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Li Y, Mondaza-Hernandez JL, Moura DS, Revenko AS, Tolentino A, Nguyen JT, Tran N, Meyer CA, Merino-Garcia J, Ramos R, Di Lernia D, Martin-Broto J, Hayenga HN, Bleris L. STAT6-targeting antisense oligonucleotides against solitary fibrous tumor. MOLECULAR THERAPY. NUCLEIC ACIDS 2024; 35:102154. [PMID: 38511173 PMCID: PMC10950871 DOI: 10.1016/j.omtn.2024.102154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/13/2024] [Indexed: 03/22/2024]
Abstract
Solitary fibrous tumor (SFT) is a rare, non-hereditary soft tissue sarcoma thought to originate from fibroblastic mesenchymal stem cells. The etiology of SFT is thought to be due to an environmental intrachromosomal gene fusion between NGFI-A-binding protein 2 (NAB2) and signal transducer and activator protein 6 (STAT6) genes on chromosome 12, wherein the activation domain of STAT6 is fused with the DNA-binding domain of NAB2 resulting in the oncogenesis of SFT. All NAB2-STAT6 fusion variations discovered in SFTs contain the C-terminal of STAT6 transcript, and thus can serve as target site for antisense oligonucleotides (ASOs)-based therapies. Indeed, our in vitro studies show the STAT6 3' untranslated region (UTR)-targeting ASO (ASO 993523) was able to reduce expression of NAB2-STAT6 fusion transcripts in multiple SFT cell models with high efficiency (half-maximal inhibitory concentration: 116-300 nM). Encouragingly, in vivo treatment of SFT patient-derived xenograft mouse models with ASO 993523 resulted in acceptable tolerability profiles, reduced expression of NAB2-STAT6 fusion transcripts in xenograft tissues (21.9%), and, importantly, reduced tumor growth (32.4% decrease in tumor volume compared with the untreated control). Taken together, our study established ASO 993523 as a potential agent for the treatment of SFTs.
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Affiliation(s)
- Yi Li
- Department of Bioengineering, University of Texas at Dallas, Richardson, TX 75080, USA
- Center for Systems Biology, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Jose L. Mondaza-Hernandez
- Health Research Institute Fundacion Jimenez Diaz, Universidad Autonoma de Madrid (IIS/FJD-UAM), 28049 Madrid, Spain
- University Hospital General de Villalba, 28400 Madrid, Spain
| | - David S. Moura
- Health Research Institute Fundacion Jimenez Diaz, Universidad Autonoma de Madrid (IIS/FJD-UAM), 28049 Madrid, Spain
| | - Alexey S. Revenko
- Department of Antisense Drug Discovery, Ionis Pharmaceuticals, Inc, Carlsbad, CA 92010, USA
| | - Angelica Tolentino
- Department of Antisense Drug Discovery, Ionis Pharmaceuticals, Inc, Carlsbad, CA 92010, USA
| | - John T. Nguyen
- Department of Bioengineering, University of Texas at Dallas, Richardson, TX 75080, USA
- Center for Systems Biology, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Nam Tran
- Neurosurgical Oncology, Department of Neuro-Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Clark A. Meyer
- Department of Bioengineering, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Jose Merino-Garcia
- Pathology Department, University Hospital Fundacion Jimenez Diaz, Universidad Autonoma, Av. Reyes Catolicos 2, 28040 Madrid, Spain
| | - Rafael Ramos
- Pathology Department, University Hospital Son Espases, 07120 Palma de Mallorca, Spain
| | - Davide Di Lernia
- Health Research Institute Fundacion Jimenez Diaz, Universidad Autonoma de Madrid (IIS/FJD-UAM), 28049 Madrid, Spain
| | - Javier Martin-Broto
- Health Research Institute Fundacion Jimenez Diaz, Universidad Autonoma de Madrid (IIS/FJD-UAM), 28049 Madrid, Spain
- University Hospital General de Villalba, 28400 Madrid, Spain
- Medical Oncology Department, University Hospital Fundacion Jimenez Diaz, 28040 Madrid, Spain
| | - Heather N. Hayenga
- Department of Bioengineering, University of Texas at Dallas, Richardson, TX 75080, USA
| | - Leonidas Bleris
- Department of Bioengineering, University of Texas at Dallas, Richardson, TX 75080, USA
- Center for Systems Biology, University of Texas at Dallas, Richardson, TX 75080, USA
- Department of Biological Sciences, University of Texas at Dallas, Richardson, TX 75080, USA
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2
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Occhipinti G, Laudani C, Spagnolo M, Finocchiaro S, Mazzone PM, Faro DC, Mauro MS, Rochira C, Agnello F, Giacoppo D, Ammirabile N, Landolina D, Imbesi A, Sangiorgio G, Greco A, Capodanno D. Pharmacological and clinical appraisal of factor XI inhibitor drugs. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:245-258. [PMID: 38196141 DOI: 10.1093/ehjcvp/pvae002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/04/2023] [Accepted: 01/08/2024] [Indexed: 01/11/2024]
Abstract
The evolution of anticoagulation therapy, from vitamin K antagonists to the advent of direct oral anticoagulants (DOACs) almost two decades ago, marks significant progress. Despite improved safety demonstrated in pivotal trials and post-marketing observations, persistent concerns exist, particularly regarding bleeding risk and the absence of therapeutic indications in specific subgroups or clinical contexts. Factor XI (FXI) has recently emerged as a pivotal contributor to intraluminal thrombus formation and growth, playing a limited role in sealing vessel wall injuries. Inhibiting FXI presents an opportunity to decouple thrombosis from haemostasis, addressing concerns related to bleeding events while safeguarding against thromboembolic events. Notably, FXI inhibition holds promise for patients with end-stage renal disease or cancer, where clear indications for DOACs are currently lacking. Various compounds have undergone design, testing, and progression to phase 2 clinical trials, demonstrating a generally favourable safety and tolerability profile. However, validation through large-scale phase 3 trials with sufficient power to assess both safety and efficacy outcomes is needed. This review comprehensively examines FXI inhibitors, delving into individual classes, exploring their pharmacological properties, evaluating the latest evidence from randomized trials, and offering insights into future perspectives.
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Affiliation(s)
- Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Daniele Giacoppo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Giuseppe Sangiorgio
- Department of Biomedical and Biotechnological Sciences, University of Catania, Catania 95123, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Catania 95123, Italy
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3
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Ali AE, Becker RC. Factor XI: structure, function and therapeutic inhibition. J Thromb Thrombolysis 2024:10.1007/s11239-024-02972-5. [PMID: 38622277 DOI: 10.1007/s11239-024-02972-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/17/2024]
Abstract
Arterial and venous thromboembolism is a major medical concern that requires therapeutic anticoagulation in various medical fields to prevent its drastic consequences. Despite significant advances in anticoagulant therapy, thrombosis remains a leading cause of morbidity and mortality worldwide. Traditional anticoagulants like heparin and vitamin K antagonists (VKAs) have shown efficacy in preventing and treating thrombosis but come with an inherent risk of bleeding due to their non-specific inhibition of multiple coagulation factors. Subsequent direct oral anticoagulants (DOACs), targeting specific factors such as Xa or thrombin, demonstrated improved safety profiles compared to VKAs, yet bleeding remains a concern. Accordingly, research is focused on developing anticoagulants with improved safety profiles. A safer class of anticoagulants would have broad appeal. The intrinsic pathway of coagulation, involving factor XI (FXI), has attracted attention as a potential target for safer anticoagulants. Preclinical studies and epidemiological data indicate that FXI deficiency or inhibition protects against thrombosis with minimal bleeding. Current research involves evaluating various FXI-directed strategies, and phase 2 studies have shown promising results in orthopedic surgery, atrial fibrillation, end-stage renal disease (ESRD), myocardial infarction, and ischemic stroke. Several agents, such as antisense oligonucleotides, monoclonal antibodies, small synthetic molecules, natural peptides, and aptamers, have been developed to inhibit FXI at different stages, offering potentially safer alternatives to traditional anticoagulants. However, the optimal balance between preventing thrombosis and the risk of bleeding associated with FXI inhibitors requires validation through extensive phase 3 clinical trials using definite clinical endpoints. Several of such trials are currently underway or planned to define the role of FXI inhibitors in clinical practice and determine the most suitable FXI inhibitor for each specific indication. The current review highlights the rationale behind developing FXI inhibitors, presenting the most advanced agents in development, summarizing completed clinical trials, and discussing ongoing research efforts.
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Affiliation(s)
- Ahmed E Ali
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Richard C Becker
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA.
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Ades M, Simard C, Vanassche T, Verhamme P, Eikelboom J, Mavrakanas TA. Factor XI Inhibitors: Potential Role in End-Stage Kidney Disease. Semin Nephrol 2023; 43:151484. [PMID: 38272779 DOI: 10.1016/j.semnephrol.2023.151484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Patients with end-stage kidney disease (ESKD) experience a high thrombotic risk but are also at increased risk of bleeding. There is an unmet need for safer antithrombotic therapy in patients with ESKD on hemodialysis. Factor XI (FXI) represents an attractive therapeutic target for anticoagulation because of the potential to mitigate the bleeding risks associated with currently approved anticoagulants, especially in patients at high risk of bleeding. FXI inhibition is also an attractive option in settings where coagulation is activated by exposure of the blood to artificial surfaces, including the extracorporeal circuit during hemodialysis. Therapies targeting FXI that are in the most advanced stages of clinical development include antisense oligonucleotides, monoclonal antibodies, and synthetic small molecules, which serve either to lower FXI levels or block its physiological effects. This review article presents the most recent pharmacological data with FXI inhibitors, briefly describes phase 2 and 3 clinical trials with these agents, and critically examines the potential future use of FXI inhibitors for extracorporeal circuit anticoagulation in patients with ESKD. In addition, laboratory monitoring and reversal of FXI inhibitors are briefly discussed.
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Affiliation(s)
- Matthew Ades
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Canada
| | - Camille Simard
- Division of General Internal Medicine, Department of Medicine, McGill University, Montreal, Canada; Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, Canada
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - John Eikelboom
- Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada
| | - Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Center and Research Institute, Montreal, Canada.
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5
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Sim MMS, Shiferawe S, Wood JP. Novel strategies in antithrombotic therapy: targeting thrombosis while preserving hemostasis. Front Cardiovasc Med 2023; 10:1272971. [PMID: 37937289 PMCID: PMC10626538 DOI: 10.3389/fcvm.2023.1272971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/06/2023] [Indexed: 11/09/2023] Open
Abstract
Antithrombotic therapy is a delicate balance between the benefits of preventing a thrombotic event and the risks of inducing a major bleed. Traditional approaches have included antiplatelet and anticoagulant medications, require careful dosing and monitoring, and all carry some risk of bleeding. In recent years, several new targets have been identified, both in the platelet and coagulation systems, which may mitigate this bleeding risk. In this review, we briefly describe the current state of antithrombotic therapy, and then present a detailed discussion of the new generation of drugs that are being developed to target more safely existing or newly identified pathways, alongside the strategies to reverse direct oral anticoagulants, showcasing the breadth of approaches. Combined, these exciting advances in antithrombotic therapy bring us closer than we have ever been to the "holy grail" of the field, a treatment that separates the hemostatic and thrombotic systems, preventing clots without any concurrent bleeding risk.
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Affiliation(s)
- Martha M. S. Sim
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY, United States
- Saha Cardiovascular Research Center, University of Kentucky, Lexington, KY, United States
| | - Semekidus Shiferawe
- Saha Cardiovascular Research Center, University of Kentucky, Lexington, KY, United States
| | - Jeremy P. Wood
- Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, KY, United States
- Saha Cardiovascular Research Center, University of Kentucky, Lexington, KY, United States
- Division of Cardiovascular Medicine Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, United States
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Kohs TCL, Fallon ME, Oseas EC, Healy LD, Tucker EI, Gailani D, McCarty OJT, Vandenbark AA, Offner H, Verbout NG. Pharmacological targeting of coagulation factor XI attenuates experimental autoimmune encephalomyelitis in mice. Metab Brain Dis 2023; 38:2383-2391. [PMID: 37341855 PMCID: PMC10530106 DOI: 10.1007/s11011-023-01251-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023]
Abstract
Multiple sclerosis (MS) is the most common causes of non-traumatic disability in young adults worldwide. MS pathophysiologies include the formation of inflammatory lesions, axonal damage and demyelination, and blood brain barrier (BBB) disruption. Coagulation proteins, including factor (F)XII, can serve as important mediators of the adaptive immune response during neuroinflammation. Indeed, plasma FXII levels are increased during relapse in relapsing-remitting MS patients, and previous studies showed that reducing FXII levels was protective in a murine model of MS, experimental autoimmune encephalomyelitis (EAE). Our objective was to determine if pharmacological targeting of FXI, a major substrate of activated FXII (FXIIa), improves neurological function and attenuates CNS damage in the setting of EAE. EAE was induced in male mice using murine myelin oligodendrocyte glycoprotein peptides combined with heat-inactivated Mycobacterium tuberculosis and pertussis toxin. Upon onset of symptoms, mice were treated every other day intravenously with anti-FXI antibody, 14E11, or saline. Disease scores were recorded daily until euthanasia for ex vivo analyses of inflammation. Compared to the vehicle control, 14E11 treatment reduced the clinical severity of EAE and total mononuclear cells, including CD11b+CD45high macrophage/microglia and CD4+ T cell numbers in brain. Following pharmacological targeting of FXI, BBB disruption was reduced, as measured by decreased axonal damage and fibrin(ogen) accumulation in the spinal cord. These data demonstrate that pharmacological inhibition of FXI reduces disease severity, immune cell migration, axonal damage, and BBB disruption in mice with EAE. Thus, therapeutic agents targeting FXI and FXII may provide a useful approach for treating autoimmune and neurologic disorders.
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Affiliation(s)
- Tia C L Kohs
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA.
| | - Meghan E Fallon
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
| | - Ethan C Oseas
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
| | - Laura D Healy
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
| | - Erik I Tucker
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
- Aronora, Inc., Portland, OR, USA
| | - David Gailani
- Department of Pathology and Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
| | - Arthur A Vandenbark
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Department of Molecular Microbiology & Immunology, Oregon Health & Science University, Portland, OR, USA
- Veterans Affairs Portland Health Care System, Portland, OR, USA
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Halina Offner
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Norah G Verbout
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S. Bond Avenue, Portland, OR, 97239, USA
- Aronora, Inc., Portland, OR, USA
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Jones A, Al-Horani RA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors. Med Sci (Basel) 2023; 11:49. [PMID: 37606428 PMCID: PMC10443384 DOI: 10.3390/medsci11030049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7-14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration.
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Affiliation(s)
| | - Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA;
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D'Allesandro N, Cave B, Hough A. Asundexian: an oral small molecule factor XIa inhibitor for the treatment of thrombotic disorders. Future Cardiol 2023; 19:477-486. [PMID: 37830334 DOI: 10.2217/fca-2023-0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Abstract
Oral anticoagulants, including warfarin and direct oral anticoagulants, are the standard of care for thrombosis prevention and treatment; however, concerns of bleeding often dictate treatment decisions. Inhibition of the intrinsic coagulation system via factor XIa may allow for selective inhibition of the coagulation cascade without significantly impacting hemostasis after injury. Asundexian is an oral small molecule factor XIa inhibitor that, via this novel mechanism, may prove to be a safe and effective option compared with available anticoagulants. Early clinical data for asundexian was promising as a safer alternative to current therapies and prompted further analysis in certain patient populations at increased thrombotic risk. Currently, studies are ongoing to evaluate the safety and efficacy in stroke prevention in atrial fibrillation and in patients following an acute noncardioembolic ischemic stroke or high-risk transient ischemic attack.
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Affiliation(s)
- Nicasia D'Allesandro
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
| | - Brandon Cave
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
| | - Augustus Hough
- West Palm Beach Veterans Affairs Medical Center, 7305 N Military Trail, West Palm Beach, FL 33410, USA
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Spiezia L, Forestan C, Campello E, Simion C, Simioni P. Persistently High Levels of Coagulation Factor XI as a Risk Factor for Venous Thrombosis. J Clin Med 2023; 12:4890. [PMID: 37568292 PMCID: PMC10420025 DOI: 10.3390/jcm12154890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/12/2023] [Accepted: 07/24/2023] [Indexed: 08/13/2023] Open
Abstract
Coagulation factor XI (FXI) promotes fibrin formation and inhibits fibrinolysis. Elevated plasma FXI levels, limited to a single measurement, are associated with a higher thrombotic risk. Our case-control study aimed to identify the effect of persistently increased plasma FXI levels on the risk of deep vein thrombosis (DVT). All patients evaluated between January 2016 and January 2018 for a first episode of proximal DVT of the lower extremity were considered for enrolment. Plasma FXI levels were measured at least 1 month after the discontinuation of anticoagulant treatment (T1). The patients with increased plasma FXI levels (>90th percentile of controls) were tested again 3 months later (T2). Among the 200 enrolled patients (M/F 114/86, age range 26-87 years), 47 patients had increased plasma FXI levels at T1 and16 patients had persistently increased plasma FXI levels at T2. The adjusted odds ratio for DVT was 2.4 (95% CI, 1.3 to 5.5, p < 0.001) for patients with increased FXI levels at T1 and 5.2 (95% CI, 2.3 to 13.2, p < 0.001) for patients with persistently high FXI levels at T2. Elevated FXI levels constitute a risk factor for deep vein thrombosis, and this risk nearly doubled in patients with persistently increased plasma FXI levels. Larger prospective studies are needed to confirm our findings.
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Affiliation(s)
- Luca Spiezia
- General Medicine and Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, University of Padova, 35138 Padova, Italy; (C.F.); (E.C.); (C.S.); (P.S.)
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10
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Piel I, Engelen A, Lang D, Schulz SI, Gerisch M, Brase C, Janssen W, Fiebig L, Heitmeier S, Kanefendt F. Metabolism and Disposition of the Novel Oral Factor XIa Inhibitor Asundexian in Rats and in Humans. Eur J Drug Metab Pharmacokinet 2023:10.1007/s13318-023-00838-4. [PMID: 37365440 DOI: 10.1007/s13318-023-00838-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Current anticoagulants pose an increased risk of bleeding. The development of drugs targeting factor XIa, like asundexian, may provide a safer treatment option. A human mass‑balance study was conducted to gain a deeper understanding of the absorption, distribution, metabolism, excretion, and potential for drug-drug interaction of asundexian. Additionally, an overview of the biotransformation and clearance pathways for asundexian in humans and bile-duct cannulated (BDC) rats in vivo, as well as in vitro in hepatocytes of both species, is reported. METHODS The mass balance, biotransformation, and excretion pathways of asundexian were investigated in six healthy volunteers (single oral dose of 25 mg [14C]asundexian) and in BDC rats (intravenous [14C]asundexian 1 mg/kg). RESULTS Overall recovery of radioactivity was 101% for humans (samples collected up to 14 days after dosing), and 97.9% for BDC rats (samples collected in the 24 h after dosing). Radioactivity was mainly excreted into feces in humans (80.3%) and into bile/feces in BDC rats (> 94%). The predominant clearance pathways in humans were amide hydrolysis to metabolite M1 (47%) and non-labeled M9 with subsequent N-acetylation to M10; oxidative biotransformation was a minor pathway (13%). In rats, hydrolysis of the terminal amide to M2 was the predominant pathway. In human plasma, asundexian accounted for 61.0% of total drug-related area under the plasma concentration-time curve (AUC); M10 was the major metabolite (16.4% of the total drug-related AUC). Excretion of unmetabolized drug was a significant clearance pathway in both species (human, ~ 37%; BDC rat, ~ 24%). The near-complete bioavailability of asundexian suggests negligible limitations on absorption and first-pass metabolism. Comparison with radiochromatograms from incubations with human or rat hepatocytes indicated consistency across species and a good overall in vitro/in vivo correlation. CONCLUSIONS Similar to preclinical experiments, total asundexian-derived radioactivity is cleared quantitatively predominantly via feces. Excretion occurs mainly via amide hydrolysis and as the unchanged drug.
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Affiliation(s)
- Isabel Piel
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Anna Engelen
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Dieter Lang
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Simone I Schulz
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Michael Gerisch
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | | | - Wiebke Janssen
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
| | - Lukas Fiebig
- Drug Metabolism and Pharmacokinetics, Bayer AG, Wuppertal, Germany
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Xia Y, Hu Y, Tang L. Factor XIa Inhibitors as a Novel Anticoagulation Target: Recent Clinical Research Advances. Pharmaceuticals (Basel) 2023; 16:866. [PMID: 37375813 DOI: 10.3390/ph16060866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/03/2023] [Accepted: 06/04/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND While current clinically administered anticoagulant medications have demonstrated effectiveness, they have also precipitated significant risks: severe bleeding complications including, but not limited to, gastrointestinal hemorrhaging and intracranial and other life-threatening major bleedings. An ongoing effort is being made to identify the best targets for anticoagulant-targeted drugs. Coagulation factor XIa (FXIa) is emerging as an important target of current anticoagulant treatment. OBJECTIVE This review will summarize the development of anticoagulants and recent advances in clinical trials of experimental factor XI inhibitors from a clinical application perspective. RESULTS As of 1 January 2023, our search screening included 33 clinical trials. We summarized the research progress of FXIa inhibitors from seven clinical trials that evaluated their efficacy and safety. The results showed no statistically meaningful distinction in the primary efficacy between patients receiving FXIa inhibitors compared to controls (RR = 0.796; 95% CI: 0.606-1.046; I2 = 68%). The outcomes did not indicate a statistical difference in the occurrence of any bleeding between patients receiving FXIa inhibitors compared to controls (RR = 0.717; 95% CI: 0.502-1.023; I2 = 60%). A subgroup analysis found significant differences in severe bleeding and clinically relevant hemorrhaging in subjects receiving FXIa inhibitors compared to Enoxaparin (RR = 0.457; 95% CI: 0.256-0.816; I2 = 0%). CONCLUSIONS Clinical trials to date have indicated that factor XIa is a potential anticoagulation target, and factor XIa inhibitors may play an important role in the development of anticoagulants.
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Affiliation(s)
- Yunqing Xia
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
- Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Liang Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1277 Jiefang Avenue, Wuhan 430022, China
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12
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Yin Q, Zhang X, Liao S, Huang X, Wan CC, Wang Y. Potential anticoagulant of traditional chinese medicine and novel targets for anticoagulant drugs. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 116:154880. [PMID: 37267694 DOI: 10.1016/j.phymed.2023.154880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/04/2023] [Accepted: 05/12/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Anticoagulants are the main drugs used for the prevention and treatment of thrombosis. Currently, anticoagulant drugs are primarily multitarget heparin drugs, single-target FXa inhibitors and FIIa inhibitors. In addition, some traditional Chinese drugs also have anticoagulant effects, but they are not the main direction of treatment at present. But the anticoagulant drugs mentioned above, all have a common side effect is bleeding. Many other anticoagulation targets are under investigation. With further exploration of coagulation mechanism, how to further determine new anticoagulant targets and how to make traditional Chinese medicine play anticoagulant role have become a new field of exploration. PURPOSE The purpose of the study was to summarize the recent research progress on coagulation mechanisms, new anticoagulant targets and traditional Chinese medicine. METHODS A comprehensive literature search was conducted using four electronic databases, including PubMed, Embase, CNKI, Wanfang database and ClinicalTrials.gov, from the inception of the study to 28 Feb 2023. Key words used in the literature search were "anticoagulation", "anticoagulant targets", "new targets", "coagulation mechanisms", "potential anticoagulant", "herb medicine", "botanical medicine", "Chinese medicine", "traditional Chinese medicine", "blood coagulation factor", keywords are linked with AND/OR. Recent findings on coagulation mechanisms, potential anticoagulant targets and traditional Chinese medicine were studied. RESULTS The active components extracted from the Chinese medicinal herbs, Salvia miltiorrhiza, Chuanxiong rhizoma, safflower and Panax notoginseng have obvious anticoagulant effects and can be used as potential anticoagulant drugs, but the risk of bleeding is unclear. TF/FVIIa, FVIII, FIX, FXI, FXII, and FXIII have all been evaluated as targets in animal studies or clinical trials. FIX and FXI are the most studied anticoagulant targets, but FXI inhibitors have shown stronger advantages. CONCLUSION This review of potential anticoagulants provides a comprehensive resource. Literature analysis suggests that FXI inhibitors can be used as potential anticoagulant candidates. In addition, we should not ignore the anticoagulant effect of traditional Chinese medicine, and look forward to more research and the emergence of new drugs.
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Affiliation(s)
- Qinan Yin
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China
| | - Xiaoqin Zhang
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China
| | - Suqing Liao
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China
| | - Xiaobo Huang
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China
| | - Chunpeng Craig Wan
- College of Agronomy, Jiangxi Agricultural University, Jiangxi Key Laboratory for Post-Harvest Technology and Nondestructive Testing of Fruits & Vegetables, Nanchang 330045, PR. China.
| | - Yi Wang
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China.
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13
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Bentounes NK, Melicine S, Martin AC, Smadja DM, Gendron N. Development of new anticoagulant in 2023: Prime time for anti-factor XI and XIa inhibitors. JOURNAL DE MEDECINE VASCULAIRE 2023; 48:69-80. [PMID: 37422330 DOI: 10.1016/j.jdmv.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/14/2023] [Indexed: 07/10/2023]
Abstract
Thrombosis remains one of the leading causes of death in the world. The history of anticoagulation has evolved considerably from non-specific drugs (i.e., heparins and vitamin K antagonists, VKA) to agents that directly target specific coagulation factors (i.e., argatroban, fondaparinux and direct oral anticoagulants, DOAC). Since the last decade, DOAC are widely used in clinical practice because of their ease to use with favorable pharmacological profile and not requiring monitoring, particularly for venous thromboembolism treatment and prevention and stroke prevention in atrial fibrillation. However, despite having a better safety profile than VKA, their bleeding risk is not negligible. Therefore, research is underway to develop new anticoagulant therapies with a better safety profile. One of these news approaches to reduce the risk of bleeding is to target the coagulation in the intrinsic pathway, in particular the contact activation, with the ultimate goal of preventing thrombosis without impairing hemostasis. Based on epidemiological data with patients with inherited factor XI (FXI) deficiency and preclinical studies, FXI emerged as the most promising candidate target separating hemostasis from thrombosis. This review summaries the role of FXI and FXIa in hemostasis, provides evidence of initial success with FXI pathway inhibitors in clinical trials (such as IONIS-FXIRx, fesomersen, osocimab, abelacimab, milvexian, asundexian or xisomab 3G3) and highlights the opportunities and challenges for this next generation of anticoagulants.
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Affiliation(s)
- Nûn K Bentounes
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France
| | - Sophie Melicine
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France
| | - Anne Céline Martin
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Cardiology Department, Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France
| | - David M Smadja
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France; INNOVTE, F-CRIN, Saint-Étienne, France
| | - Nicolas Gendron
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France.
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14
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Affiliation(s)
- Eugene Braunwald
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Hale Building for Transformative Medicine, Suite 7022, 60 Fenwood Road, Boston, MA 02115, USA
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15
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Greco A, Laudani C, Spagnolo M, Agnello F, Faro DC, Finocchiaro S, Legnazzi M, Mauro MS, Mazzone PM, Occhipinti G, Rochira C, Scalia L, Capodanno D. Pharmacology and Clinical Development of Factor XI Inhibitors. Circulation 2023; 147:897-913. [PMID: 36913497 DOI: 10.1161/circulationaha.122.062353] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Therapeutic anticoagulation is indicated for a variety of circumstances and conditions in several fields of medicine to prevent or treat venous and arterial thromboembolism. According to the different mechanisms of action, the available parenteral and oral anticoagulant drugs share the common principle of hampering or blocking key steps of the coagulation cascade, which unavoidably comes at the price of an increased propensity to bleed. Hemorrhagic complications affect patient prognosis both directly and indirectly (ie, by preventing the adoption of an effective antithrombotic strategy). Inhibition of factor XI (FXI) has emerged as a strategy with the potential to uncouple the pharmacological effect and the adverse events of anticoagulant therapy. This observation is based on the differential contribution of FXI to thrombus amplification, in which it plays a major role, and hemostasis, in which it plays an ancillary role in final clot consolidation. Several agents were developed to inhibit FXI at different stages (ie, suppressing biosynthesis, preventing zymogen activation, or impeding the biological action of the active form), including antisense oligonucleotides, monoclonal antibodies, small synthetic molecules, natural peptides, and aptamers. Phase 2 studies of different classes of FXI inhibitors in orthopedic surgery suggested that dose-dependent reductions in thrombotic complications are not paralleled by dose-dependent increases in bleeding compared with low-molecular-weight heparin. Likewise, the FXI inhibitor asundexian was associated with lower rates of bleeding compared with the activated factor X inhibitor apixaban in patients with atrial fibrillation, although no evidence of a therapeutic effect on stroke prevention is available so far. FXI inhibition could also be appealing for patients with other conditions, including end-stage renal disease, noncardioembolic stroke, or acute myocardial infarction, for which other phase 2 studies have been conducted. The balance between thromboprophylaxis and bleeding achieved by FXI inhibitors needs confirmation in large-scale phase 3 clinical trials powered for clinical end points. Several of such trials are ongoing or planned to define the role of FXI inhibitors in clinical practice and to clarify which FXI inhibitor may be most suited for each clinical indication. This article reviews the rationale, pharmacology, results of medium or small phase 2 studies, and future perspectives of drugs inhibiting FXI.
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Affiliation(s)
- Antonio Greco
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Claudio Laudani
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Marco Spagnolo
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Federica Agnello
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | | | - Simone Finocchiaro
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Marco Legnazzi
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Maria Sara Mauro
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | | | | | - Carla Rochira
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Lorenzo Scalia
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
| | - Davide Capodanno
- A.O.U. Policlinico "G. Rodolico - San Marco", University of Catania, Italy
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16
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Kanefendt F, Brase C, Unger S, Kubitza D. Effects of Tablet Formulation, Food, or Gastric pH on the Bioavailability of Asundexian. Clin Pharmacol Drug Dev 2023; 12:219-230. [PMID: 36507617 PMCID: PMC10107294 DOI: 10.1002/cpdd.1207] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 11/07/2022] [Indexed: 12/14/2022]
Abstract
Absolute bioavailability (F) and the impact of gastric pH, tablet formulation, and food on the pharmacokinetics and safety of asundexian, an oral factor XIa inhibitor, was assessed in healthy White men aged 18-45 years in 4 studies. For F, fasted participants received 50 μg of [13 C7 ,15 N]-labeled asundexian intravenously 2 hours after 25 mg of asundexian orally. Tablet formulation (50-mg immediate release [IR], and different amorphous solid dispersion [ASD] IR 25-mg and 50-mg ASD IR tablets) and food effects were explored in 2 studies. Formulation was compared using 50-mg IR versus 25-mg ASD IR and 25-mg ASD IR versus 50-mg ASD IR (fasted); food effect using 25-mg ASD IR and 50-mg ASD IR. Gastric pH modulation was assessed using omeprazole or antacid coadministration with asundexian in the fasted state. Pharmacokinetic parameters included area under the concentration-time curve (AUC; and AUC/dose [D]) and maximum observed concentration (Cmax and Cmax /D) data were evaluable for 59 participants. F was 103.9%. Relative bioavailability with 25-mg ASD IR and 50-mg ASD IR tablets, respectively, was marginally affected by formulation (AUC/D ratios, 94.3% and 95.1%; Cmax /D ratios, 95.5% and 88.7%), food (AUC[/D] ratios, 91.1% and 96.9%; Cmax [/D] ratios: 78.3% and 95.1%), and gastric pH (omeprazole, no effect; antacid, AUC ratio, 89.9% and Cmax ratio, 83.7%). No serious adverse events or deaths occurred; most adverse events were mild or moderate. In summary, oral asundexian was well tolerated and demonstrated complete bioavailability irrespective of tablet formulation, food, or gastric pH.
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Affiliation(s)
- Friederike Kanefendt
- Bayer AG, Research and Early Development, Clinical Pharmacology, Wuppertal, Germany
| | - Christine Brase
- Bayer AG, Research and Early Development, Clinical Pharmacology, Wuppertal, Germany
| | - Sigrun Unger
- Bayer AG, Research and Early Development, Statistics, Wuppertal, Germany
| | - Dagmar Kubitza
- Bayer AG, Research and Early Development, Clinical Pharmacology, Wuppertal, Germany
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17
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De Caterina R, Prisco D, Eikelboom JW. Factor XI inhibitors: cardiovascular perspectives. Eur Heart J 2023; 44:280-292. [PMID: 36263776 DOI: 10.1093/eurheartj/ehac464] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/15/2022] [Accepted: 08/11/2022] [Indexed: 01/28/2023] Open
Abstract
Anticoagulants are the cornerstone for prevention and treatment of thrombosis but are not completely effective, and concerns about the risk of bleeding continue to limit their uptake. Animal studies and experience from patients with genetic coagulation factor XI deficiency suggesting that this factor is more important for thrombosis than for haemostasis raises the potential for drugs that target factor XI to provide safer anticoagulation. Multiple factor XI inhibitors are currently under evaluation in clinical trials, including parenterally administered antisense oligonucleotides, monoclonal antibodies, and orally active small-molecule inhibitors. Promising results of phase 2 trials in patients undergoing major orthopaedic surgery, and in those with end-stage kidney disease, atrial fibrillation and acute coronary syndromes have led to large phase 3 trials that are currently ongoing. We here review premises for the use of these agents, results so far accrued, ongoing studies, and perspectives for future patient care.
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Affiliation(s)
- Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Division of Cardiology, Pisa University Hospital, Pisa, Italy
| | - Domenico Prisco
- Chair of Internal Medicine, Department of Experimental and Clinical Medicine, University of Florence and Careggi University Hospital, Florence, Italy
| | - John W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
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18
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Platelet-Neutrophil Crosstalk in Thrombosis. Int J Mol Sci 2023; 24:ijms24021266. [PMID: 36674781 PMCID: PMC9861587 DOI: 10.3390/ijms24021266] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/02/2023] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
Platelets are essential for the formation of a haemostatic plug to prevent bleeding, while neutrophils are the guardians of our immune defences against invading pathogens. The interplay between platelets and innate immunity, and subsequent triggering of the activation of coagulation is part of the host system to prevent systemic spread of pathogen in the blood stream. Aberrant immunothrombosis and excessive inflammation can however, contribute to the thrombotic burden observed in many cardiovascular diseases. In this review, we highlight how platelets and neutrophils interact with each other and how their crosstalk is central to both arterial and venous thrombosis and in COVID-19. While targeting platelets and coagulation enables efficient antithrombotic treatments, they are often accompanied with a bleeding risk. We also discuss how novel approaches to reduce platelet-mediated recruitment of neutrophils could represent promising therapies to treat thrombosis without affecting haemostasis.
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19
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Cohen O, Ageno W. Coming soon to a pharmacy near you? FXI and FXII inhibitors to prevent or treat thromboembolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:495-505. [PMID: 36485148 PMCID: PMC9821115 DOI: 10.1182/hematology.2022000386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Anticoagulants have been in use for nearly a century for the treatment and prevention of venous and arterial thromboembolic disorders. The most dreaded complication of anticoagulant treatment is the occurrence of bleeding, which may be serious and even life-threatening. All available anticoagulants, which target either multiple coagulation factors or individual components of the tissue factor (TF) factor VIIa or the common pathways, have the potential to affect hemostasis and thus to increase bleeding risk in treated patients. While direct oral anticoagulants introduced an improvement in care for eligible patients in terms of safety, efficacy, and convenience of treatment, there remain unmet clinical needs for patients requiring anticoagulant drugs. Anticoagulant therapy is sometimes avoided for fear of hemorrhagic complications, and other patients are undertreated due to comorbidities and the perception of increased bleeding risk. Evidence suggests that the contact pathway of coagulation has a limited role in initiating physiologic in vivo coagulation and that it contributes to thrombosis more than it does to hemostasis. Because inhibition of the contact pathway is less likely to promote bleeding, it is an attractive target for the development of anticoagulants with improved safety. Preclinical and early clinical data indicate that novel agents that selectively target factor XI or factor XII can reduce venous and arterial thrombosis without an increase in bleeding complications.
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Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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20
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Bar Barroeta A, Marquart JA, Bakhtiari K, Meijer AB, Urbanus RT, Meijers JCM. Nanobodies against factor XI apple 3 domain inhibit binding of factor IX and reveal a novel binding site for high molecular weight kininogen. J Thromb Haemost 2022; 20:2538-2549. [PMID: 35815349 PMCID: PMC9795894 DOI: 10.1111/jth.15815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/21/2022] [Accepted: 07/05/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Factor XI (FXI) is a promising target for novel anticoagulants because it shows a strong relation to thromboembolic diseases, while fulfilling a mostly supportive role in hemostasis. Anticoagulants targeting FXI could therefore reduce the risk for thrombosis, without increasing the chance of bleeding side effects. OBJECTIVES To generate nanobodies that can interfere with FXIa mediated activation of factor IX (FIX). METHODS Nanobodies were selected for binding to the apple 3 domain of FXI and their effects on FXI and coagulation were measured in purified protein systems as well as in plasma-based coagulation assays. Additionally, the binding epitope of selected nanobodies was assessed by hydrogen-deuterium exchange mass spectrometry. RESULTS We have identified five nanobodies that inhibit FIX activation by FXI by competing with the FIX binding site on FXI. Interestingly, a sixth nanobody was found to target a different binding epitope in the apple 3 domain, resulting in competition with the FXI-high molecular weight kininogen (HK) interaction. CONCLUSIONS We have characterized a nanobody targeting the FXI apple 3 domain that elucidates the binding orientation of HK on FXI. Moreover, we have produced five nanobodies that can inhibit the FXI-FIX interaction.
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Affiliation(s)
| | | | - Kamran Bakhtiari
- Department of Molecular HematologySanquinAmsterdamthe Netherlands
| | - Alexander B. Meijer
- Department of Molecular HematologySanquinAmsterdamthe Netherlands
- Department of PharmaceuticsUtrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht UniversityUtrechtthe Netherlands
| | - Rolf T. Urbanus
- Center for Benign Haematology, Thrombosis and Haemostasis, Van CreveldkliniekUniversity Medical Center Utrecht, University UtrechtUtrechtthe Netherlands
| | - Joost C. M. Meijers
- Department of Molecular HematologySanquinAmsterdamthe Netherlands
- Department of Experimental Vascular MedicineAmsterdam UMC, University of AmsterdamAmsterdamthe Netherlands
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and ThrombosisAmsterdamthe Netherlands
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21
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Luo Q, Wenzel P. Properdin (factor P) as a new target cleaved by factor
XIa
: Intrinsic coagulation at the crossroads with inflammation. Res Pract Thromb Haemost 2022; 6:e12835. [PMID: 36349265 PMCID: PMC9634820 DOI: 10.1002/rth2.12835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/14/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Qi Luo
- Center for Thrombosis and Hemostasis Mainz University Medical Center Mainz Mainz Germany
- Department of Biochemistry, CARIM School for Cardiovascular Research Maastricht University Maastricht The Netherlands
| | - Philip Wenzel
- Center for Thrombosis and Hemostasis Mainz University Medical Center Mainz Mainz Germany
- Department of Biochemistry, CARIM School for Cardiovascular Research Maastricht University Maastricht The Netherlands
- Center for Cardiology, Cardiology I University Medical Center Mainz Mainz Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Rhine Main University Medical Center Mainz Mainz Germany
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22
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Heitmeier S, Visser M, Tersteegen A, Dietze‐Torres J, Glunz J, Gerdes C, Laux V, Stampfuss J, Roehrig S. Pharmacological profile of asundexian, a novel, orally bioavailable inhibitor of factor XIa. J Thromb Haemost 2022; 20:1400-1411. [PMID: 35289054 PMCID: PMC9313898 DOI: 10.1111/jth.15700] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/02/2022] [Accepted: 03/07/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Activated coagulation factor XI (FXIa) contributes to the development and propagation of thrombosis but plays only a minor role in hemostasis; therefore, it is an attractive antithrombotic target. OBJECTIVES To evaluate the pharmacology of asundexian (BAY 2433334), a small molecule inhibitor targeting FXIa, in vitro and in various rabbit models. METHODS The effects of asundexian on FXIa activity, selectivity versus other proteases, plasma thrombin generation, and clotting assays were evaluated. Antithrombotic effects were determined in FeCl2 - and arterio-venous (AV) shunt models. Asundexian was administered intravenously or orally, before or during thrombus formation, and with or without antiplatelet drugs (aspirin and ticagrelor). Potential effects of asundexian on bleeding were evaluated in ear-, gum-, and liver injury models. RESULTS Asundexian inhibited human FXIa with high potency and selectivity. It reduced FXIa activity, thrombin generation triggered by contact activation or low concentrations of tissue factor, and prolonged activated partial thromboplastin time in human, rabbit, and various other species, but not in rodents. In the FeCl2 -injury models, asundexian reduced thrombus weight versus control, and in the arterial model when added to aspirin and ticagrelor. In the AV shunt model, asundexian reduced thrombus weight when administered before or during thrombus formation. Asundexian alone or in combination with antiplatelet drugs did not increase bleeding times or blood loss in any of the models studied. CONCLUSIONS Asundexian is a potent oral FXIa inhibitor with antithrombotic efficacy in arterial and venous thrombosis models in prevention and intervention settings, without increasing bleeding.
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Affiliation(s)
- Stefan Heitmeier
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Mayken Visser
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | | | | | - Julia Glunz
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Christoph Gerdes
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Volker Laux
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Jan Stampfuss
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
| | - Susanne Roehrig
- Bayer AGResearch and Development PharmaceuticalsWuppertalGermany
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23
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Poenou G, Dumitru Dumitru T, Lafaie L, Mismetti V, Heestermans M, Bertoletti L. Factor XI Inhibition for the Prevention of Venous Thromboembolism: An Update on Current Evidence and Future perspectives. Vasc Health Risk Manag 2022; 18:359-373. [PMID: 35707632 PMCID: PMC9191224 DOI: 10.2147/vhrm.s331614] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/30/2022] [Indexed: 12/18/2022] Open
Abstract
During the past decade, emergence of direct oral anticoagulants (DOACs) has drastically improved the prevention of thrombosis. However, several unmet needs prevail in the field of thrombosis prevention, even in the DOACs’ era. The use of DOACs is still constrained and the drugs cannot be administered in every clinical scenario, such as an increased anticoagulant-associated bleeding risk, particularly in some specific populations (cancer – notably those with gastrointestinal or genitourinary cancer – and frail patients), the impossibility to be used in certain patients (eg, end-stage kidney failure during hemodialysis, pregnancy and breastfeeding), and their lack of efficacy in certain clinical scenarios (eg, mechanical heart valves, triple-positive antiphospholipid syndrome). Efforts to find a factor that upon antagonization prevents thrombosis but spares haemostasis have resulted in the identification of coagulation factor XI (FXI) as a therapeutic target. After briefly recapitulating the role of factor XI in the balance of haemostasis, we propose a narrative review of the key data published to date with compounds targeting factor XI to prevent thrombosis as well as the main ongoing clinical studies, opening up prospects for improving the care of patients requiring thrombosis prevention.
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Affiliation(s)
- Geraldine Poenou
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
| | - Teona Dumitru Dumitru
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
- Internal Medicine Department, University Hospital Santa Lucía, Cartagena, Murcia, Spain
- Catholic University San Antonio, Murcia, Spain
| | - Ludovic Lafaie
- Geriatric Department, University Hospital of Saint Etienne, Saint Etienne, France
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
| | - Valentine Mismetti
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- Pneumology Department, University Hospital of Saint Etienne, Saint Etienne, France
| | - Marco Heestermans
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- Auvergne-Rhône-Alpes French Blood Donation Agency, Saint-Etienne, F-42100, France
| | - Laurent Bertoletti
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- INSERM, CIC-1408, University Hospital of Saint Etienne, Saint Etienne, France
- Correspondence: Laurent Bertoletti, Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France, Tel +33477827771, Fax +33477820482, Email
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Ding L, Shu Z, Hao J, Luo X, Ye X, Zhu W, Duan W, Chen Z. Schixator, a new FXa inhibitor from Schistosoma japonicum with antithrombotic effect and low bleeding risk. Biochem Biophys Res Commun 2022; 603:138-143. [DOI: 10.1016/j.bbrc.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
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Mosconi MG, Paciaroni M, Ageno W. Investigational drugs for ischemic stroke: what's in the clinical development pipeline for acute phase and prevention? Expert Opin Investig Drugs 2022; 31:645-667. [PMID: 35486110 DOI: 10.1080/13543784.2022.2072725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Stroke is a leading cause of disability and mortality and its burden expected to increase. The only approved drug for acute ischemic stroke is the intravenous thrombolytic alteplase. The risk of bleeding complications is one of the reasons for the undertreatment of eligible patients. Numerous drugs are currently being developed to improve safety-efficacy. AREAS COVERED We reviewed literature from January 1st, 2000, to 15th January 2022 for the development and testing of novel drugs with the aim of targeting treatment at prevention of ischemic stroke: PubMed, MEDLINE, Google Scholar, and ClinicalTrial.gov. EXPERT OPINION The pathophysiology of ischemic stroke involves multiple pathways causing cerebral artery obstruction and brain tissue ischemia. Data suggest that tenecteplase is a more promising fibrinolytic agent with a superior efficacy-safety profile, compared to the currently approved alteplase. Current guidelines consider a short-term cycle of mannitol or hypertonic saline to be advisable in patients with space-occupying hemispheric infarction. Regarding primary and secondary prevention, research is primarily focused on identifying mechanisms to improve the safety-efficacy profile using a "hemostasis-sparing" approach. Further evaluation on those agents that have already shown promise for their risk/benefit profiles, would benefit greatly a neurologist's capacity to successfully prevent and treat ischemic stroke patients.
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Affiliation(s)
- Maria Giulia Mosconi
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Maurizio Paciaroni
- Emergency and vascular medicine Stroke Unit University of Perugia, Perugia, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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A FRET-based assay for the quantitation of the thrombin-factor XI interaction. Thromb Res 2022; 214:23-28. [DOI: 10.1016/j.thromres.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/30/2022] [Accepted: 04/11/2022] [Indexed: 11/23/2022]
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Kluge KE, Seljeflot I, Arnesen H, Jensen T, Halvorsen S, Helseth R. Coagulation factors XI and XII as possible targets for anticoagulant therapy. Thromb Res 2022; 214:53-62. [DOI: 10.1016/j.thromres.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 04/04/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
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Chen H, Shen M, Niu R, Mu X, Jiang Q, Peng R, Yuan Y, Wang H, Wang Q, Yang H, Guo H, He M, Zhang X, Wu T. Associations of coagulation factor X and XI with incident acute coronary syndrome and stroke: A nested case-control study. J Thromb Haemost 2021; 19:2781-2790. [PMID: 34351069 PMCID: PMC9290014 DOI: 10.1111/jth.15486] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 06/23/2021] [Accepted: 07/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coagulation cascade contributes to thrombotic and hemorrhagic diseases, but it remains unclear whether coagulation factors X (FX) and XI (FXI) levels are associated with cardiovascular diseases. OBJECTIVE To evaluate prospective associations of FX and FXI levels with incident acute coronary syndrome (ACS), stroke, and their subtypes (acute myocardial infarction, unstable angina, ischemic stroke, and hemorrhagic stroke). METHODS We performed a nested case-control study (n = 1846) within the Dongfeng-Tongji cohort from 2013 to 2016 matched on age (within 1 year), sex, and sampling date (within 1 month) by incidence density sampling, and measured plasma FX and FXI levels by enzyme-linked immunosorbent assay. FX and FXI levels were categorized into three groups (low, <25th; middle, 25th to <75th; and high ≥75th percentiles) according to distributions, and conditional logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS After adjustment for traditional cardiovascular risk factors, compared with middle groups, the OR (95% CI) in high levels of FX and FXI were 1.11 (0.79-1.56) and 0.96 (0.68-1.36) for incident ACS, and 1.01 (0.63-1.62) and 1.72 (1.14-2.60) for incident stroke, respectively. As for subtypes of ACS and stroke, only high FXI levels were significantly associated with incident ischemic stroke (OR 1.66, 95% CI 1.05-2.65). Moreover, all associations remained steady after additional adjustment for platelet and leukocyte. CONCLUSION FXI levels were associated with a greater risk of incident ischemic stroke but not hemorrhagic stroke or ACS. FX levels were not associated with incident ACS or stroke.
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Affiliation(s)
- Huiting Chen
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Miaoyan Shen
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Rundong Niu
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xuanwen Mu
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Qin Jiang
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Rong Peng
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yu Yuan
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Hao Wang
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Qiuhong Wang
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Handong Yang
- Department of Cardiovascular DiseasesSinopharm Dongfeng General HospitalHubei University of MedicineShiyanChina
| | - Huan Guo
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Meian He
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Xiaomin Zhang
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Tangchun Wu
- Department of Occupational and Environmental HealthKey Laboratory of Environment and HealthMinistry of Education and State Key Laboratory of Environmental Health (Incubating)School of Public HealthTongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
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Narducci ML, Patrono C. Abelacimab and factor XI inhibition: a novel mechanism for the prevention of venous thromboembolism. Eur Heart J 2021; 42:4109-4110. [PMID: 34519340 DOI: 10.1093/eurheartj/ehab590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Maria Lucia Narducci
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A.Gemelli IRCCS, Catholic University School of Medicine, Largo A. Gemelli, 8, Rome 00168, Italy
| | - Carlo Patrono
- Department of Pharmacology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Catholic University School of Medicine, Largo A. Gemelli, 8, Rome 00168, Italy
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Eikelboom J, Floege J, Thadhani R, Weitz JI, Winkelmayer WC. Anticoagulation in patients with kidney failure on dialysis: factor XI as a therapeutic target. Kidney Int 2021; 100:1199-1207. [PMID: 34600964 DOI: 10.1016/j.kint.2021.08.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/23/2021] [Accepted: 08/26/2021] [Indexed: 12/18/2022]
Abstract
Chronic kidney disease is present in almost 10% of the world population and is associated with excess mortality and morbidity. Reduced glomerular filtration rate and the presence and extent of proteinuria, key domains of chronic kidney disease, have both been shown to be strong and independent risk factors for cardiovascular disease. Patients with kidney failure requiring dialysis are at highest risk for cardiovascular events (e.g., stroke or myocardial infarction), and of developing chronic cardiovascular conditions, such as heart failure. Despite the high burden of cardiovascular disease, there is a paucity of evidence supporting therapies to reduce this risk. Although long-term anticoagulant treatment has the potential to prevent thromboembolism in persons with kidney failure on dialysis, this possibility remains understudied. The limited data available on anticoagulation in patients with kidney failure has focused on vitamin K antagonists or direct oral anticoagulants that inhibit thrombin or factor (F) Xa. The risk of bleeding is a major concern with these agents. However, FXI is emerging as a potential safer target for new anticoagulants because FXI plays a greater part in thrombosis than in hemostasis. In this article, we (i) explain the rationale for considering anticoagulation therapy in patients with kidney failure to reduce atherothrombotic events, (ii) highlight the limitations of current anticoagulants in this patient population, (iii) explain the potential benefits of FXI inhibitors, and (iv) summarize ongoing studies investigating FXI inhibition in patients with kidney failure on dialysis.
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Affiliation(s)
- John Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jürgen Floege
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Ravi Thadhani
- Division of Nephrology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey I Weitz
- Departments of Medicine and Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton General Hospital, Hamilton, Ontario, Canada
| | - Wolfgang C Winkelmayer
- Department of Medicine, Section of Nephrology and Selzman Institute for Kidney Health, Baylor College of Medicine, Houston, Texas, USA.
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Thomas D, Kanefendt F, Schwers S, Unger S, Yassen A, Boxnick S. First evaluation of the safety, pharmacokinetics, and pharmacodynamics of BAY 2433334, a small molecule targeting coagulation factor XIa. J Thromb Haemost 2021; 19:2407-2416. [PMID: 34192419 PMCID: PMC8518835 DOI: 10.1111/jth.15439] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/21/2021] [Accepted: 06/28/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Coagulation factor XI (FXI) contributes to the development of thrombosis but appears to play a minor role in hemostasis and is, therefore, an attractive anticoagulant drug target. OBJECTIVES To evaluate the safety, pharmacokinetic, and pharmacodynamic properties of BAY 2433334, an orally administered small molecule targeting activated FXI (FXIa), in healthy men. PATIENTS/METHODS This phase 1 study was conducted in two parts. In part 1, 70 volunteers were randomized 4:1 to receive a single oral dose of BAY 2433334 (5-150 mg as oral solution or immediate-release tablets) or placebo. In part 2, 16 volunteers received a single oral dose of five BAY 2433334 5-mg tablets with or without a high-calorie breakfast in a randomized crossover study design. Adverse events, pharmacokinetic parameters, and pharmacodynamic parameters were assessed up to 72 h after drug administration. Volunteers were followed up after 7 to 14 days. RESULTS BAY 2433334 demonstrated favorable safety and tolerability with a dose-dependent increase in exposure and a terminal half-life of 14.2 to 17.4 h. A high-calorie breakfast reduced mean maximum plasma concentration and exposure by 31% and 12.4%, respectively. AY 2433334 was associated with a dose-dependent inhibition of FXIa activity and an increase in activated partial thromboplastin time. Bleeding times in volunteers who had received BAY 2433334 were similar to those in volunteers who had received placebo. CONCLUSIONS These data indicate that BAY 2433334 is a promising development candidate for once-daily oral anticoagulation; it is being evaluated in phase 2 dose-finding studies in patients at risk of thrombosis.
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Affiliation(s)
- Dirk Thomas
- Research and Development PharmaceuticalsBayer AGWuppertalGermany
| | | | - Stephan Schwers
- Research and Development PharmaceuticalsBayer AGWuppertalGermany
| | - Sigrun Unger
- Research and Development PharmaceuticalsBayer AGWuppertalGermany
| | - Ashraf Yassen
- Research and Development PharmaceuticalsBayer AGWuppertalGermany
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Abstract
Factor XI (FXI) deficiency (hemophilia C or Rosenthal disease) was first described in the 1950s in a multigenerational family experiencing bleeding related to surgery and dental procedures. Managing patients with FXI deficiency presents several challenges, including a lack of correlation of bleeding symptoms with FXI activity levels, the large volume of fresh frozen plasma required to achieve hemostatic FXI levels, lack of availability of FXI concentrate in certain regions of the world, and the inherent thrombotic risk associated with replacement therapy. This article summarizes presentation, diagnosis, and management of patients with FXI deficiency in a variety of clinical settings.
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Affiliation(s)
| | - Jean Marie Connors
- Hematology Division, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, 75 Francis Street, Boston, MA 02215, USA. https://twitter.com/connors_md
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D’Andrea G, Margaglione M. Rare Defects: Looking at the Dark Face of the Thrombosis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179146. [PMID: 34501736 PMCID: PMC8430787 DOI: 10.3390/ijerph18179146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 12/16/2022]
Abstract
Venous thromboembolism (VTE) constitutes a serious and potentially fatal disease, often complicated by pulmonary embolism and is associated with inherited or acquired factors risk. A series of risk factors are known to predispose to venous thrombosis, and these include mutations in the genes that encode anticoagulant proteins as antithrombin, protein C and protein S, and variants in genes that encode instead pro-coagulant factors as factor V (FV Leiden) and factor II (FII G20210A). However, the molecular causes responsible for thrombotic events in some individuals with evident inherited thrombosis remain unknown. An improved knowledge of risk factors, as well as a clear understanding of their role in the pathophysiology of VTE, are crucial to achieve a better identification of patients at higher risk. Moreover, the identification of genes with rare variants but a large effect size may pave the way for studies addressing new antithrombotic agents in order to improve the management of VTE patients. Over the past 20 years, qualitative or quantitative genetic risk factors such as inhibitor proteins of the hemostasis and of the fibrinolytic system, including fibrinogen, thrombomodulin, plasminogen activator inhibitor-1, and elevated concentrations of factors II, FV, VIII, IX, XI, have been associated with thrombotic events, often with conflicting results. The aim of this review is to evaluate available data in literature on these genetic variations to give a contribution to our understanding of the complex molecular mechanisms involved in physiologic and pathophysiologic clot formation and their role in clinical practice.
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Mavromanoli AC, Barco S, Konstantinides SV. Antithrombotics and new interventions for venous thromboembolism: Exploring possibilities beyond factor IIa and factor Xa inhibition. Res Pract Thromb Haemost 2021; 5:S2475-0379(22)01378-4. [PMID: 34027284 PMCID: PMC8130658 DOI: 10.1002/rth2.12509] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 02/19/2021] [Accepted: 03/04/2021] [Indexed: 12/17/2022] Open
Abstract
Direct oral anti-activated factor X and antithrombin agents have largely replaced vitamin K antagonists as the standard of care in treatment of venous thromboembolism. However, gaps in efficacy and safety persist, notably in end-stage renal disease, implantable heart valves or assist devices, extracorporeal support of the circulation, and antiphospholipid syndrome. Inhibition of coagulation factor XI (FXI) emerges as a promising new therapeutic target. Antisense oligonucleotides offer potential advantages as a prophylactic or therapeutic modality, with one dose-finding trial in orthopedic surgery already published. In addition, monoclonal antibodies blocking activation and/or activity of activated factor XI are investigated, as are small-molecule inhibitors with rapid offset of action. Further potential targets include upstream components of the contact pathway such as factor XII, polyphosphates, or kallikrein. Finally, catheter-directed, pharmacomechanical antithrombotic strategies have been developed for high- and intermediate-risk pulmonary embolism, and large randomized trials aiming to validate their efficacy, safety, and prognostic impact are about to start.
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Affiliation(s)
- Anna C. Mavromanoli
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Clinic of AngiologyUniversity Hospital ZurichZurichSwitzerland
| | - Stavros V. Konstantinides
- Center for Thrombosis and Hemostasis (CTH)University Medical Center of the Johannes Gutenberg UniversityMainzGermany
- Department of CardiologyDemocritus University of ThraceAlexandroupolisGreece
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Abstract
Despite advances in anticoagulant therapy, thrombosis remains the leading cause of morbidity and mortality worldwide. Heparin and vitamin K antagonists (VKAs), the first anticoagulants to be used successfully for the prevention and treatment of thrombosis, are associated with a risk of bleeding. These agents target multiple coagulation factors. Thus, by activating antithrombin, heparin mainly inhibits factor Xa and thrombin, whereas VKAs lower the levels of the vitamin K-dependent clotting factors. Direct oral anticoagulants, which have replaced VKAs for many indications, inhibit only factor Xa or thrombin. Although the direct oral anticoagulants are associated with less bleeding than VKAs, bleeding remains their major side effect. Epidemiological and animal studies have identified factor XI as a target for potentially safer anticoagulant drugs because factor XI deficiency or inhibition protects against thrombosis and is associated with little or no bleeding. Several factor XI-directed strategies are currently under investigation. This article (1) reviews the rationale for the development of factor XI inhibitors, (2) identifies the agents in most advanced stages of development, (3) describes the results of completed clinical trials and provides a summary of those underway, and (4) highlights the opportunities and challenges for this next generation of anticoagulants.
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Affiliation(s)
- James C Fredenburgh
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
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A novel rationale for targeting FXI: Insights from the hemostatic microRNA targetome for emerging anticoagulant strategies. Pharmacol Ther 2021; 218:107676. [DOI: 10.1016/j.pharmthera.2020.107676] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 09/03/2020] [Indexed: 02/07/2023]
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Demoulin S, Godfroid E, Hermans C. Dual inhibition of factor XIIa and factor XIa as a therapeutic approach for safe thromboprotection. J Thromb Haemost 2021; 19:323-329. [PMID: 33047454 DOI: 10.1111/jth.15130] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/11/2020] [Accepted: 10/05/2020] [Indexed: 12/11/2022]
Abstract
Clinical practice shows that a critical unmet need in the field of medical device-associated thrombosis prevention is the availability of an anticoagulant therapy without hemorrhagic risk. In the quest for new drugs that are at least as effective as those currently available, while avoiding bleeding complications, molecules that target nearly every step of the coagulation pathway have been developed. Among these molecules, inhibitors of factor XII (FXII) or factor XI (FXI) are promising alternatives as deficiencies in these factors protect against thrombosis without causing spontaneous hemorrhage, as revealed by epidemiological and preclinical data. Ixodes ricinus-contact phase inhibitor (Ir-CPI), a new anticoagulant candidate with an innovative mechanism of action could be this ideal anticoagulant agent for safe prevention from clotting on medical devices. This protein, which selectively binds to FXIIa, FXIa, and plasma kallikrein and inhibits the reciprocal activation of FXII, prekallikrein, and FXI in human plasma, was shown to prevent thrombosis in an ovine cardiopulmonary bypass system associated with cardiac surgeries. Furthermore, as opposed to unfractionated heparin, Ir-CPI appears to be devoid of bleeding risk. This review outlines the rationale for targeting upstream coagulation factors in order to prevent medical device-associated thrombosis; examines the novel approaches under development; and focuses on Ir-CPI, which shows promising properties in the field of thrombosis prevention.
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Affiliation(s)
| | | | - Cédric Hermans
- Division of Hematology, Hemostasis and Thrombosis Unit, Saint-Luc University Hospital, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
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Design and synthesis of a multivalent catch-and-release assay to measure circulating FXIa. Thromb Res 2021; 200:16-22. [PMID: 33513452 DOI: 10.1016/j.thromres.2021.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/11/2020] [Accepted: 01/04/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Decreased blood coagulation factor (F)XIa levels have been shown to protect from thrombosis without bleeding side effects, but less is known on effects of increased FXIa levels. Studies are hampered by lack of a reliable and robust method for FXIa quantification in blood. We aim to develop a new assay employing a unique multivalent catch-and-release system. The system selectively isolates and protects homodimeric FXIa from plasma and releases free FXIa allowing subsequent quantification. METHODS A dynamic multivalent construct was synthesized by complexing four identical FXIa inhibitors from the snake Bungarus Fasxiatus to avidin through desthiobiotin-PEG-linkers, allowing dissociation of FXIa by excess biotin. PEG-linker lengths were optimised for FXIa inhibitory activity and analysed by Michaelis-Menten kinetics. Finally, the catch-and-release assay was validated in buffer and plasma model systems. RESULTS Monovalent and multivalent inhibitor constructs were successfully obtained by total chemical synthesis. Multimerisation of Fasxiator resulted in a 30-fold increase in affinity for FXIa from 1.6 nM to 0.05 nM. With use of this system, FXIa could be quantified down to a concentration of 7 pM in buffer and 20 pM in plasma. CONCLUSION In this proof-of-concept study, we have shown that the catch-and-release approach is a promising technique to quantify FXIa in plasma or buffer. By binding FXIa to the multivalent construct directly after blood drawing, FXIa is hypothesized to be inaccessible for serpin inhibition or auto inactivation. This results in a close reflection of actual circulating FXIa levels at the moment of blood drawing.
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Hisada Y, Moser B, Kawano T, Revenko AS, Crosby JR, Spronk HM, Mackman N. The Intrinsic Pathway does not Contribute to Activation of Coagulation in Mice Bearing Human Pancreatic Tumors Expressing Tissue Factor. Thromb Haemost 2021; 121:967-970. [PMID: 33498089 DOI: 10.1055/s-0040-1722193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Yohei Hisada
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Bernhard Moser
- Institute of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Tomohiro Kawano
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Alexey S Revenko
- Ionis Pharmaceuticals, Inc., Antisense Drug Discovery, Carlsbad, California, United States
| | - Jeff R Crosby
- Ionis Pharmaceuticals, Inc., Antisense Drug Discovery, Carlsbad, California, United States
| | - Henri M Spronk
- Department of Internal Medicine and Biochemistry, Laboratory for Clinical Thrombosis and Hemostasis, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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Fredenburgh JC, Weitz JI. New anticoagulants: Moving beyond the direct oral anticoagulants. J Thromb Haemost 2021; 19:20-29. [PMID: 33047462 DOI: 10.1111/jth.15126] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 01/23/2023]
Abstract
Although anticoagulants have been in use for more than 80 years, heparin and vitamin K antagonists were the sole available options until recently. Although these agents revolutionized the prevention and treatment of thrombotic diseases, their use has been hampered by the necessity for coagulation monitoring and by bleeding complications resulting in part from their multiple sites of action. Owing to advances in basic science, animal models, and epidemiology, the arsenal of available anticoagulants has expanded in the past two decades. This evolution has yielded many novel compounds that target single coagulation enzymes. Initially, thrombin and factor Xa were targeted because of their critical roles in coagulation. However, attention has now shifted to compounds that target upstream reactions, particularly those catalyzed by factors XIIa and XIa, which are part of the contact system. This shift is predicated on epidemiological and experimental evidence suggesting that these factors are more important for thrombosis than for hemostasis. With the goal of developing a new class of anticoagulants associated with a lower risk of bleeding than currently available agents, dozens of drugs targeting the contact system are now in development. This article focuses on the rationale, development, and testing of these new agents with a concentration on those that have reached or completed phase 2 evaluation for at least one indication.
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Affiliation(s)
- James C Fredenburgh
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Departments of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Departments of Medicine, McMaster University, Hamilton, ON, Canada
- Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada
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Liang Y, Jackson JW, Woodle SA, Surov SS, Parunov LA, Scott DE, Weinstein M, Lee TK, Ovanesov MV. Detecting factor XIa in immune globulin products: Commutability of international reference materials for traditional and global hemostasis assays. Res Pract Thromb Haemost 2021; 5:211-222. [PMID: 33537546 PMCID: PMC7845073 DOI: 10.1002/rth2.12467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/21/2020] [Accepted: 11/03/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Activated coagulation factor XIa (FXIa) is an impurity and primary source of procoagulant activity in thrombosis-implicated immune globulin (IG) products. Several assays, of varying quality and precision are used to assess FXIa-like procoagulant activity in units relevant to their respective principles. OBJECTIVES To advance unified reporting, we sought to employ the World Health Organization reference reagents (RRs) to present the results of differing methodologies in units of FXIa activity and rank the sensitivity and robustness of these methodologies. METHODS RR 11/236 served as a calibrator in several FXIa-sensitive blood coagulation tests: two commercial chromogenic FXIa assays (CAs); a nonactivated partial thromboplastin time (NaPTT); an in-house fibrin generation (FG) assay; an in-house thrombin generation (TG) assay; and an assay for FXIa- and kallikrein-like proteolytic activities based on cleavage of substrate SN13a. Some assays were tested in either normal or FXI-deficient plasma. RESULTS Each method demonstrated a sigmoidal dose-response to RRs. NaPTT was the least sensitive to FXIa and the least precise; our in-house TG was the most sensitive; and the two CAs were the most precise. All methods, except for SN13a, which is less specific for thrombotic impurities, gave comparable (within 20% difference) FXIa activity assignments for IG lots. CONCLUSIONS Purified FXIa reference standards support quantitation of FXIa levels in IG products in all tested assay methodologies. This should help to standardize the measurement of thrombotic potentials in IG products and prevent products exhibiting high procoagulant activity from distribution for patient use. Further research is needed to address the effect of IG product-specific matrixes on assay performance.
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Affiliation(s)
- Yideng Liang
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
| | - Joseph W. Jackson
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
| | - Samuel A. Woodle
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
| | - Stepan S. Surov
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
| | - Leonid A. Parunov
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
| | - Dorothy E. Scott
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
| | - Mark Weinstein
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
| | - Timothy K. Lee
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
| | - Mikhail V. Ovanesov
- Center for Biologics Evaluation and ResearchU.S. Food and Drug AdministrationSilver SpringMDUSA
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42
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Crooke ST, Liang XH, Baker BF, Crooke RM. Antisense technology: A review. J Biol Chem 2021; 296:100416. [PMID: 33600796 PMCID: PMC8005817 DOI: 10.1016/j.jbc.2021.100416] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 12/15/2022] Open
Abstract
Antisense technology is beginning to deliver on the broad promise of the technology. Ten RNA-targeted drugs including eight single-strand antisense drugs (ASOs) and two double-strand ASOs (siRNAs) have now been approved for commercial use, and the ASOs in phase 2/3 trials are innovative, delivered by multiple routes of administration and focused on both rare and common diseases. In fact, two ASOs are used in cardiovascular outcome studies and several others in very large trials. Interest in the technology continues to grow, and the field has been subject to a significant number of reviews. In this review, we focus on the molecular events that result in the effects observed and use recent clinical results involving several different ASOs to exemplify specific molecular mechanisms and specific issues. We conclude with the prospective on the technology.
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Affiliation(s)
- Stanley T Crooke
- Core Antisense Research, Ionis Pharmaceuticals, Inc, Carlsbad, California, USA.
| | - Xue-Hai Liang
- Core Antisense Research, Ionis Pharmaceuticals, Inc, Carlsbad, California, USA
| | - Brenda F Baker
- Development Communication, Ionis Pharmaceuticals, Inc, Carlsbad, California, USA
| | - Rosanne M Crooke
- Antisense Drug Discovery, Ionis Pharmaceuticals, Inc, Carlsbad, California, USA
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43
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Camelo-Castillo A, Marín F, Roldán V. Factor XI, much more than an innocent observer. J Thromb Haemost 2020; 18:3172-3173. [PMID: 33467843 DOI: 10.1111/jth.15093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Anny Camelo-Castillo
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, University of Murcia, Murcia, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, University of Murcia, Murcia, Spain
| | - Vanessa Roldán
- Department of Hematology and Clinical Oncology, Hospital General Universitario Morales Meseguer, University of Murcia, Murcia, Spain
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Cave BE, Shah SP. Turning Up to Eleven: Factor XI Inhibitors as Novel Agents to Maximize Safety and Maintain Efficacy in Thromboembolic Disease. Curr Probl Cardiol 2020; 46:100696. [PMID: 32994051 DOI: 10.1016/j.cpcardiol.2020.100696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/23/2020] [Indexed: 11/16/2022]
Abstract
Within the past decade nonvitamin K oral anticoagulants have emerged as the standard of care for the prevention and treatment of thromboembolic disorders, however safety of anticoagulants remain a concern for many patients and providers. There exists new interest in factor XI inhibition as novel therapeutic target based on observations of lower thrombotic rates and without significant bleed risk in individuals with inherited factor XI deficiency. Several classes of factor XI inhibitors including antisense oligonucleotides, monoclonal antibodies, and small molecule inhibitors have undergone preclinical studies and clinical trials in humans. Both osocimab and IONIS-FXI have been evaluated in patients undergoing orthopedic surgery and demonstrated superiority to enoxaparin without increasing major bleeding. Future studies with both these agents are ongoing, as well as the continued development of other inhibitors of factor XI. Early data regarding factor XI inhibition is encouraging as a potent anticoagulant and may offer a safer alternative compared to therapeutic currently available in contemporary practice for thromboembolic disease.
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45
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Novel antithrombotic strategies for treatment of venous thromboembolism. Blood 2020; 135:351-359. [PMID: 31917385 DOI: 10.1182/blood.2019000919] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 12/16/2019] [Indexed: 12/25/2022] Open
Abstract
Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cause of vascular death after heart attack and stroke. Anticoagulation therapy is the cornerstone of VTE treatment. Despite such therapy, up to 50% of patients with DVT develop postthrombotic syndrome, and up to 4% of patients with PE develop chronic thromboembolic pulmonary hypertension. Therefore, better therapies are needed. Although direct oral anticoagulants are more convenient and safer than warfarin for VTE treatment, bleeding remains the major side effect, particularly in cancer patients. Factor XII and factor XI have emerged as targets for new anticoagulants that may be safer. To reduce the complications of VTE, attenuation of thrombin activatable fibrinolysis inhibitor activity is under investigation in PE patients to enhance endogenous fibrinolysis, whereas blockade of leukocyte interaction with the vessel wall is being studied to reduce the inflammation that contributes to postthrombotic syndrome in DVT patients. Focusing on these novel antithrombotic strategies, this article explains why safer anticoagulants are needed, provides the rationale for factor XII and XI as targets for such agents, reviews the data on the factor XII- and factor XI-directed anticoagulants under development, describes novel therapies to enhance fibrinolysis and decrease inflammation in PE and DVT patients, respectively, and offers insights into the opportunities for these novel VTE therapies.
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46
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Watts LM, Karwatowska-Prokopczuk E, Hurh E, Alexander VJ, Balogh K, O'Dea L, Geary RS, Tsimikas S. Treatment with Volanesorsen, a 2'-O-Methoxyethyl-Modified Antisense Oligonucleotide Targeting APOC3 mRNA, Does Not Affect the QTc Interval in Healthy Volunteers. Nucleic Acid Ther 2020; 30:198-206. [PMID: 32589506 PMCID: PMC7415887 DOI: 10.1089/nat.2019.0837] [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] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to assess the effect of volanesorsen on the corrected QT (QTc) interval. This thorough QT study enrolled 52 healthy male and female subjects who were randomized at a single site in a four-way crossover study. Subjects were randomly assigned to 1 of 12 treatment sequences and crossed over into four treatment periods over the course of which each subject was to receive a single therapeutic dose of volanesorsen as a 300 mg subcutaneous (SC) injection, a single supratherapeutic dose of volanesorsen as 300 mg intravenous (IV) infusion, a single oral (PO) dose of moxifloxacin (positive control), and placebo dose. The study demonstrated that volanesorsen 300 mg SC and 300 mg IV did not have a clinically relevant effect on ΔΔQTcF exceeding 10 ms. The largest mean effect at any postdose time point was 3.0 ms (90% confidence interval [CI]: 0.8–5.2) after SC dosing and 1.8 ms (90% CI −0.4 to 4.0) after IV dosing. Volanesorsen, at the studied therapeutic and supratherapeutic doses, does not have a clinically meaningful effect on the QTc.
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Affiliation(s)
- Lynnetta M Watts
- Clinical Development, Ionis Pharmaceutical, Inc, Carlsbad, California, USA
| | | | - Eunju Hurh
- Clinical Development, Akcea Therapeutic, Boston, Massachusetts, USA
| | | | - Kristin Balogh
- Clinical Development, Ionis Pharmaceutical, Inc, Carlsbad, California, USA
| | - Louis O'Dea
- Clinical Development, Akcea Therapeutic, Boston, Massachusetts, USA
| | - Richard S Geary
- Clinical Development, Ionis Pharmaceutical, Inc, Carlsbad, California, USA
| | - Sotirios Tsimikas
- Clinical Development, Ionis Pharmaceutical, Inc, Carlsbad, California, USA.,Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California, USA
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Abstract
Activation of the intrinsic pathway of coagulation contributes to the pathogenesis of arterial and venous thrombosis. Critical insights into the involvement of intrinsic pathway factors have been derived from the study of gene-specific knockout animals and targeted inhibitors. Importantly, preclinical studies have indicated that targeting components of this pathway, including FXI (factor XI), FXII, and PKK (prekallikrein), reduces thrombosis with no significant effect on protective hemostatic pathways. This review highlights the advances made from studying the intrinsic pathway using gene-specific knockout animals and inhibitors in models of arterial and venous thrombosis. Development of inhibitors of activated FXI and FXII may reduce thrombosis with minimal increases in bleeding compared with current anticoagulant drugs.
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Affiliation(s)
- Steven P Grover
- From the Division of Hematology and Oncology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill
| | - Nigel Mackman
- From the Division of Hematology and Oncology, Department of Medicine, UNC Blood Research Center, University of North Carolina at Chapel Hill
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48
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Harshfield EL, Sims MC, Traylor M, Ouwehand WH, Markus HS. The role of haematological traits in risk of ischaemic stroke and its subtypes. Brain 2020; 143:210-221. [PMID: 31755939 PMCID: PMC6935746 DOI: 10.1093/brain/awz362] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/05/2019] [Accepted: 09/25/2019] [Indexed: 12/13/2022] Open
Abstract
Thrombosis and platelet activation play a central role in stroke pathogenesis, and antiplatelet and anticoagulant therapies are central to stroke prevention. However, whether haematological traits contribute equally to all ischaemic stroke subtypes is uncertain. Furthermore, identification of associations with new traits may offer novel treatment opportunities. The aim of this research was to ascertain causal relationships between a wide range of haematological traits and ischaemic stroke and its subtypes. We obtained summary statistics from 27 published genome-wide association studies of haematological traits involving over 375 000 individuals, and genetic associations with stroke from the MEGASTROKE Consortium (n = 67 000 stroke cases). Using two-sample Mendelian randomization we analysed the association of genetically elevated levels of 36 blood cell traits (platelets, mature/immature red cells, and myeloid/lymphoid/compound white cells) and 49 haemostasis traits (including clotting cascade factors and markers of platelet function) with risk of developing ischaemic (AIS), cardioembolic (CES), large artery (LAS), and small vessel stroke (SVS). Several factors on the intrinsic clotting pathway were significantly associated (P < 3.85 × 10-4) with CES and LAS, but not with SVS (e.g. reduced factor VIII activity with AIS/CES/LAS; raised factor VIII antigen with AIS/CES; and increased factor XI activity with AIS/CES). On the common pathway, increased gamma (γ') fibrinogen was significantly associated with AIS/CES. Furthermore, elevated plateletcrit was significantly associated with AIS/CES, eosinophil percentage of white cells with LAS, and thrombin-activatable fibrinolysis inhibitor activation peptide antigen with AIS. We also conducted a follow-up analysis in UK Biobank, which showed that amongst individuals with atrial fibrillation, those with genetically lower levels of factor XI are at reduced risk of AIS compared to those with normal levels of factor XI. These results implicate components of the intrinsic and common pathways of the clotting cascade, as well as several other haematological traits, in the pathogenesis of CES and possibly LAS, but not SVS. The lack of associations with SVS suggests thrombosis may be less important for this stroke subtype. Plateletcrit and factor XI are potentially tractable new targets for secondary prevention of ischaemic stroke, while factor VIII and γ' fibrinogen require further population-based studies to ascertain their possible aetiological roles.
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Affiliation(s)
- Eric L Harshfield
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Matthew C Sims
- Department of Haematology, University of Cambridge, Cambridge, UK
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Matthew Traylor
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Willem H Ouwehand
- Department of Haematology, University of Cambridge, Cambridge, UK
- National Health Service (NHS) Blood and Transplant, Cambridge Biomedical Campus, Cambridge, UK
- British Heart Foundation Cambridge Centre of Research Excellence, University of Cambridge, Cambridge, UK
- Department of Human Genetics, Wellcome Trust Sanger Institute, Wellcome Trust Genome Campus, Hinxton, UK
- National Institute for Health Research Blood and Transplant Research Unit in Donor Health and Genomics, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Corte JR, Pinto DJP, Fang T, Osuna H, Yang W, Wang Y, Lai A, Clark CG, Sun JH, Rampulla R, Mathur A, Kaspady M, Neithnadka PR, Li YXC, Rossi KA, Myers JE, Sheriff S, Lou Z, Harper TW, Huang C, Zheng JJ, Bozarth JM, Wu Y, Wong PC, Crain EJ, Seiffert DA, Luettgen JM, Lam PYS, Wexler RR, Ewing WR. Potent, Orally Bioavailable, and Efficacious Macrocyclic Inhibitors of Factor XIa. Discovery of Pyridine-Based Macrocycles Possessing Phenylazole Carboxamide P1 Groups. J Med Chem 2019; 63:784-803. [DOI: 10.1021/acs.jmedchem.9b01768] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- James R. Corte
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Donald J. P. Pinto
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Tianan Fang
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Honey Osuna
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Wu Yang
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Yufeng Wang
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Amy Lai
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Charles G. Clark
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Jung-Hui Sun
- Research and Development, Bristol-Myers Squibb Company, US Rt. 206 & Province Line Road, Princeton, New Jersey 08540, United States
| | - Richard Rampulla
- Research and Development, Bristol-Myers Squibb Company, US Rt. 206 & Province Line Road, Princeton, New Jersey 08540, United States
| | - Arvind Mathur
- Research and Development, Bristol-Myers Squibb Company, US Rt. 206 & Province Line Road, Princeton, New Jersey 08540, United States
| | - Mahammed Kaspady
- Bristol-Myers Squibb Research Center, Syngene International Pvt. Ltd., Biocon Park, Plot No. 2 & 3, Bommasandra−Jigani Road, Bangalore 560 100, India
| | - Premsai Rai Neithnadka
- Bristol-Myers Squibb Research Center, Syngene International Pvt. Ltd., Biocon Park, Plot No. 2 & 3, Bommasandra−Jigani Road, Bangalore 560 100, India
| | - Yi-Xin Cindy Li
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Karen A. Rossi
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Joseph E. Myers
- Research and Development, Bristol-Myers Squibb Company, US Rt. 206 & Province Line Road, Princeton, New Jersey 08540, United States
| | - Steven Sheriff
- Research and Development, Bristol-Myers Squibb Company, US Rt. 206 & Province Line Road, Princeton, New Jersey 08540, United States
| | - Zhen Lou
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Timothy W. Harper
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Christine Huang
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Joanna J. Zheng
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Jeffrey M. Bozarth
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Yiming Wu
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Pancras C. Wong
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Earl J. Crain
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Dietmar A. Seiffert
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Joseph M. Luettgen
- Research and Development, Bristol-Myers Squibb Company, 311 Pennington-Rocky Hill Road, Pennington, New Jersey 08543, United States
| | - Patrick Y. S. Lam
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - Ruth R. Wexler
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
| | - William R. Ewing
- Research and Development, Bristol-Myers Squibb Company, 350 Carter Road, Hopewell, New Jersey 08540, United States
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50
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