausanne University Hospital and University of LausanneLausanneSwitzerland
- Institute of Pharmaceutical Sciences of Western SwitzerlandUniversity of Geneva, University of LausanneGeneva, LausanneSwitzerland
- Service of Clinical PharmacologyLausanne University Hospital and University of LausanneLausanneSwitzerland
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Gilyarevsky SR. Clinically Significant Drug Interactions for Direct Oral Anticoagulants: State of the Art. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-05-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The article is devoted to modern ideas about the role of drug interactions as a factor affecting the efficacy and safety of the use of direct oral anticoagulants (DOACs) in clinical practice. Data on drug interactions of apixaban, rivaroxaban and dabigatran with the drugs most frequently used in patients with cardiovascular diseases are given. Drug interactions for DOACs, depending on concomitant use of drugs that are inhibitors or inducers of the CYP3A4 enzyme or P-glycoprotein enzymes, are determined by most of the drug interactions of DOACs are considered. The results of studies in which drug interactions of DOACs were assessed by changes in indicators such as the area under the concentration-time curve and the maximum or minimum concentration of drugs in the blood are discussed. The data presented in the article may be useful for accounting for drug interactions in the treatment of patients with DOACs in clinical practice, despite the current lack of reasonable dose adjustment rules depending on the majority of such interactions. The data presented in the article suggest that apixaban has the fewest number of clinically significant interactions among the DOACs available in Russia.
Collapse
|
10
|
Wong PC, Crain E. Calibration and validation of the rabbit model of electrolytic-mediated arterial thrombosis against the standard-of-care anticoagulant apixaban. Pharmacol Res Perspect 2022; 10:e00963. [PMID: 35680619 PMCID: PMC9184285 DOI: 10.1002/prp2.963] [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: 02/20/2022] [Accepted: 04/22/2022] [Indexed: 11/25/2022] Open
Abstract
Apixaban is a factor Xa (FXa) inhibitor and standard‐of‐care anticoagulant with FXa Ki and plasma protein binding (free fraction) averages 0.08 nM and 0.13 in humans and 0.16 nM and 0.37 in rabbits, respectively. Apixaban at the approved dose of 5 mg BID achieved maximum and minimum plasma concentration of 373 nM (95% CI: 198 – 699 nM) and 224 nM (95% CI 89–501 nM), respectively, in patients with nonvalvular atrial fibrillation (AF). We calibrated the rabbit model of electrolytic‐mediated arterial thrombosis (ECAT) against apixaban and correlated the potencies derived from the rabbit ECAT to in vivo efficacious exposure levels in AF patients. Vehicle and apixaban at multiple doses were infused IV in ECAT rabbits and their effects on thrombus weight were measured. Apixaban exhibited dose‐related efficacy in preventing thrombosis in ECAT rabbits with EC20, EC50, EC60, EC70 and EC80 of 18, 101, 169, 296, and 585 nM, respectively. After correcting for the human‐to‐rabbit potency based on FXa Ki and plasma protein binding, we estimated a rabbit‐equally‐effective plasma concentration of 157 and 259 nM to the trough and peak plasma concentration in AF patients treated with 5 mg BID of apixaban. These rabbit‐equally‐effective plasma concentrations matched well with the rabbit ECAT EC60 and EC70. This study supports the potential of the rabbit ECAT to predict in vivo therapeutic drug exposure of FXa inhibitors. Achieving human‐equally‐effective plasma concentrations to the rabbit ECAT EC60 and EC70 may produce clinical efficacy in patient populations like AF.
Collapse
Affiliation(s)
- Pancras C Wong
- Cardiovascular & Fibrosis Drug Discovery Biology, Bristol Myers Squibb Company, Princeton, New Jersey, USA
| | - Earl Crain
- Cardiovascular & Fibrosis Drug Discovery Biology, Bristol Myers Squibb Company, Princeton, New Jersey, USA
| |
Collapse
|
11
|
Wong PC, Crain EJ, Bozarth JM, Wu Y, Dilger AK, Wexler RR, Ewing WR, Gordon D, Luettgen JM. Milvexian, an orally bioavailable, small-molecule, reversible, direct inhibitor of factor XIa: In vitro studies and in vivo evaluation in experimental thrombosis in rabbits. J Thromb Haemost 2022; 20:399-408. [PMID: 34752670 PMCID: PMC9299130 DOI: 10.1111/jth.15588] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/12/2021] [Accepted: 11/05/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Milvexian (BMS-986177/JNJ-70033093) is an orally bioavailable factor XIa (FXIa) inhibitor currently in phase 2 clinical trials. OBJECTIVES To evaluate in vitro properties and in vivo characteristics of milvexian. METHODS In vitro properties of milvexian were evaluated with coagulation and enzyme assays, and in vivo profiles were characterized with rabbit models of electrolytic-induced carotid arterial thrombosis and cuticle bleeding time (BT). RESULTS Milvexian is an active-site, reversible inhibitor of human and rabbit FXIa (Ki 0.11 and 0.38 nM, respectively). Milvexian increased activated partial thromboplastin time (APTT) without changing prothrombin time and potently prolonged plasma APTT in humans and rabbits. Milvexian did not alter platelet aggregation to ADP, arachidonic acid, or collagen. Milvexian was evaluated for in vivo prevention and treatment of thrombosis. For prevention, milvexian 0.063 + 0.04, 0.25 + 0.17, and 1 + 0.67 mg/kg+mg/kg/h preserved 32 ± 6*, 54 ± 10*, and 76 ± 5%* of carotid blood flow (CBF) and reduced thrombus weight by 15 ± 10*, 45 ± 2*, and 70 ± 4%*, respectively (*p < .05; n = 6/dose). For treatment, thrombosis was initiated for 15 min and CBF decreased to 40% of control. Seventy-five minutes after milvexian administration, CBF averaged 1 ± 0.3, 39 ± 10, and 66 ± 2%* in groups treated with vehicle and milvexian 0.25 + 0.17 and 1 + 0.67 mg/kg+mg/kg/h, respectively (*p < .05 vs. vehicle; n = 6/group). The combination of milvexian 1 + 0.67 mg/kg+mg/kg/h and aspirin 4 mg/kg/h intravenous did not increase BT versus aspirin monotherapy. CONCLUSIONS Milvexian is an effective antithrombotic agent with limited impact on hemostasis, even when combined with aspirin in rabbits. This study supports inhibition of FXIa with milvexian as a promising antithrombotic therapy with a wide therapeutic window.
Collapse
Affiliation(s)
- Pancras C. Wong
- Cardiovascular and Fibrosis Drug Discovery BiologyBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| | - Earl J. Crain
- Cardiovascular and Fibrosis Drug Discovery BiologyBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| | - Jeffrey M. Bozarth
- Cardiovascular and Fibrosis Drug Discovery BiologyBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| | - Yiming Wu
- Cardiovascular and Fibrosis Drug Discovery BiologyBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| | - Andrew K. Dilger
- Cardiovascular Drug Discovery ChemistryBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| | - Ruth R. Wexler
- Cardiovascular Drug Discovery ChemistryBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| | - William R. Ewing
- Cardiovascular Drug Discovery ChemistryBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| | - David Gordon
- Cardiovascular and Fibrosis Drug Discovery BiologyBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| | - Joseph M. Luettgen
- Cardiovascular and Fibrosis Drug Discovery BiologyBristol Myers Squibb CompanyPrincetonNew JerseyUSA
| |
Collapse
|
12
|
From basic science to life-saving therapy: the rationale, and drug discovery efforts that led to the direct factor Xa inhibitor eliquis. J Thromb Thrombolysis 2021; 52:403-407. [PMID: 34351559 DOI: 10.1007/s11239-021-02529-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
Over the past few decades, drug discovery directed at the treatment and prevention of thromboembolic diseases has been challenged by the need to balance robust efficacy with improved safety relative to the standard of care. To this end, the most impactful advance to date has been the discovery and development of oral factor Xa inhibitors. In this essay, a brief account of the program that culminated in the discovery of Eliquis (apixaban) and the commitment to identify a compound with an optimal profile are described.
Collapse
|
13
|
Herrera ND, Birschmann I, Wolny M, Papich MG, Brooks MB, Goggs R. Pharmacokinetics and Biologic Activity of Apixaban in Healthy Dogs. Front Vet Sci 2021; 8:702821. [PMID: 34291105 PMCID: PMC8287028 DOI: 10.3389/fvets.2021.702821] [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: 04/30/2021] [Accepted: 06/07/2021] [Indexed: 12/02/2022] Open
Abstract
Thrombosis is common in critically ill dogs and causes considerable morbidity and mortality. The direct factor Xa inhibitor apixaban is safe, efficacious, and convenient in humans. This study aimed to determine the pharmacokinetics (PK), bioactivity, protein binding, and bioavailability of apixaban following intravenous (IV) and oral (PO) administration to healthy dogs. Six healthy, adult, mixed-breed dogs were administered apixaban 0.18 mg/kg IV and then following a minimum 2-week washout period administered apixaban 0.2 mg/kg PO. Dogs were monitored using an apixaban-calibrated anti-Xa bioassay, prothrombin time (PT) and activated partial thromboplastin time (aPTT) and tissue-factor thromboelastography (TF-TEG). Plasma apixaban concentrations were measured using liquid chromatography-tandem mass spectrometry. Concentration-time plots were constructed, and PK modeling performed using compartmental methods. Administration of IV and PO apixaban was well-tolerated. Following IV administration, mean half-life was 4.1 h, and volume of distribution was 177 ml/kg. Apixaban was highly protein bound (98.6%). Apixaban concentrations and anti-Xa activity were highly correlated (R2 0.994, P < 0.0001). Intravenous apixaban significantly prolonged PT at time points up to 1 h, and aPTT at time points up to 0.25 h post-administration. Coagulation times were positively correlated with apixaban concentrations (PT R2 0.599, P < 0.0001; aPTT R2 0.430, P < 0.0001) and TF-TEG R-time was significantly prolonged 0.25 h post-administration. Following oral administration, mean bioavailability was 28.4%, lag time was 2 h, time to Cmax was 5 h and the apparent elimination half-life was 3.1 h. Oral apixaban significantly prolonged PT at 4, 6, and 8 h but aPTT and TF-TEG were not consistently affected by oral apixaban. Apixaban concentrations are best monitored using anti-Xa activity. Future studies should determine PK and bioactivity of other doses using commercial tablets and following multidose administration and establish safe, effective dosing ranges in sick dogs.
Collapse
Affiliation(s)
- Noelle D. Herrera
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY, United States
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Monika Wolny
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | - Mark G. Papich
- Department of Molecular Biomedical Sciences, North Carolina State College of Veterinary Medicine, Raleigh, NC, United States
| | - Marjory B. Brooks
- Department of Population Medicine and Diagnostic Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY, United States
| | - Robert Goggs
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, NY, United States
| |
Collapse
|
14
|
Quintal Martínez JP, Segura Campos MR. Cnidoscolus Aconitifolius (Mill.) I.M. Johnst.: A Food Proposal Against Thromboembolic Diseases. FOOD REVIEWS INTERNATIONAL 2021. [DOI: 10.1080/87559129.2021.1934002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
15
|
Wong PC, Quan ML. Improved efficacy/safety profile of factor XIa inhibitor BMS-724296 versus factor Xa inhibitor apixaban and thrombin inhibitor dabigatran in cynomolgus monkeys. Res Pract Thromb Haemost 2021; 5:e12524. [PMID: 34095733 PMCID: PMC8162232 DOI: 10.1002/rth2.12524] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 12/31/2022] Open
Abstract
Background Inhibition of activated factor XI (FXIa) is a promising antithrombotic drug target. BMS-724296 is a selective, reversible, small-molecule inhibitor of human FXIa (Ki 0.3 nM). Objectives This study assessed effects of BMS-724296 versus standard-of-care oral anticoagulants apixaban (activated factor X inhibitor) and dabigatran (thrombin inhibitor) on arterial thrombosis, kidney bleeding time (KBT), and clotting time (CT) in nonhuman primate (NHP) cynomolgus monkey models. Methods Carotid artery thrombosis was produced by electrical stimulation in anesthetized NHPs. Hemostasis was assessed with a provoked KBT model. Thrombosis, KBT, and CT were monitored. Vehicle and various doses of BMS-724296, apixaban, and dabigatran were administered as bolus (intravenous [i.v.]) followed by infusion starting 30 minutes before initiation of thrombosis and continued until the experiment's end (n = 3-8/group). Primary end points included thrombus weight reduction (TWR), KBT, and CT (activated partial thromboplastin time [aPTT], prothrombin time [PT], and thrombin time [TT]). Results BMS-724296 at 0.025 + 0.05, 0.05 + 0.1, 0.102 + 0.2, and 0.4 + 0.8 mg/kg+mg/kg/h i.v. (bolus + infusion) reduced thrombus weight by 0 ± 0, 35 ± 7*, 72 ± 4*, and 86 ± 4%*, respectively (*P < .05 vs vehicle; n = 5-6/group). BMS-724296 at the highest dose (0.4 + 0.8 mg/kg+mg/kg/h) did not increase KBT compared to vehicle (109 ± 6 vs 113 ± 20 seconds, respectively) and increased ex vivo aPTT by 2.9 ± 0.1-fold without changing PT and TT. In companion NHP studies, high doses of apixaban and dabigatran produced similar TWR as BMS-724296, but increased KBT 4.3 ± 0.5-fold and 5.8 ± 0.5-fold, respectively (n = 3-4/group). Conclusions BMS-724296 produced similar antithrombotic efficacy as apixaban and dabigatran but with no increase in KBT in NHPs. These findings suggest that FXIa inhibitors may provide safe and effective antithrombotic therapy.
Collapse
Affiliation(s)
- Pancras C Wong
- Cardiovascular & Fibrosis Drug Discovery Biology Bristol Myers Squibb Princeton NJ USA
| | - Mimi L Quan
- Cardiovascular & Fibrosis Drug Discovery Biology Bristol Myers Squibb Princeton NJ USA
| |
Collapse
|
16
|
Cocrystal of Apixaban-Quercetin: Improving Solubility and Bioavailability of Drug Combination of Two Poorly Soluble Drugs. Molecules 2021; 26:molecules26092677. [PMID: 34063645 PMCID: PMC8124247 DOI: 10.3390/molecules26092677] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/17/2022] Open
Abstract
Drug combinations have been the hotspot of the pharmaceutical industry, but the promising applications are limited by the unmet solubility and low bioavailability. In this work, novel cocrystals, consisting of two antithrombotic drugs with poor solubility and low bioavailability in vivo, namely, apixaban (Apx) and quercetin (Que), were developed to discover a potential method to improve the poor solubility and internal absorption of the drug combination. Compared with Apx, the dissolution behavior of Apx–Que (1:1) and Apx–Que–2ACN (1:1:2) was enhanced significantly, while the physical mixture of the chemicals failed to exhibit the advantages. The dissolution improvements of Apx–Que–2ACN could be explained by the fact that the solid dispersion-like structure and column-shaped cage of Que accelerated the access of the solvent to the inner layer of Apx. The fracture of the hydrogen bonds of Apx, which was the joint of the adjacent Que chains, facilitated the break-up of the structures. Besides, the bioavailability of Apx–Que was increased compared with the physical mixture and Apx, and Apx–Que remained stable in high temperature and illumination conditions. Therefore, a drug–drug cocrystal of two antithrombotic agents with poor solubility was developed, which exhibited greatly improved solubility, bioavailability and superior stability, indicating a novel method to overcome the shortages of drug combination.
Collapse
|
17
|
Grimaldi G, Ancona D, Tricarico D, Stella P, Procacci C, Germinario A, Bavaro V, Montanaro V, Delle Donne A. Analysis of the Introduction in Clinical Practice of New Oral Anticoagulants in Local Health Agency BT: Translation of the Clinical Trial Data to a Local Health Care Area. Pharmaceutics 2021; 13:pharmaceutics13020252. [PMID: 33670408 PMCID: PMC7918324 DOI: 10.3390/pharmaceutics13020252] [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: 12/16/2020] [Revised: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 11/16/2022] Open
Abstract
The commercial release of the New Oral Anticoagulants (NOACs) has been the most significant change in anticoagulant therapy in recent years. The work aimed to evaluate the economic and health impact for the Local Health Agency Barletta-Andria-Trani (BT). Through the Regional Information System data about naïve patients on NOAC treatment and patients on anti-vitamin-k (VKA), treatments were extrapolated. We assessed therapeutic continuity, pharmaceutical expenditure, hospitalizations, and deaths in 2017 and 2018. Therapeutic continuity was similar in the two groups. The number and the average cost of hospitalizations for a patient treated with VKAs were almost constant, while those of patients treated with NOACs decreased. The treatment of adult-aged naïve patients with NOACs, compared to VKAs therapy, involves an increase in expenditure of about 100€ for a patient, but the reduced hospitalizations could generate, in the long term, saving for the Health System. Clinical data, according to the Real-World Data, confirmed the safety and effectiveness of these drugs. However, attention to the special population is necessary to improve the safety and effectiveness of NOACs. Innovative formulations for pediatric patients are being developed. The challenge for Health Systems is the appropriate use of available resources through health interventions with transversal competences.
Collapse
Affiliation(s)
- Gianluca Grimaldi
- Local Health Agency BT, via Fornaci 201, 76123 Andria, Italy; (G.G.); (C.P.); (A.G.); (A.D.D.)
| | - Domenica Ancona
- Local Health Agency BT, via Fornaci 201, 76123 Andria, Italy; (G.G.); (C.P.); (A.G.); (A.D.D.)
- Correspondence: ; Tel.: +39-0883-483516
| | - Domenico Tricarico
- Department of Pharmacy-Pharmaceutical Sciences, University Aldo Moro, via Orabona 4, 70125 Bari, Italy;
| | - Paolo Stella
- Department for the Promotion of Health, Social Welfare and Sport for All, via Gentile 52, 70126 Bari, Italy; (P.S.); (V.B.); (V.M.)
| | - Cataldo Procacci
- Local Health Agency BT, via Fornaci 201, 76123 Andria, Italy; (G.G.); (C.P.); (A.G.); (A.D.D.)
| | - Antonio Germinario
- Local Health Agency BT, via Fornaci 201, 76123 Andria, Italy; (G.G.); (C.P.); (A.G.); (A.D.D.)
| | - Vito Bavaro
- Department for the Promotion of Health, Social Welfare and Sport for All, via Gentile 52, 70126 Bari, Italy; (P.S.); (V.B.); (V.M.)
| | - Vito Montanaro
- Department for the Promotion of Health, Social Welfare and Sport for All, via Gentile 52, 70126 Bari, Italy; (P.S.); (V.B.); (V.M.)
| | - Alessandro Delle Donne
- Local Health Agency BT, via Fornaci 201, 76123 Andria, Italy; (G.G.); (C.P.); (A.G.); (A.D.D.)
| |
Collapse
|
18
|
Edoxaban, a direct oral factor Xa inhibitor, ameliorates coagulation, microvascular thrombus formation, and acute liver injury in a lipopolysaccharide-induced coagulopathy model in rats. J Thromb Thrombolysis 2021; 52:9-17. [PMID: 33534029 PMCID: PMC7856452 DOI: 10.1007/s11239-021-02381-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 11/29/2022]
Abstract
Infection increases the risk of thrombosis through the activation of inflammation and coagulation. Edoxaban, a direct oral factor Xa inhibitor, is used for the prevention and treatment of thrombotic diseases. The aim of this study was to determine the effects of edoxaban on microvascular thrombus formation in a rat model of lipopolysaccharide (LPS)-induced coagulopathy. Rats were intravenously injected with 7.5 mg/kg of LPS (Escherichia coli 055:B5). Immediately after LPS injection, the rats were treated with subcutaneous injection of edoxaban. At 2 and 6 h after the injection of LPS, biomarkers of coagulation and organ damages and inflammatory cytokines were measured. Microvascular thrombus formation in organs was evaluated using 125I-fibrinogen (human) or by the pathological analysis. Mortality was examined 24 h after LPS injection. After the injection of LPS, D-dimer and thrombin-antithrombin complex increased and platelet numbers decreased, indicating the activation of coagulation. Microvascular thrombi were found in the liver. Markers of liver injury (aspartate aminotransferase and alanine aminotransferase) also increased. Treatment with edoxaban attenuated the changes in the coagulation markers and microvascular thrombus formation in the liver. Edoxaban suppressed the increase in the liver injury markers and reduced the mortality. Edoxaban did not affect the levels of inflammatory cytokines. In conclusions, edoxaban significantly inhibited the activation of coagulation, the formation of microvascular thrombus in the liver and the liver damage, and reduced mortality in rats injected with LPS. These results suggest that the FXa inhibition by edoxaban might be a beneficial therapy for the management of infection-associated thrombosis.
Collapse
|
19
|
Ieko M, Ohmura K, Naito S, Yoshida M, Sakuma I, Ikeda K, Ono S, Suzuki T, Takahashi N. Novel assay based on diluted prothrombin time reflects anticoagulant effects of direct oral factor Xa inhibitors: Results of multicenter study in Japan. Thromb Res 2020; 195:158-164. [PMID: 32707358 DOI: 10.1016/j.thromres.2020.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/08/2020] [Accepted: 07/08/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Direct oral anticoagulants targeting factor Xa (DXaIs) are administered as prophylaxis for various venothrombotic diseases without routine monitoring required. However, assessment of their anticoagulant effects is necessary to prevent severe events, including major bleeding and/or refractory thrombosis. OBJECTIVES We examined the correlation of ratio of inhibited thrombin generation (RITG), determined using a novel assay based on dilute prothrombin time (dPT), with coagulant markers and laboratory test results to show drug effects. In addition, RITG usefulness as a confirmation test for DXaI therapy was investigated. METHODS Citrated plasma samples were obtained from patients treated with rivaroxaban (n = 882), apixaban (n = 1214), or edoxaban (n = 820) at 4 different institutions in Japan. Laboratory tests, including prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, and plasma concentrations of DXaIs, were conducted, with drug concentrations divided into peak and trough groups, within and after 5 h of administration. RESULTS In each DXaI group, RITG was positively correlated with PT, APTT, and drug concentration, and negatively with D-dimer. RITG fluctuation during the peak and trough periods reflected the anticoagulant activity characteristic of each DXaI, which was different from blood concentration fluctuations. RITG showed a significant decrease in cases with thrombosis, while that was increased in those with hemorrhage. CONCLUSION We developed RITG, a novel measurement method based on dPT. RITG represents residual coagulation ability in plasma samples, and is useful for assessment of bleeding and thrombotic tendencies in DXaI patients. RITG can be utilized to confirm the effectiveness of oral anticoagulation therapy with DXaI agents.
Collapse
Affiliation(s)
- Masahiro Ieko
- Department of Internal Medicine, Health Sciences University of Hokkaido, Hokkaido, Japan; Department of Clinical Laboratory, Iwate Prefectural Chubu Hospital, Iwate, Japan.
| | - Kazumasa Ohmura
- Department of Internal Medicine, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Sumiyoshi Naito
- Department of Clinical Laboratory, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Mika Yoshida
- Department of Clinical Laboratory, Health Sciences University of Hokkaido, Hokkaido, Japan
| | - Ichiro Sakuma
- Cardiovascular Medicine, Caress Sapporo Hokko Memorial Clinic, Hokkaido, Japan
| | - Kozue Ikeda
- Cardiovascular Medicine, Shinoda General Hospital, Yamagata, Japan
| | - Shouko Ono
- Division of Endoscopy, Hokkaido University Hospital, Hokkaido, Japan
| | | | - Nobuhiko Takahashi
- Department of Internal Medicine, Health Sciences University of Hokkaido, Hokkaido, Japan
| |
Collapse
|
20
|
Foerster KI, Hermann S, Mikus G, Haefeli WE. Drug-Drug Interactions with Direct Oral Anticoagulants. Clin Pharmacokinet 2020; 59:967-980. [PMID: 32157630 PMCID: PMC7403169 DOI: 10.1007/s40262-020-00879-x] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A large body of evidence suggests that not only direct anticoagulant effects but also major bleeding events and stroke prevention depend on plasma concentrations of direct oral anticoagulants (DOACs). Concomitant drugs that cause drug–drug interactions (DDIs) alter DOAC exposure by increasing or decreasing DOAC bioavailability and/or clearance; hence, they might affect the efficacy and safety of DOAC therapy. Patients with renal impairment already receive smaller DOAC maintenance doses because avoidance of elevated DOAC exposure might prevent serious bleeding events. For other causes of increased exposure such as DDIs, management is often less well-defined. Considering that DOAC patients are often older and have multiple co-morbidities, polypharmacy is highly prevalent. However, the effect of multiple drugs on DOAC exposure, and especially the impact of DDIs when concurring with drug–disease interactions as observed in renal impairment, has not been thoroughly elucidated. In order to provide effective and safe anticoagulation with DOACs, understanding the mechanisms and magnitude of DDIs appears relevant. Instead of avoiding drug combinations with DOACs, more DDI trials should be conducted and new strategies such as dose adjustments based on therapeutic drug monitoring should be investigated. However, dose adjustments based on concentration measurements cannot currently be recommended because evidence-based data are missing.
Collapse
Affiliation(s)
- Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Simon Hermann
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Gerd Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| |
Collapse
|
21
|
Koehl JL, Hayes BD, Al‐Samkari H, Rosovsky R. A comprehensive evaluation of apixaban in the treatment of venous thromboembolism. Expert Rev Hematol 2020; 13:155-173. [DOI: 10.1080/17474086.2020.1711731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Jennifer L Koehl
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Bryan D. Hayes
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
| | - Hanny Al‐Samkari
- Division of Hematology & Oncology, Department of Medicine, Massachusetts Hospital, Boston, MA, USA
| | - Rachel Rosovsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts Hospital, Boston, MA, USA
| |
Collapse
|
22
|
A multi-national trial of a direct oral anticoagulant in children with cardiac disease: Design and rationale of the Safety of ApiXaban On Pediatric Heart disease On the preventioN of Embolism (SAXOPHONE) study. Am Heart J 2019; 217:52-63. [PMID: 31493728 DOI: 10.1016/j.ahj.2019.08.002] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/01/2019] [Indexed: 12/16/2022]
Abstract
Anticoagulation in children is problematic for multiple reasons. Currently used anticoagulants have significant disadvantages and may negatively affect quality of life (QOL). This manuscript describes the design, rationale, and methods of a prospective, randomized, open label phase II multi-national clinical trial of a direct oral anticoagulant (DOAC), apixaban, in children and infants with congenital and acquired heart disease. This trial is designed to gather preliminary safety and pharmacokinetics (PK) data, as well as generate data on QOL of individuals taking apixaban compared to the standard of care (SOC) anticoagulants vitamin K antagonists (VKA) or low molecular weight heparin (LMWH). A key issue this trial seeks to address is the practice of using therapeutics tested in adult trials in the pediatric population without robust pediatric safety or efficacy data. Pediatric heart diseases are not common, and specific diagnoses often meet the criteria of a rare disease; thus, statistical efficacy may be difficult to achieve. This trial will provide valuable PK and safety data intended to inform clinical practice for anticoagulation in pediatric heart diseases, a setting in which a fully powered phase III clinical trial is not feasible. A second consideration this trial addresses is that metrics besides efficacy, such as QOL, have not been traditionally used as endpoints in regulated anticoagulation studies yet may add substantial weight to the clinical decision for use of a DOAC in place of VKA or LMWH. This study examines QOL related to both heart disease and anticoagulation among children randomized to either SOC or apixaban. There are considerable strengths and benefits to conducting a clinical trial in pediatric rare disease populations via an industry-academic collaboration. The SAXOPHONE study represents a collaboration between Bristol-Myers Squibb (BMS)/Pfizer Alliance, and the National Heart, Lung, and Blood Institute's (NHLBI) Pediatric Heart Network (PHN) and may be an attractive model for future pediatric drug trials.
Collapse
|
23
|
Núñez-Navarro NE, Santana FM, Parra LP, Zacconi FC. Surfing the Blood Coagulation Cascade: Insight into the Vital Factor Xa. Curr Med Chem 2019; 26:3175-3200. [PMID: 29376487 DOI: 10.2174/0929867325666180125165340] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 12/28/2017] [Accepted: 01/11/2018] [Indexed: 01/19/2023]
Abstract
Factor Xa (FXa) plays a key role in haemostasis, it is a central part of the blood coagulation cascade which catalyzes the production of thrombin and leads to clot formation and wound closure. Therefore, FXa is an attractive target for the development of new anticoagulant agents. In this review, we will first describe the molecular features of this fundamental protein in order to understand its mechanism of action, an essential background for the design of novel inhibitors by means of synthetic organic chemistry or using peptides obtained from recombinant methodologies. Then, we will review the current state of the synthesis of novel direct FXa inhibitors along with their mechanisms of action. Finally, approved reversal agents that aid in maintaining blood haemostasis by using these commercial drugs will also be discussed.
Collapse
Affiliation(s)
- Nicolás E Núñez-Navarro
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Department of Chemical and Bioprocesses Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Fabián M Santana
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Loreto P Parra
- Department of Chemical and Bioprocesses Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Flavia C Zacconi
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Research Center for Nanotechnology and Advanced Materials "CIEN-UC", Pontificia Universidad Catolica de Chile, Santiago, Chile
| |
Collapse
|
24
|
Huppertz A, Grond-Ginsbach C, Dumschat C, Foerster KI, Burhenne J, Weiss J, Czock D, Purrucker JC, Rizos T, Haefeli WE. Unexpected excessive apixaban exposure: case report of a patient with polymorphisms of multiple apixaban elimination pathways. BMC Pharmacol Toxicol 2019; 20:53. [PMID: 31464657 PMCID: PMC6716843 DOI: 10.1186/s40360-019-0331-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/23/2019] [Indexed: 12/22/2022] Open
Abstract
Background Apixaban effectively lowers the risk of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation. Systemic exposure to a given apixaban dose depends on multiple clearance pathways. Though routine quantification of direct oral anticoagulants (DOACs) in neurological emergency situations has not been widely established, suspected associations of DOAC peak concentrations with bleeding events and DOAC trough concentrations with efficacy and safety suggest that such information might support clinical decision making. Case presentation We describe the case of a 75 year-old woman with atrial fibrillation maintained on apixaban who was admitted due to suspected acute stroke. Clinical work-up did not confirm ischemic or hemorrhagic stroke but routine quantification of apixaban revealed an excessively high apixaban plasma concentration (~ 3 h after the last drug intake: 1100 ng/ml (expected range: 91–321 ng/ml); ~ 12 h after drug intake: 900 ng/ml (expected range: 41–230 ng/ml)) and a substantially prolonged elimination half-life (~ 31 h). The corresponding apixaban concentration-to-dose ratio was 9900 (ng/ml)/(mg/kg/d) and 8100 (ng/ml)/(mg/kg/d), respectively (expected range: 249–463 (ng/ml)/(mg/kg/d)). Renal function was only moderately impaired (creatinine 1.36 mg/dl (0.5–1.1 mg/dl), creatinine clearance 40 ml/min). Genotype analyses revealed that the patient was a CYP3A5*3/*3 non-expressor, a heterozygous carrier of the ABCG2 c.421C/A alleles, and a homozygous carrier of ABCB1 c.2677 T/T and ABCB1 c.3435 T/T. In the absence of known drug interactions explaining apixaban clearance impairment, excessive apixaban concentrations were most probably caused by moderate renal impairment combined with multiple functional polymorphisms of apixaban clearance pathways. Conclusions This case suggests that concurrent genetic polymorphisms can impair multiple apixaban elimination pathways and thus substantially increase its exposure.
Collapse
Affiliation(s)
- Andrea Huppertz
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Caspar Grond-Ginsbach
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.,Department of Vascular and Endovascular Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Chris Dumschat
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Kathrin I Foerster
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jürgen Burhenne
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Johanna Weiss
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - David Czock
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Timolaos Rizos
- Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Walter E Haefeli
- Department of Clinical Pharmacology and Pharmacoepidemiology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| |
Collapse
|
25
|
Papadaki S, Tselepis AD. Nonhemostatic Activities of Factor Xa: Are There Pleiotropic Effects of Anti-FXa Direct Oral Anticoagulants? Angiology 2019; 70:896-907. [PMID: 31010298 DOI: 10.1177/0003319719840861] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Factor Xa (FXa) is the key serine protease of the coagulation cascade as it is the point of convergence of the intrinsic and extrinsic pathways, leading to the formation of thrombin. Factor Xa is an established target of anticoagulation therapy, due to its central role in coagulation. Over the past years, several direct oral anticoagulants (DOACs) targeting FXa have been developed. Rivaroxaban, apixaban, and edoxaban are used in clinical practice for prevention and treatment of thrombotic diseases. Increasing evidence suggests that FXa exerts nonhemostatic cellular effects that are mediated mainly through protease-activated receptors-1 and -2 and are involved in pathophysiological conditions, such as atherosclerosis, inflammation, and fibrosis. Direct inhibition of FXa by DOACs could be beneficial in these conditions. This is a narrative review that focuses on the cellular effects of FXa in various cell types and conditions, as well as on the possible pleiotropic effects of FXa-targeting DOACs.
Collapse
Affiliation(s)
- Styliani Papadaki
- 1 Department of Chemistry, Atherothrombosis Research Centre/Laboratory of Biochemistry, University of Ioannina, Ioannina, Greece
| | - Alexandros D Tselepis
- 1 Department of Chemistry, Atherothrombosis Research Centre/Laboratory of Biochemistry, University of Ioannina, Ioannina, Greece
| |
Collapse
|
26
|
Blais MC, Bianco D, Goggs R, Lynch AM, Palmer L, Ralph A, Sharp CR. Consensus on the Rational Use of Antithrombotics in Veterinary Critical Care (CURATIVE): Domain 3-Defining antithrombotic protocols. J Vet Emerg Crit Care (San Antonio) 2019; 29:60-74. [PMID: 30654416 DOI: 10.1111/vec.12795] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/10/2018] [Accepted: 12/08/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES To systematically examine the evidence for use of a specific protocol (dose, frequency, route) of selected antithrombotic drugs, in comparisons to no therapy or to other antithrombotic therapies, to reduce the risk of complications or improve outcomes in dogs and cats at risk for thrombosis. DESIGN Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence (LOE) and quality (Good, Fair, or Poor), and development of consensus on conclusions via a Delphi-style survey for application of the concepts to clinical practice. SETTINGS Academic and referral veterinary medical centers. RESULTS Databases searched included Medline via PubMed and CAB abstracts. Eight different antithrombotic drugs were investigated using a standardized Patient, Intervention, Comparison, Outcome (PICO) question format both for dogs and cats, including aspirin, clopidogrel, warfarin, unfractionated heparin (UFH), dalteparin, enoxaparin, fondaparinux, and rivaroxaban, generating a total of 16 worksheets. Most studies identified were experimental controlled laboratory studies in companion animals (LOE 3) with only four randomized controlled clinical trials in companion animals (LOE 1). CONCLUSIONS Overall, evidence-based recommendations concerning specific protocols could not be formulated for most antithrombotic drugs evaluated, either because of the wide range of dosage reported (eg, aspirin in dogs) or the lack of evidence in the current literature. However, clopidogrel administration in dogs and cats at risk of arterial thrombosis, notably in cats at risk of cardiogenic thromboembolism, is supported by the literature, and specific protocols were recommended. Comparably, aspirin should not be used as a sole antithrombotic in cats with cardiomyopathy. Using the available safety profile information contained in the literature, the panel reached consensus on suggested dosage schemes for most antithrombotics. Significant knowledge gaps were highlighted, which will hopefully drive novel research.
Collapse
Affiliation(s)
- Marie-Claude Blais
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Université de Montréal, St-Hyacinthe, Quebec, Canada
| | - Domenico Bianco
- Internal Medicine Department, Metropolitan Animal Specialty Hospital, Los Angeles, CA
| | - Robert Goggs
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - Alex M Lynch
- Department of Clinical Sciences, North Carolina State University, Raleigh, NC
| | - Lee Palmer
- Lieutenant Colonel, US Army Reserve, Veterinary Corps, Chair K9 Tactical Emergency Casualty Care Working Group, New Orleans, LA
| | | | - Claire R Sharp
- School of Veterinary and Life Sciences, Murdoch University, Murdoch, Australia
| |
Collapse
|
27
|
Serpa PBS, Brooks MB, Divers T, Ness S, Birschmann I, Papich MG, Stokol T. Pharmacokinetics and Pharmacodynamics of an Oral Formulation of Apixaban in Horses After Oral and Intravenous Administration. Front Vet Sci 2018; 5:304. [PMID: 30564584 PMCID: PMC6288471 DOI: 10.3389/fvets.2018.00304] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 11/19/2018] [Indexed: 01/20/2023] Open
Abstract
Horses with inflammatory and infectious disorders are often treated with injectable heparin anticoagulants to prevent thrombotic complications. In humans, a new class of direct oral acting anticoagulants (DOAC) appear as effective as heparin, while eliminating the need for daily injections. Our study in horses evaluated apixaban, a newly approved DOAC for human thromboprophylaxis targeting activated factor X (Xa). Our goals were to: (1) Determine pharmacokinetics and pharmacodynamics of apixaban after oral (PO) and intravenous (IV) administration in horses; (2) Detect any inhibitory effects of apixaban on ex vivo Equid herpesvirus type 1 (EHV-1)-induced platelet activation, and (3) Compare an anti-Xa bioactivity assay with ultra-performance liquid chromatography-mass spectrometry (UPLC-MS) for measuring apixaban concentrations. In a blinded placebo-controlled cross-over study, five horses received a single dose (0.2 mg/kg) of apixaban or placebo PO or IV. Blood was collected before and at 3 (IV) or 15 (PO) min, 30 and 45 min, and 1, 2, 3, 4, 6, 8, and 24 h after dosing for measuring apixaban UPLC-MS concentrations and anti-Xa activity. Pharmacodynamic response was measured in a dilute prothrombin time (dPT) assay. Flow cytometric EHV-1-induced platelet P-selectin expression and clinical pathologic safety testing were performed at baseline, 2 and 24 h and baseline and 24 h, respectively. We found no detectable apixaban in plasma PO administration. After IV administration, plasma apixaban levels followed a two-compartment model, with concentrations peaking at 3 min and decreasing to undetectable levels by 8 h. The elimination half-life was 1.3 ± 0.2 h, with high protein binding (92–99%). The dPT showed no relationship to apixaban UPLC-MS concentration and apixaban did not inhibit EHV-1-induced platelet activation after IV dosing. Apixaban anti-Xa activity showed excellent correlation to UPLC-MS (r2 = 0.9997). Our results demonstrate that apixaban has no apparent clinical utility as an anticoagulant for horses due to poor oral availability.
Collapse
Affiliation(s)
- Priscila B S Serpa
- Department of Population Medicine and Diagnostic Science, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Marjory B Brooks
- Department of Population Medicine and Diagnostic Science, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Thomas Divers
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Sally Ness
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Ingvild Birschmann
- Institut für Laboratoriums-und Transfusionsmedizin, Herz-und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Mark G Papich
- Department of Molecular Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Tracy Stokol
- Department of Population Medicine and Diagnostic Science, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| |
Collapse
|
28
|
Torres L, Conran N. Emerging pharmacotherapeutic approaches for the management of sickle cell disease. Expert Opin Pharmacother 2018; 20:173-186. [DOI: 10.1080/14656566.2018.1548610] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Lidiane Torres
- Hematology Center, University of Campinas – UNICAMP, Campinas, Brazil
| | - Nicola Conran
- Hematology Center, University of Campinas – UNICAMP, Campinas, Brazil
| |
Collapse
|
29
|
Bashir B, Stickle DF, Chervoneva I, Kraft WK. Drug-Drug Interaction Study of Apixaban with Cyclosporine and Tacrolimus in Healthy Volunteers. Clin Transl Sci 2018; 11:590-596. [PMID: 29972633 PMCID: PMC6226116 DOI: 10.1111/cts.12580] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 06/18/2018] [Indexed: 12/21/2022] Open
Abstract
Apixaban is metabolized by cytochrome P450 (CYP) 3A4 in the liver and intestine, undergoes direct intestinal excretion, and is a substrate to permeability glycoprotein (P-gp) and breast cancer resistance protein (BCRP) transporters. We examined the drug interactions between cyclosporine and tacrolimus (combined inhibitors of CYP3A4, P-gp, and BCRP) with apixaban in 12 healthy adult male volunteers. Apixaban 10 mg was administered orally alone, in combination with 100 mg cyclosporine or 5 mg tacrolimus. Co-administration with cyclosporine resulted in increase in apixaban maximum plasma concentration (Cmax ) and area under the plasma concentration-time curve from time zero to the last quantifiable concentration (AUC(0-tlast) ) with associated geometric mean ratios (GMRs) and 90% confidence intervals (CIs) of 143% (112, 183) and 120% (97, 148), respectively. Co-administration with tacrolimus resulted in reduction in apixaban Cmax and AUC(0-tlast) with associated GMRs (90% CI) of 87% (69, 112) and 78% (63, 97), respectively. The observed changes in apixaban exposure margins with cyclosporine or tacrolimus are within the range of the historical clinical development program, therefore, apixaban dose adjustments are not warranted.
Collapse
Affiliation(s)
- Babar Bashir
- Department of Pharmacologyand Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
- Department of Medical OncologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Douglas F. Stickle
- Department of PathologyThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Inna Chervoneva
- Department of Pharmacologyand Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Walter K. Kraft
- Department of Pharmacologyand Experimental TherapeuticsThomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| |
Collapse
|
30
|
Shinozawa E, Kawamura M. Anti-thrombotic effect of a factor Xa inhibitor TAK-442 in a rabbit model of arteriovenous shunt thrombosis stimulated with tissue factor. BMC Res Notes 2018; 11:776. [PMID: 30376878 PMCID: PMC6208035 DOI: 10.1186/s13104-018-3886-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/25/2018] [Indexed: 11/18/2022] Open
Abstract
Objective Arterial thrombosis is triggered by tissue factor, which is a transmembrane glycoprotein can be released into the blood circulation after plaque rupture. Animal models with reflecting ruptured plaque lesions will be useful to understand efficacy of anticoagulant. In this study, we sought to improve a common arteriovenous shunt model in rabbits, aiming for a model of thrombosis stimulated with tissue factor, and to investigate the anti-thrombotic effect of a direct factor Xa inhibitor TAK-442 in the model. Results In the model where thrombus was stimulated with a thrombogenic silk thread soaked with recombinant human tissue factor, thrombus formation was significantly reduced by TAK-442 at more than 37.5 µg/kg, accompanied with prolonged plasma hemostatic parameters. Although efficacious doses of anti-coagulants in ordinary arteriovenous thrombosis models are widely reported to be higher than those in venous thrombosis models, TAK-442 showed its efficacy in the present arteriovenous shunt thrombosis model, with equivalent sensitivity in a previously reported venous model. TAK-442 might be effective under conditions thrombus formed is more influenced by tissue factor pathway.
Collapse
Affiliation(s)
- Emiko Shinozawa
- Research, Takeda Pharmaceutical Company Limited, 26-1, Muraokahigashi 2-chome, Fujisawa, Kanagawa, 251-8555, Japan.
| | - Masaki Kawamura
- Research, Takeda Pharmaceutical Company Limited, 26-1, Muraokahigashi 2-chome, Fujisawa, Kanagawa, 251-8555, Japan
| |
Collapse
|
31
|
Frost C, Shenker A, Jhee S, Yu Z, Wang J, Bragat A, Pursley J, LaCreta F. Evaluation of the single-dose pharmacokinetics and pharmacodynamics of apixaban in healthy Japanese and Caucasian subjects. Clin Pharmacol 2018; 10:153-163. [PMID: 30498375 PMCID: PMC6207247 DOI: 10.2147/cpaa.s169505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose This double-blind, placebo-controlled, intra-subject, dose-escalation study assessed single-dose safety, pharmacokinetics, and pharmacodynamics of apixaban in healthy Japanese and Caucasian subjects. Subjects and methods Sixteen healthy male Japanese and sixteen healthy male Caucasian subjects, matched for age, weight, and smoking status were randomized to receive four sequential single oral doses of either apixaban (2.5, 10, 25, and 50 mg) or matched placebo. Doses were separated by a ≥5-day washout. Blood samples were collected for the determination of apixaban plasma concentration, clotting times (international normalized ratio [INR], activated partial thromboplastin time, and modified prothrombin time [mPT]), and ex vivo thrombin generation (TG). Urine samples were collected for the analysis of apixaban concentration. Results Ascending single doses of apixaban 2.5–50 mg were safe and well tolerated by all subjects. Apixaban exposure increased the dose proportionally up to 10 mg. Apixaban reached maximum concentrations (Cmax) 3–4 h postdose, with mean Cmax ranging from 52.5–485.0 to 44.8–494.3 ng/mL in Japanese and Caucasian subjects. The mean half-life was ~8 and ~13 h and the renal clearance was 1.1 and 0.8 L/h in Japanese and Caucasian subjects, respectively. Pharmacodynamic assessments were similar between ethnic groups, with comparable dose-related prolongation of INR and mPT and inhibition of TG. Conclusion Ascending single doses of apixaban over a 20-fold dose range were safe and well tolerated in Japanese and Caucasian subjects in this study. The consistency between pharmacokinetic and pharmacodynamic measures in Japanese and Caucasian subjects indicates that apixaban may be administered as a fixed dose with no need for adjustment in Japanese patients.
Collapse
Affiliation(s)
- Charles Frost
- Exploratory Clinical and Translational Research, Bristol-Myers Squibb, Princeton, NJ, USA,
| | - Andrew Shenker
- Exploratory Clinical and Translational Research, Bristol-Myers Squibb, Princeton, NJ, USA,
| | - Stanford Jhee
- PAREXEL International Early Phase, Glendale, CA, USA
| | - Zhigang Yu
- Exploratory Clinical and Translational Research, Bristol-Myers Squibb, Princeton, NJ, USA,
| | - Jessie Wang
- Exploratory Development Global Biometric Sciences, Bristol-Myers Squibb, Princeton, NJ, USA
| | - Alexander Bragat
- Exploratory Clinical and Translational Research, Bristol-Myers Squibb, Princeton, NJ, USA,
| | - Janice Pursley
- Analytical and Bioanalytical Development, Bristol Myers Squibb, Princeton, NJ, USA
| | - Frank LaCreta
- Exploratory Clinical and Translational Research, Bristol-Myers Squibb, Princeton, NJ, USA,
| |
Collapse
|
32
|
Qiu X, Zhou J, Wang W, Zhao Z, Tang L, Sun S. Effect of a new inhibitor of factor Xa zifaxaban, on thrombosis in the inferior vena cava in rabbits. J Thromb Thrombolysis 2018; 47:80-86. [PMID: 30298304 DOI: 10.1007/s11239-018-1743-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In recent years, oral factor Xa inhibitors have become a research focus as anticoagulant drugs. Zifaxaban is the first oral FXa inhibitor to enter clinical trials in China. The aim of this study was to determine the inhibitory effect of zifaxaban on thrombosisthrough a model ofinferior vena cava (IVC) thrombosis in rabbits. IVC thrombosis model was established by electrical injury and stenosis, and zifaxaban was administered (p.o.) for 5 consecutive days, then coagulation indicators and bleeding were observed. The results showed that zifaxaban had obvious inhibitory effects on FXa, and had a significant inhibitory effect on IVC thrombosis induced by electrical damage and stenosis. The effect of zifaxaban was similar to that of rivaroxaban, but the bleeding side-effects of zifaxaban were less severe than those of rivaroxaban. Zifaxaban could prolong the prothrombin time and activated partial thromboplastin time of plasma similar to that of other oral FXa inhibitors. Zifaxaban had a significant inhibitory effect on FXa, but it had no obvious effect on other coagulation factors, major anticoagulant factors or fibrinolytic indices. Our results suggest that zifaxaban had specific inhibitory effects on FXa and inhibited IVC thrombosis in rabbits with its hemorrhagic effect was less than that of rivaroxaban. Zifaxaban is ecpected to be developed as a new drug for the prevention of deep venous thrombosis, providing more medication options for patients with such disease, more research is required to support it in the future.
Collapse
Affiliation(s)
- Xiaomiao Qiu
- Tianjin Medical University School, Tianjin, 300070, People's Republic of China
| | - Junjun Zhou
- Department of Pharmacology, Dalian Medical University, Dalian, 116044, Liaoning, People's Republic of China
| | - Weiting Wang
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co.Ltd, 308, Huiren Street, Binhai New Area, Tianjin, 300301, People's Republic of China
| | - Zhuanyou Zhao
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co.Ltd, 308, Huiren Street, Binhai New Area, Tianjin, 300301, People's Republic of China
| | - Lida Tang
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co.Ltd, 308, Huiren Street, Binhai New Area, Tianjin, 300301, People's Republic of China
| | - Shuangyong Sun
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co.Ltd, 308, Huiren Street, Binhai New Area, Tianjin, 300301, People's Republic of China.
| |
Collapse
|
33
|
Erdoes G, Martinez Lopez De Arroyabe B, Bolliger D, Ahmed AB, Koster A, Agarwal S, Boer C, von Heymann C. International consensus statement on the peri-operative management of direct oral anticoagulants in cardiac surgery. Anaesthesia 2018; 73:1535-1545. [DOI: 10.1111/anae.14425] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2018] [Indexed: 02/06/2023]
Affiliation(s)
- G. Erdoes
- Department of Anaesthesiology and Pain Medicine; Inselspital; University Hospital Bern; University of Bern; Bern Switzerland
| | | | - D. Bolliger
- Department of Anaesthesia; Surgical Intensive Care; Prehospital Emergency Medicine, and Pain Therapy; University Hospital Basel; Basel Switzerland
| | - A. B. Ahmed
- Department of Anaesthesia; University Hospitals of Leicester NHS Trust; Leicester UK
- Department of Cardiovascular Sciences; University of Leicester; Leicester UK
| | - A. Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre NRW; Ruhr-University Bochum; Bad Oeynhausen Germany
| | - S. Agarwal
- Department of Anaesthesia; Liverpool Heart and Chest Hospital; Liverpool UK
| | - C. Boer
- Department of Anaesthesiology; VU University Medical Centre; Amsterdam the Netherlands
| | - C. von Heymann
- Department of Anaesthesia; Intensive Care Medicine, Emergency Medicine and Pain Therapy; Vivantes Klinikum im Friedrichshain; Berlin Germany
| |
Collapse
|
34
|
Development and Validation of a Stability-Indicating Liquid Chromatographic Method with Mass-Spectrometric Detection for the Analysis of Apixaban and Determination of Production Related Impurities. Pharm Chem J 2018. [DOI: 10.1007/s11094-018-1862-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
35
|
Gelosa P, Castiglioni L, Tenconi M, Baldessin L, Racagni G, Corsini A, Bellosta S. Pharmacokinetic drug interactions of the non-vitamin K antagonist oral anticoagulants (NOACs). Pharmacol Res 2018; 135:60-79. [PMID: 30040996 DOI: 10.1016/j.phrs.2018.07.016] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 07/10/2018] [Accepted: 07/16/2018] [Indexed: 12/20/2022]
Abstract
The use of warfarin, the most commonly prescribed oral anticoagulant, is being questioned by clinicians worldwide due to warfarin several limitations (a limited therapeutic window and significant variability in dose-response among individuals, in addition to a potential for drug-drug interactions). Therefore, the need for non-vitamin K antagonist oral anticoagulants (NOACs) with a rapid onset of antithrombotic effects and a predictable pharmacokinetic (PK) and pharmacodynamic (PD) profile led to the approval of five new drugs: the direct factor Xa (F-Xa) inhibitors rivaroxaban, apixaban, edoxaban and betrixaban (newly approved by FDA) and the direct thrombin (factor-IIa) inhibitor dabigatran etexilate. The advantages of NOACs over warfarin are a fixed-dosage, the absence of the need for drug monitoring for changes in anti-coagulation and fewer clinically significant PK and PD drug-drug interactions. NOACs exposure will likely be increased by the administration of strong P-glycoprotein (P-gp) and cytochrome P450 (CYP) 3A4-inhibitors and may increase the risk of bleeds. On the contrary, P-gp inducers could significantly decrease the NOACs plasma concentration with an associated reduction in their anticoagulant effects. This manuscript gives an overview of NOACs PK profiles and their drug-drug interactions potential. This is meant to be of help to physicians in choosing the best therapeutic approach for their patients.
Collapse
Affiliation(s)
- Paolo Gelosa
- Centro Cardiologico Monzino IRCCS, Via C. Parea, 4, 20138 Milan, Italy.
| | - Laura Castiglioni
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy.
| | - Marco Tenconi
- EDRA S.p.A., Via G. Spadolini, 7, 20141 Milan, Italy.
| | | | - Giorgio Racagni
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy.
| | - Alberto Corsini
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy; IRCCS MultiMedica, via G. Fantoli 16, 20138 Milan, Italy.
| | - Stefano Bellosta
- Department of Pharmacological and Biomolecular Sciences, Università degli Studi di Milano, Via G. Balzaretti 9, 20133 Milan, Italy; IRCCS MultiMedica, via G. Fantoli 16, 20138 Milan, Italy.
| |
Collapse
|
36
|
Münzel T, Konstantinides S. Apixaban. Hamostaseologie 2017; 32:203-11. [DOI: 10.5482/hamo-12-05-0010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 06/19/2012] [Indexed: 11/05/2022] Open
Abstract
SummaryApixaban is a potent reversible inhibitor of the activated human coagulation factor X. This new oral anticoagulant has favourable pharmacokinetic and pharmocodynamic properties which include a concentration-dependent anticoagulant effect, good oral bioavailability, balanced elimination and excretion, infrequent drug or food interactions, and the lack of liver toxicity. Apixaban has already completed a large part of its phase 3 clinical trial programme. In the ARISTOTLE study, which focused on stroke prevention in atrial fibrillation, apixaban showed a balanced efficacy and safety profile, being superior to warfarin both in the prevention of strokes and in the risk of causing major bleeding. A further trial related to this indication, AVERROES, demonstrated the clear superiority of apixaban compared to aspirin treatment. In the primary prophylaxis of venous thromboembolism after orthopaedic surgery, apixaban successfully completed the ADVANCE study programme and was approved in Europe for patients undergoing elective hip or knee replacement. The results of the AMPLIFY and AMPLIFY- EXT studies will soon show whether the inhibitor is also effective in the treatment and secondary prophylaxis after acute deep vein thrombosis and pulmonary embolism. On the other hand, the use of apixaban in the primary prophylaxis of venous thrombosis in hospitalised medical patients, and its administration on top of antiplatelet therapy to patients who have suffered an acute coronary syndrome, have not received support by the results of ADOPT and APPRAISE-II, respectively. In conclusion, on the basis of the available evidence, apixaban appears to be a valuable therapeutic option for the prevention of venous thrombosis and embolic stroke.
Collapse
|
37
|
Luscher TF, Steffel J. Vitamin K antagonists. Hamostaseologie 2017; 32:249-57. [DOI: 10.5482/ha-12050008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 08/28/2012] [Indexed: 11/05/2022] Open
Abstract
SummaryFor the last decades, anticoagulation for stroke prevention in atrial fibrillation (AF) as well as for the prophylaxis and long-term treatment of venous thromboembolism has been entirely based on vitamin K antagonists (VKA). Although very effective under optimal conditions, long-term treatment with these drugs is flawed by the fact that the time in the therapeutic range frequently is suboptimal due to biological factors, drug interactions and compliance.The direct thrombin inhibitor dabigatran, as well as the direct FXa inhibitors rivaroxaban and apixaban provide more consistent anticoagulation and have proven their efficacy and safety against VKAs in several large scale randomized clinical trials for stroke prevention in atrial fibrillation as well as for the treatment and prevention of venous thromboembolism. In view of these convincing data and other advantages such as the lack of mandatory monitoring and only few drug interactions,VKAs will most likely be replaced in a majority of patients for these indications. Based on the most recent trial evidence, the current review discusses the role of VKA treatmentand that of the novel anticoagulants.
Collapse
|
38
|
David T, Kim YC, Ely LK, Rondon I, Gao H, O'Brien P, Bolt MW, Coyle AJ, Garcia JL, Flounders EA, Mikita T, Coughlin SR. Factor XIa-specific IgG and a reversal agent to probe factor XI function in thrombosis and hemostasis. Sci Transl Med 2017; 8:353ra112. [PMID: 27559095 DOI: 10.1126/scitranslmed.aaf4331] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 07/11/2016] [Indexed: 11/02/2022]
Abstract
Thrombosis is a major cause of morbidity and mortality. Current antithrombotic drugs are not ideal in that they must balance prevention of thrombosis against bleeding risk. Inhibition of coagulation factor XI (FXI) may offer an improvement over existing antithrombotic strategies by preventing some forms of thrombosis with lower bleeding risk. To permit exploration of this hypothesis in humans, we generated and characterized a series of human immunoglobulin Gs (IgGs) that blocked FXIa active-site function but did not bind FXI zymogen or other coagulation proteases. The most potent of these IgGs, C24 and DEF, inhibited clotting in whole human blood and prevented FeCl3-induced carotid artery occlusion in FXI-deficient mice reconstituted with human FXI and in thread-induced venous thrombosis in rabbits at clinically relevant doses. At doses substantially higher than those required for inhibition of intravascular thrombus formation in these models, DEF did not increase cuticle bleeding in rabbits or cause spontaneous bleeding in macaques over a 2-week study. Anticipating the desirability of a reversal agent, we also generated a human IgG that rapidly reversed DEF activity ex vivo in human plasma and in vivo in rabbits. Thus, an active site-directed FXIa-specific antibody can block thrombosis in animal models and, together with the reversal agent, may facilitate exploration of the roles of FXIa in human disease.
Collapse
Affiliation(s)
- Tovo David
- Cardiovascular Research Institute, University of California, San Francisco, Room SC452P, 555 Mission Bay Boulevard South, San Francisco, CA 94143-3122, USA
| | - Yun Cheol Kim
- Centers for Therapeutic Innovation San Francisco, Pfizer Inc., 1700 Owens Street, San Francisco, CA 94158, USA
| | - Lauren K Ely
- Centers for Therapeutic Innovation San Francisco, Pfizer Inc., 1700 Owens Street, San Francisco, CA 94158, USA
| | - Isaac Rondon
- Centers for Therapeutic Innovation San Francisco, Pfizer Inc., 1700 Owens Street, San Francisco, CA 94158, USA
| | - Huilan Gao
- Centers for Therapeutic Innovation Boston, Pfizer Inc., 18th Floor, 3 Blackfan Circle, Boston, MA 02115, USA
| | - Peter O'Brien
- Pharmacokinetics, Dynamics, and Metabolism Biotherapeutics and Translational Research, Pfizer Inc., 10724 Science Center Drive, San Diego, CA 92121, USA
| | - Michael W Bolt
- Drug Safety Research and Development, Pfizer Inc., 1 Burtt Road, Andover, MA 01810, USA
| | - Anthony J Coyle
- Centers for Therapeutic Innovation Boston, Pfizer Inc., 18th Floor, 3 Blackfan Circle, Boston, MA 02115, USA
| | - Jorge L Garcia
- PMI Preclinical, 1031 Bing Street, San Carlos, CA 94070, USA
| | | | - Thomas Mikita
- Centers for Therapeutic Innovation San Francisco, Pfizer Inc., 1700 Owens Street, San Francisco, CA 94158, USA.
| | - Shaun R Coughlin
- Cardiovascular Research Institute, University of California, San Francisco, Room SC452P, 555 Mission Bay Boulevard South, San Francisco, CA 94143-3122, USA.
| |
Collapse
|
39
|
Tsuji N, Honda Y, Kamisato C, Morishima Y, Shibano T, Fukuda T. Comparison of antithrombotic efficacy between edoxaban, a direct factor Xa inhibitor, and fondaparinux, an indirect factor Xa inhibitor under low and high shear rates. Thromb Haemost 2017; 106:1062-8. [DOI: 10.1160/th11-07-0451] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 08/17/2011] [Indexed: 11/05/2022]
Abstract
SummaryEdoxaban is an oral, direct factor Xa (FXa) inhibitor under late-phase clinical development. This study compared the antithrombotic efficacy of edoxaban with that of an indirect FXa inhibitor, fondaparinux, in in vivo venous and arterial thrombosis models and in ex vivo perfusion chamber thrombosis model under low and high shear rates in rats. Venous and arterial thrombi were induced by platinum wire insertion into the inferior vena cava and by application of FeCl3 to the carotid artery, respectively. The perfusion chamber thrombus was formed by blood perfusion into a collagen-coated capillary at 150 s-1 (low shear rate) and 1,600 s-1 (high shear rate). Effective doses of edoxaban that reduced thrombus formation by 50% (ED50) in venous and arterial thrombosis models were 0.076 and 0.093 mg/kg/h, respectively. In contrast, ED50 of fondaparinux in the arterial thrombosis model (>10 mg/kg/h) was markedly higher compared to ED50 in the venous thrombosis model (0.021 mg/kg/h). In the perfusion chamber thrombosis model, the ratio of ED50 under high shear rate (1.13 mg/kg/h) to that under low shear rate (0.63 mg/kg/h) for edoxaban was 1.9, whereas that for fondaparinux was more than 66. While the efficacy of fondaparinux markedly decreased in arterial thrombosis and in a high-shear state, edoxaban exerted consistent antithrombotic effects regardless of flow conditions. These results suggest that shear rate is a key factor in different antithrombotic effects between edoxaban and fondaparinux.
Collapse
|
40
|
Interpatient Variation in Rivaroxaban and Apixaban Plasma Concentrations in Routine Care. Can J Cardiol 2017; 33:1036-1043. [DOI: 10.1016/j.cjca.2017.04.008] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 03/03/2017] [Accepted: 04/20/2017] [Indexed: 12/26/2022] Open
|
41
|
Villari A, Giurdanella G, Bucolo C, Drago F, Salomone S. Apixaban Enhances Vasodilatation Mediated by Protease-Activated Receptor 2 in Isolated Rat Arteries. Front Pharmacol 2017; 8:480. [PMID: 28769809 PMCID: PMC5513931 DOI: 10.3389/fphar.2017.00480] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/04/2017] [Indexed: 01/08/2023] Open
Abstract
Apixaban (APX) is a direct inhibitor of factor X (FXa) approved for prophylaxis and treatment of deep venous thrombosis and atrial fibrillation. Because FXa activates protease-activated receptor 2 (PAR-2) in endothelium and vascular smooth muscle, inhibition of FXa by APX may affect vasomotor function. The effect of APX was assessed in vitro, by wire myography, in rat mesenteric resistance arteries (MRAs) and basilar arteries challenged with vasoconstrictors [phenylephrine (PE); 5-hydroxytryptamine (5-HT)], vasodilators [acetylcholine (ACh); sodium nitroprusside (SNP)] or with the PAR-2 peptide agonist SLIGRL. APX (10 μM) reduced the vasoconstriction to PE and 5-HT while did not change the vasodilatation to ACh or SNP. SLIGRL induced concentration-dependent vasodilation in pre-constricted arteries, that was reduced by incubation with the NO inhibitor NG-nitro-L-arginine (L-NNA) and abolished by endothelium removal. APX enhanced vasodilation to SLIGRL either in the presence or in the absence of L-NNA, but was ineffective in endothelium-denuded vessels. In preparations from heparin-treated rats (to inhibit FXa) APX did not change the vasodilation to SLIGRL. FXa enzymatic activity, detected in mesentery homogenates from controls, was inhibited by APX, whereas APX-sensitive enzymatic activity was undetectable in homogenates from heparin-treated rats. Immunoblot analysis showed that incubation of MRA or aorta with APX increased the abundance of PAR-2, an effect not seen in MRA from heparin-treated rats or in endothelium-denuded aortas. In conclusion, inhibition of FXa by APX increases vasodilatation mediated by PAR-2. APX may act by inhibiting PAR-2 desensitization induced by endogenous FXa. This effect could be useful in the context of endothelial dysfunction associated to cardiovascular diseases.
Collapse
Affiliation(s)
- Ambra Villari
- Pharmacology Section, Department of Biomedical and Biotechnological Sciences, University of CataniaCatania, Italy
| | - Giovanni Giurdanella
- Pharmacology Section, Department of Biomedical and Biotechnological Sciences, University of CataniaCatania, Italy
| | - Claudio Bucolo
- Pharmacology Section, Department of Biomedical and Biotechnological Sciences, University of CataniaCatania, Italy
| | - Filippo Drago
- Pharmacology Section, Department of Biomedical and Biotechnological Sciences, University of CataniaCatania, Italy
| | - Salvatore Salomone
- Pharmacology Section, Department of Biomedical and Biotechnological Sciences, University of CataniaCatania, Italy
| |
Collapse
|
42
|
Yetman RJ, Barrett YC, Wang Z, Adamczyk R, Wang J, Ramacciotti E, Frost C. Apixaban pharmacodynamic activity in umbilical cord, paediatric, and adult plasma. Thromb Haemost 2017; 117:1518-1527. [PMID: 28536722 DOI: 10.1160/th16-06-0423] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 05/09/2017] [Indexed: 11/05/2022]
Abstract
The objective was to characterise apixaban pharmacodynamic (PD) activity in umbilical cord (UC), paediatric, and adult plasma. Plasma was obtained from blood samples from six UC donors, 70 paediatric (neonates [birth-≤1 month], infants [>1-≤6 months], toddlers [>6 months-≤2 years], young children [>2-≤6 years], children [>6-≤12 years], adolescents [>12-≤18 years]), and six adult (19-45 years) subjects. Plasma spiked with apixaban 0 (baseline), 30, or 110 ng/ml was analysed for anti-factor Xa activity, factor X levels, prothrombin time (PT), and modified PT (mPT). Apixaban had similar concentration-related effects on anti-factor Xa activity across groups (30 ng/ml: 0.223-0.295 IU/ml; 110 ng/ml: 1.212-1.474 IU/ml). Endogenous baseline factor X levels were 43 %-68 % lower in plasma from UC and subjects ≤6 months versus adults. Factor Xa inhibition (percentage change from baseline in apparent factor X levels) was similar for both apixaban concentrations across groups, except UC, neonate, and infant groups, which showed greater inhibition vs adults for apixaban 110 ng/ml. Baseline PT and mPT were similar across groups. Apixaban had no effect on PT at the concentrations tested. Apixaban 110 ng/ml prolonged mPT similarly across groups (44.4-53.2 s to 64.5-70.0 s); no prolongation was found with apixaban 30 ng/ml. Apixaban demonstrated consistent concentration-related effects on other PD endpoints in plasma samples from all age groups, except factor Xa inhibition.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Charles Frost
- Charles Frost, PharmD, Route 206 and Province Line Road, Princeton, NJ, 08543, USA, Tel.: +1 609 252 3552, Fax: +1 609 252 6313, E-mail:
| |
Collapse
|
43
|
Abstract
Several direct oral anticoagulants (DOACs), including direct thrombin and factor Xa inhibitors, have been approved as alternatives to vitamin K antagonist anticoagulants. As with any anticoagulant, DOAC use carries a risk of bleeding. In patients with major bleeding or needing urgent surgery, reversal of DOAC anticoagulation may be required, presenting a clinical challenge. The optimal strategy for DOAC reversal is being refined, and may include use of hemostatic agents such as prothrombin complex concentrates (PCCs; a source of concentrated clotting factors), or DOAC-specific antidotes (which bind their target DOAC to abrogate its activity). Though promising, most specific antidotes are still in development.Preclinical animal research is the key to establishing the efficacy and safety of potential reversal agents. Here, we summarize published preclinical animal studies on reversal of DOAC anticoagulation. These studies (n = 26) were identified via a PubMed search, and used rodent, rabbit, pig, and non-human primate models. The larger of these animals have the advantages of similar blood volume/hemodynamics to humans, and can be used to model polytrauma. We find that in addition to varied species being used, there is variability in the models and assays used between studies; we suggest that blood loss (bleeding volume) is the most clinically relevant measure of DOAC anticoagulation-related bleeding and its reversal.The studies covered indicate that both PCCs and specific reversal agents have the potential to be used as part of a clinical strategy for DOAC reversal. For the future, we advocate the development and use of standardized, clinically, and pharmacologically relevant animal models to study novel DOAC reversal strategies.
Collapse
|
44
|
Lester PA, Coleman DM, Diaz JA, Jackson TO, Hawley AE, Mathues AR, Grant BT, Knabb RM, Ramacciotti E, Frost CE, Song Y, Wakefield TW, Myers DD. Apixaban Versus Warfarin for Mechanical Heart Valve Thromboprophylaxis in a Swine Aortic Heterotopic Valve Model. Arterioscler Thromb Vasc Biol 2017; 37:942-948. [DOI: 10.1161/atvbaha.116.308649] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 02/06/2017] [Indexed: 12/15/2022]
Abstract
Objective—
Warfarin is the current standard for oral anticoagulation therapy in patients with mechanical heart valves, yet optimal therapy to maximize anticoagulation and minimize bleeding complications requires routine coagulation monitoring, possible dietary restrictions, and drug interaction monitoring. As alternatives to warfarin, oral direct acting factor Xa inhibitors are currently approved for the prophylaxis and treatment of venous thromboembolism and reduction of stroke and systemic embolization. However, no in vivo preclinical or clinical studies have been performed directly comparing oral factor Xa inhibitors such as apixaban to warfarin, the current standard of therapy.
Approach and Results—
A well-documented heterotopic aortic valve porcine model was used to test the hypothesis that apixaban has comparable efficacy to warfarin for thromboprophylaxis of mechanical heart valves. Sixteen swine were implanted with a bileaflet mechanical aortic valve that bypassed the ligated descending thoracic aorta. Animals were randomized to 4 groups: control (no anticoagulation; n=4), apixaban oral 1 mg/kg twice a day (n=5), warfarin oral 0.04 to 0.08 mg/kg daily (international normalized ratio 2–3; n=3), and apixaban infusion (n=4). Postmortem valve thrombus was measured 30 days post-surgery for control-oral groups and 14 days post-surgery for the apixaban infusion group. Control thrombus weight (mean) was significantly different (1422.9 mg) compared with apixaban oral (357.5 mg), warfarin (247.1 mg), and apixiban 14-day infusion (61.1 mg;
P
<0.05).
Conclusions—
Apixaban is a promising candidate and may be a useful alternative to warfarin for thromboprophylaxis of mechanical heart valves. Unlike warfarin, no adverse bleeding events were observed in any apixaban groups.
Collapse
Affiliation(s)
- Patrick A. Lester
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Dawn M. Coleman
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Jose A. Diaz
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Tatum O. Jackson
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Angela E. Hawley
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Angela R. Mathues
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Brandon T. Grant
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Robert M. Knabb
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Eduardo Ramacciotti
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Charles E. Frost
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Yan Song
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Thomas W. Wakefield
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| | - Daniel D. Myers
- From the Unit for Laboratory Animal Medicine (P.A.L., D.D.M.) and Conrad Jobst Vascular Research Laboratories (P.A.L., D.M.C., J.A.D., T.O.J., A.E.H., A.R.M., B.T.G., T.W.W., D.D.M.), University of Michigan, Ann Arbor; and Global Clinical Research, Research & Development (R.M.K., E.R.) and Exploratory Clinical and Translational Research (C.E.F., Y.S.), Bristol-Myers Squibb Company, Princeton, NJ
| |
Collapse
|
45
|
Chan NC, Eikelboom JW, Weitz JI. Evolving Treatments for Arterial and Venous Thrombosis: Role of the Direct Oral Anticoagulants. Circ Res 2017; 118:1409-24. [PMID: 27126650 DOI: 10.1161/circresaha.116.306925] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/02/2016] [Indexed: 01/23/2023]
Abstract
The direct oral anticoagulants (DOACs) represent a major advance in oral anticoagulant therapy and have replaced the vitamin K antagonists as the preferred treatment for many indications. By simplifying long-term anticoagulant therapy and improving its safety, the DOACs have the potential to reduce the global burden of thrombosis. Postmarketing studies suggest that the favorable results achieved with DOACs in the randomized controlled trials can be readily translated into practice, but highlight the need for appropriate patient, drug and dose selection, and careful follow-up. Leveraging on their success to date, ongoing studies are assessing the utility of DOACs for the prevention of thrombosis in patients with embolic stroke of unknown source, heart failure, coronary artery disease, peripheral artery disease, antiphospholipid syndrome, and cancer. The purpose of this article is to (1) review the pharmacology of the DOACs, (2) describe the advantages of the DOACs over vitamin K antagonists, (3) summarize the experience with the DOACs in established indications, (4) highlight current challenges and limitations, (5) highlight potential new indications; and (6) identify future directions for anticoagulant therapy.
Collapse
Affiliation(s)
- Noel C Chan
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.).
| | - John W Eikelboom
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.)
| | - Jeffrey I Weitz
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.)
| |
Collapse
|
46
|
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: 65] [Impact Index Per Article: 9.3] [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.
Collapse
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.)
| |
Collapse
|
47
|
Kalaitzidis RG, Duni A, Liapis G, Balafa O, Xiromeriti S, Rapsomanikis PK, Elisaf MS. Anticoagulant-related nephropathy: a case report and review of the literature of an increasingly recognized entity. Int Urol Nephrol 2017; 49:1401-1407. [DOI: 10.1007/s11255-017-1527-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 01/25/2017] [Indexed: 02/01/2023]
|
48
|
Dager W, Hellwig T. Current knowledge on assessing the effects of and managing bleeding and urgent procedures with direct oral anticoagulants. Am J Health Syst Pharm 2017; 73:S14-26. [PMID: 27147455 DOI: 10.2146/ajhp150960] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Current knowledge on managing major bleeding events with available hemostatic agents, including their combined use with potential reversal agents, in patients taking direct oral anticoagulant (DOACs) is reviewed. SUMMARY Over the past five years, a new generation of oral agents, the DOACs, has emerged as commonly used anticoagulants for stroke prevention in non-valvular atrial fibrillation, and treatment or secondary prevention of venous thromboembolism. Management of a bleeding event in the setting of DOAC therapy should take into account the relative risks of bleeding and thrombosis, which will determine the degree of anticoagulant reversal required. In the setting of a major (critical) bleeding event associated with notable blood loss, management may include transfusions of blood products to sustain the function of organ systems, and the availability of specific reversal agents will provide additional options for bleeding management. Beyond withholding the DOAC and providing supportive management that addresses any factors contributing to the bleeding event, clinicians may desire to expedite the removal of any anticoagulation effects. In general, this is accomplished by either removing or neutralizing the anticoagulant or by independently establishing hemostasis. CONCLUSION With or without reversal agents, patients may require supportive management such as mechanical pressure, volume support, transfusions of blood products, and, depending on the situation, surgery to repair the bleeding source. Specific reversal agents are currently under development or have recently been approved for the urgent management of bleeding events or the facilitation of invasive procedures in patients receiving DOACs.
Collapse
Affiliation(s)
- William Dager
- University of California Davis Medical Center, Sacramento, CA.
| | - Thaddaus Hellwig
- South Dakota State University College of Pharmacy, Sioux Falls, SDSanford USD Medical Center, Sioux Falls, SD
| |
Collapse
|
49
|
Deer TR, Narouze S, Provenzano DA, Pope JE, Falowski SM, Russo MA, Benzon H, Slavin K, Pilitsis JG, Alo K, Carlson JD, McRoberts P, Lad SP, Arle J, Levy RM, Simpson B, Mekhail N. The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Bleeding and Coagulation Management in Neurostimulation Devices. Neuromodulation 2017; 20:51-62. [DOI: 10.1111/ner.12542] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 12/15/2022]
Affiliation(s)
| | - Samer Narouze
- Summa Western Reserve Hospital; Cuyahoga Falls OH USA
| | | | | | | | | | | | | | | | | | | | | | - Shivanand P. Lad
- Division of Neurosurgery; Duke University Medical Center; Durham NC USA
| | - Jeffrey Arle
- Neurosurgery, Beth Israel Deaconess Medical Center; Boston MA USA
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
| | | |
Collapse
|
50
|
Abstract
Direct oral anticoagulants (DOACs) can be quantified using methods that can be performed in any clinical or research laboratory using manual or automated instrument platforms. Dabigatran etexilate, the oral direct thrombin inhibitor, can be quantified by drug-calibrated clot or chromogenic-based assays using either thrombin or ecarin as substrates. Oral direct anti-Xa inhibitors, such as rivaroxaban, apixaban, and edoxaban, can be quantified with drug-calibrated anti-Xa kits or reagents as typically used for measuring heparins (unfractionated, low molecular weight, or pentasaccharides).
Collapse
Affiliation(s)
- Robert C Gosselin
- Department of Pathology and Laboratory Medicine, Davis Health System, University of California, 4400 V Street, Sacramento, CA, 95817, USA.
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, University of Namur, Namur, Belgium
| |
Collapse
|