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Lyden PD, Pryor KE, Minigh J, Davis TP, Griffin JH, Levy H, Zlokovic BV. Stroke Treatment With PAR-1 Agents to Decrease Hemorrhagic Transformation. Front Neurol 2021; 12:593582. [PMID: 33790846 PMCID: PMC8005555 DOI: 10.3389/fneur.2021.593582] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/08/2021] [Indexed: 12/20/2022] Open
Abstract
Ischemic stroke is the most widespread cause of disability and a leading cause of death in developed countries. To date, the most potent approved treatment for acute stroke is recanalization therapy with thrombolytic drugs such as tissue plasminogen activator (rt-PA or tPA) or endovascular mechanical thrombectomy. Although tPA and thrombectomy are widely available in the United States, it is currently estimated that only 10-20% of stroke patients get tPA treatment, in part due to restrictive selection criteria. Recently, however, tPA and thrombectomy selection criteria have loosened, potentially allowing more patients to qualify. The relatively low rate of treatment may also reflect the perceived risk of brain hemorrhage following treatment with tPA. In translational research and a single patient study, protease activated receptor 1 (PAR-1) targeted therapies given along with thrombolysis and thrombectomy appear to reduce hemorrhagic transformation after recanalization. Such adjuncts may likely enhance the availability of recanalization and encourage more physicians to use the recently expanded selection criteria for applying recanalization therapies. This narrative review discusses stroke therapies, the role of hemorrhagic transformation in producing poor outcomes, and presents the data suggesting that PAR-1 acting agents show promise for decreasing hemorrhagic transformation and improving outcomes.
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Affiliation(s)
- Patrick D. Lyden
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, United States
- *Correspondence: Patrick D. Lyden
| | | | | | - Thomas P. Davis
- Department of Medical Pharmacology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - John H. Griffin
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA, United States
| | - Howard Levy
- Howard Levy Consulting LLC, Hopewell, NJ, United States
| | - Berislav V. Zlokovic
- Department of Physiology and Neuroscience, Keck School of Medicine, Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA, United States
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Mukherjee P, Lyden P, Fernández JA, Davis TP, Pryor KE, Zlokovic BV, Griffin JH. 3K3A-Activated Protein C Variant Does Not Interfere With the Plasma Clot Lysis Activity of Tenecteplase. Stroke 2020; 51:2236-2239. [PMID: 32568648 DOI: 10.1161/strokeaha.120.028793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A recombinant engineered variant of APC (activated protein C), 3K3A-APC, lacks anticoagulant properties (<10%) while preserving APCs anti-inflammatory, anti-apoptotic, and neuroprotective functions and is very promising in clinical trials for ischemic stroke. Therapeutic intervention with single bolus administration of the third-generation tPA (tissue-type plasminogen activator), tenecteplase, is anticipated to be widely adopted for treatment of acute ischemic stroke. 3K3A-APC is well-tolerated in stroke patients dosed with alteplase, and in vitro studies show 3K3A-APC does not interfere with alteplase-induced clot lysis. The purpose of this in vitro study was to assess the influence of 3K3A-APC on tenecteplase-induced clot lysis. METHODS Tenecteplase-mediated lysis of thrombin generated plasma clots of human normal pooled plasma was monitored in the presence of varying doses of 3K3A-APC. The effects on fibrinolysis by tenecteplase and alteplase were compared. RESULTS The presence of 3K3A-APC shortened the time for clot lysis induced by tenecteplase at very low levels but not at higher therapeutic concentrations of tenecteplase. Comparisons of alteplase-mediated clot lysis to tenecteplase clot lysis showed that both thrombolytic agents behaved similarly in the presence of 3K3A-APC. CONCLUSIONS These results indicate that 3K3A-APC does not interfere with tenecteplase's clot lysis function.
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Affiliation(s)
- Purba Mukherjee
- Department of Molecular Medicine, Scripps Research Institute, La Jolla, CA (P.M., J.A.F., J.H.G.)
| | - Patrick Lyden
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA (P.L.)
| | - José A Fernández
- Department of Molecular Medicine, Scripps Research Institute, La Jolla, CA (P.M., J.A.F., J.H.G.)
| | - Thomas P Davis
- Department of Medical Pharmacology, University of Arizona, Tucson (T.P.D.)
| | | | - Berislav V Zlokovic
- Zilkha Neurogenetic Institute, University of Southern California, Los Angeles, CA (B.V.Z.)
| | - John H Griffin
- Department of Molecular Medicine, Scripps Research Institute, La Jolla, CA (P.M., J.A.F., J.H.G.)
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Zamanlu M, Farhoudi M, Eskandani M, Mahmoudi J, Barar J, Rafi M, Omidi Y. Recent advances in targeted delivery of tissue plasminogen activator for enhanced thrombolysis in ischaemic stroke. J Drug Target 2017; 26:95-109. [PMID: 28796540 DOI: 10.1080/1061186x.2017.1365874] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Tissue plasminogen activator (tPA) is the only FDA approved medical treatment for the ischaemic stroke. However, it associates with some inevitable limitations, including: short therapeutic window, extremely short half-life and low penetration in large clots. Systemic administration may lead to complications such as haemorrhagic conversion in the brain and relapse in the form of re-occlusion. Furthermore, ultrasound has been utilised in combination with contrast agents, echogenic liposome, microspheres or nanoparticles (NPs) carrying tPA for improving thrombolysis - an approach that has resulted in slight improvement of tPA delivery and facilitated thrombolysis. Most of these delivery systems are able to extend the circulating half-life and clot penetration of tPA. Various technologies employed for ameliorated thrombolytic therapy are in different phases, some are in final steps for clinical applications while some others are under investigations for their safety and efficacy in human cases. Here, recent progresses on the thrombolytic therapy using novel nano- and micro-systems incorporating tPA are articulated. Of these, liposomes and microspheres, polymeric NPs and magnetic nanoparticles (MNPs) are discussed. Key technologies implemented for efficient delivery of tPA and advanced thrombolytic therapy and their advantages/disadvantages are further expressed.
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Affiliation(s)
- Masumeh Zamanlu
- a Neurosciences Research Center (NSRC), Faculty of Medicine , Tabriz University of Medical Sciences , Tabriz , Iran.,b Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Mehdi Farhoudi
- a Neurosciences Research Center (NSRC), Faculty of Medicine , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Morteza Eskandani
- b Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Javad Mahmoudi
- a Neurosciences Research Center (NSRC), Faculty of Medicine , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Jaleh Barar
- b Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute , Tabriz University of Medical Sciences , Tabriz , Iran.,c Department of Pharmaceutics, Faculty of Pharmacy , Tabriz University of Medical Sciences , Tabriz , Iran
| | - Mohammad Rafi
- d Department of Neurology, Sidney Kimmel College of Medicine , Thomas Jefferson University , Philadelphia , PA , USA
| | - Yadollah Omidi
- b Research Center for Pharmaceutical Nanotechnology, Biomedicine Institute , Tabriz University of Medical Sciences , Tabriz , Iran.,c Department of Pharmaceutics, Faculty of Pharmacy , Tabriz University of Medical Sciences , Tabriz , Iran
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Phase I and Phase II Therapies for Acute Ischemic Stroke: An Update on Currently Studied Drugs in Clinical Research. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4863079. [PMID: 28286764 PMCID: PMC5329656 DOI: 10.1155/2017/4863079] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 11/23/2016] [Indexed: 02/06/2023]
Abstract
Acute ischemic stroke is a devastating cause of death and disability, consequences of which depend on the time from ischemia onset to treatment, the affected brain region, and its size. The main targets of ischemic stroke therapy aim to restore tissue perfusion in the ischemic penumbra in order to decrease the total infarct area by maintaining blood flow. Advances in research of pathological process and pathways during acute ischemia have resulted in improvement of new treatment strategies apart from restoring perfusion. Additionally, limiting the injury severity by manipulating the molecular mechanisms during ischemia has become a promising approach, especially in animal research. The purpose of this article is to review completed and ongoing phases I and II trials for the treatment of acute ischemic stroke, reviewing studies on antithrombotic, thrombolytic, neuroprotective, and antineuroinflammatory drugs that may translate into more effective treatments.
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Bhat V, von Drygalski A, Gale AJ, Griffin JH, Mosnier LO. Improved coagulation and haemostasis in haemophilia with inhibitors by combinations of superFactor Va and Factor VIIa. Thromb Haemost 2015; 115:551-61. [PMID: 26466980 DOI: 10.1160/th15-07-0525] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/23/2015] [Indexed: 01/14/2023]
Abstract
Bypassing inhibitors in haemophilia patients is limited to activated (a) Factor(F)VII products. We introduced "FVa activity augmentation" as another bypassing strategy and studied effects of an engineered FVa variant designated superFVa. Procoagulant and clot stabilising properties of superFVa and recombinant human (rh)FVIIa, either alone or in combination, were studied in thrombin generation and clot lysis assays in normal human plasma (NHP) with or without anti-FVIII inhibitors, in haemophilia plasma, and in FVIII-deficient mice or in wild-type mice with anti-FVIII inhibitors. SuperFVa was as effective as rhFVIIa to improve thrombin generation or clot lysis. Furthermore, procoagulant effects were significantly enhanced when these compounds were combined. RhFVIIa at 40 nM (a therapeutic concentration) improved thrombin generation mildly, but markedly improved thrombin generation when combined with a low concentration (e. g. 3 nM) of superFVa. In clot lysis studies, the concentration of rhFVIIa to normalise clot lysis times could be reduced by 100-fold (e. g. from 40 nM to 0.4 nM) when combined with a low concentration (0.37 nM) of superFVa. In haemostasis studies of FVIII-deficient mice, blood loss was dose-dependently reduced by either superFVa or rhFVIIa. SuperFVa (200 U/kg) corrected mean blood loss indistinguishably from rhFVIII. Blood loss correction by rhFVIIa was greatly improved when combined with superFVa. Similar blood loss correction results were observed for therapies in wild-type mice after infusion with anti-FVIII inhibitors. Thus, superFVa may be an effective procoagulant agent in the setting of haemophilia with inhibitors and it merits further evaluation for new bypassing strategies.
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Affiliation(s)
| | - Annette von Drygalski
- Annette von Drygalski, MD, Pharm D, The Scripps Research Institute, Department of Molecular and Experimental Medicine, MEM 180, 10550 North Torrey Pines Road, La Jolla, CA 92037, USA, Tel.: +1 858 784 8220, Fax: +1 858 784 2243, E-mail:
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Lyden P, Levy H, Weymer S, Pryor K, Kramer W, Griffin JH, Davis TP, Zlokovic B. Phase 1 safety, tolerability and pharmacokinetics of 3K3A-APC in healthy adult volunteers. Curr Pharm Des 2014; 19:7479-85. [PMID: 24372304 DOI: 10.2174/1381612819666131230131454] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 11/19/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND PURPOSE Activated Protein C (APC) stimulates multiple cytoprotective pathways via the protease activated receptor-1 (PAR-1) and promotes anticoagulation. 3K3A-APC was designed for preserved activity at PAR-1 with reduced anticoagulation. This Phase 1 trial characterized pharmacokinetics and anticoagulation effects of 3K3A-APC. METHODS Subjects (n=64) were randomly assigned to receive 3K3A-APC (n=4) at 6, 30, 90, 180, 360, 540 or 720 µg/kg or placebo (n=6) and were observed for 24 hr. After safety review additional subjects received drug every 12 hr for 5 doses (n=6 per group) at 90, 180, 360, or 540 µg/kg or placebo (n=8) and were observed for 24 hr. RESULTS All subjects returned for safety assessments at 72 hours and 15 days. We found few adverse events in all groups. Systolic blood pressure increased in both active and placebo groups. Moderately severe headache, nausea and vomiting were reported in one of two subjects treated with 720 µg/kg so 540 µg/kg was considered the highest tolerated dose. Mean plasma concentrations increased in proportion to dose. Clearance ranged from 11,693 ± 807 to 18,701 ± 4,797 mL/hr, volume of distribution ranged from 4,873±828 to 6,971 ± 1,169 mL, and elimination half-life ranged from 0.211 ± 0.097 to 0.294 ± 0.054 hours. Elevations in aPTT were minimal. CONCLUSIONS 3K3A-APC was well tolerated at multiple doses as high as 540 µg/kg. These results should be confirmed in stroke patients with relevant co-morbidities. Clinical Trial Registration-URL: http://www.clinicaltrials.gov. Unique identifier: NCT01660230.
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