1
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Cohen O, Santagata D, Ageno W. Novel horizons in anticoagulation: the emerging role of factor XI inhibitors across different settings. Haematologica 2024; 109:3110-3124. [PMID: 38779744 PMCID: PMC11443408 DOI: 10.3324/haematol.2023.283682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Indexed: 05/25/2024] Open
Abstract
Anticoagulants have long been fundamental in preventing and treating thromboembolic disorders, with a recent shift of focus towards direct oral anticoagulants, thanks to their ease of use, efficacy, and safety. Despite these advancements, bleeding complications remain a major concern with any anticoagulant, highlighting the need for safer drugs. Factor XI (FXI) inhibitors have emerged as promising agents in this regard, offering a novel approach by targeting upstream factors in the coagulation system. Phase II trials have shown encouraging outcomes, indicating a reduced bleeding risk compared to that associated with traditional anticoagulants, particularly in the context of cardiovascular disease management when combined with antiplatelet therapy. However, the variability in findings and limited efficacy data call for a cautious interpretation pending insights from phase III trials. These trials are essential for validating the potential of FXI inhibitors to balance bleeding risk reduction and maintain anticoagulant efficacy. This review explores the pharmacology, potential indications, clinical data, and future directions of FXI inhibitors, providing a perspective on their evolving role in anticoagulant therapy. It also provides a detailed analysis of data from published clinical trials on FXI inhibitors in various indications. Preliminary data from ongoing trials are also outlined. As the field moves forward, a cautiously optimistic outlook can be expected, focusing on comprehensive data from phase III trials to define the role of FXI inhibitors in various clinical scenarios.
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Affiliation(s)
- Omri Cohen
- Department of Medicine and Surgery, University of Insubria, Varese, Italy; National Hemophilia Center and Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-Hashomer, Israel; The Amalia Biron Institute of thrombosis research, Aviv University
| | - Davide Santagata
- Department of Medicine and Surgery, University of Insubria, Varese
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese.
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2
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Galli M, Occhipinti G, Ortega-Paz L, Franchi F, Rollini F, Brugaletta S, Capodanno D, Sciarretta S, Angiolillo DJ. Therapeutic Potential of FXI Inhibitors: Hype or Hope? Drugs 2024; 84:1055-1070. [PMID: 39073551 DOI: 10.1007/s40265-024-02049-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 07/30/2024]
Abstract
Significant advancements have shaped the landscape of anticoagulant therapy in the past two decades, including the introduction of direct oral anticoagulants (DOACs), characterized by favorable safety and efficacy profiles and reduced drug-to-drug or food interaction resulting in excellent patient compliance. However, residual concerns still exist with standard-of-care anticoagulant therapy, including the inability to use DOACs in several clinical settings and the need to further reduce the risk of bleeding. Recent improvements in the understanding of the mechanisms behind thrombus formation have led to the awareness that the intrinsic pathway of the coagulation cascade may play an important role in pathological thrombosis, but not in hemostasis. This has represented the rationale for targeting this pathway with factor XI (FXI) inhibitors, with the aim of uncoupling hemostasis and thrombosis. Clinical evidence from patients with FXI deficiency further supports this concept. A number of compounds with different mechanisms of action have been developed to target FXI (i.e., asundexian, abelacimab, Ionis-FXIRx, milvexian, osocimab, and Xisomab 3G). To date, the majority of available trials have not gone beyond completion of phase 2 and results are conflictive making it difficult to appraise the clinical benefit of these compounds in the different clinical settings where they have been tested (i.e., atrial fibrillation, acute ischemic stroke, acute myocardial infarction, end-stage renal disease, total knee arthroplasty). Moreover, the largest phase 3 randomized trial designed to test the efficacy of asundexian over apixaban in patients with atrial fibrillation, the OCEANIC-AF, has been prematurely stopped as a result of the inferior efficacy of asundexian. In this review we discuss the pharmacological properties and available evidence generated thus far for factor XI inhibitors, providing a perspective on the current state of these drugs.
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Affiliation(s)
- Mattia Galli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Giovanni Occhipinti
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA
| | - Salvatore Brugaletta
- Hospital Clínic, Cardiovascular Clinic Institute, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Sebastiano Sciarretta
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
- IRCCS NeuroMed, Pozzilli, Italy
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine-Jacksonville, 655 West 8th Street, Jacksonville, FL, 32209, USA.
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Jiang S, Li Y, Zhang J, Jia W, Zheng Y, Jia Z, Yu C, Kong Y. Dual Inhibition of Factor XIIa and Factor XIa Produces a Synergistic Anticoagulant Effect. J Cardiovasc Pharmacol 2024; 84:71-80. [PMID: 38922574 DOI: 10.1097/fjc.0000000000001573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/21/2024] [Indexed: 06/27/2024]
Abstract
ABSTRACT Clinical practice shows that a critical unmet need in the field of thrombosis prevention is the availability of anticoagulant therapy without bleeding risk. Inhibitors against FXIa or FXIIa have been extensively studied because of their low bleeding risk. However, whether these compounds produce synergistic effects has not yet been explored. In this study, analyses of activated partial thromboplastin time in combination with the FXIa inhibitor PN2KPI and the FXIIa inhibitor Infestin4 at different proportions were performed using the SynergyFinder tool identifying synergistic anticoagulation effects. Both an FeCl 3 -induced carotid artery thrombosis mouse model and a transient occlusion of the middle cerebral artery mouse model showed that the combination of PN2KPI and Infestin4, which are 28.57% and 6.25% of the effective dose, respectively, significantly prevents coagulation, and furthermore, dual inhibition does not cause bleeding risk.
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Affiliation(s)
- Shuai Jiang
- School of Life Science and Technology, China Pharmaceutical University, Nanjing, China ; and
| | - Yitong Li
- School of Life Science and Technology, China Pharmaceutical University, Nanjing, China ; and
| | - Jiali Zhang
- School of Life Science and Technology, China Pharmaceutical University, Nanjing, China ; and
| | - Wenhui Jia
- School of Life Science and Technology, China Pharmaceutical University, Nanjing, China ; and
| | - Yizheng Zheng
- School of Life Science and Technology, China Pharmaceutical University, Nanjing, China ; and
| | - Zhiping Jia
- School of Life Science and Technology, China Pharmaceutical University, Nanjing, China ; and
| | - Chenming Yu
- Department of Intervention Radiology, Lishui District People's Hospital, Nanjing, China
| | - Yi Kong
- School of Life Science and Technology, China Pharmaceutical University, Nanjing, China ; and
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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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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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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: 44] [Impact Index Per Article: 44.0] [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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Pandey A, Verma R, Eikelboom J, Verma S. Factor XI inhibitors: what should clinicians know. Curr Opin Cardiol 2023; 38:88-93. [PMID: 36718618 DOI: 10.1097/hco.0000000000001015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW Factor XI (FXI) inhibitors were developed to address unmet needs and limitations of current anticoagulants and are currently being studied in several indications. In this paper, we review the rationale for the development of these agents and summarize what clinicians should know about drugs that target FXI. RECENT FINDINGS Patients with FXI deficiency may have a lower risk of venous thromboembolism and cardiovascular events and have a variable but generally mild bleeding diathesis. FXI has been proposed as a target for anticoagulants due to the potential for reduction in thrombosis with a lower risk of bleeding than current anticoagulant agents. Several classes of drugs that target FXI are under development, of which three classes (small molecule inhibitors, antisense oligonucleotides and monoclonal antibodies) have been studied in Phase II trials. At least three large Phase III trial programs are planned or are underway, and will study the efficacy and safety of FXI inhibitors in tens of thousands of patients across a variety of indications including atrial fibrillation, stroke and cancer-associated venous thromboembolism. SUMMARY FXI inhibitors were developed with the hope of attenuating thrombosis with reduced bleeding/impairment of haemostasis. These agents have shown promise in preliminary trials with a low rate of bleeding. Ongoing Phase III investigations will inform the utility of these agents in clinical practice.
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Affiliation(s)
| | - Raj Verma
- Royal College of Surgeons in Ireland, Dublin, Ireland
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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: 3] [Impact Index Per Article: 1.5] [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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Badimon JJ, Escolar G, Zafar MU. Factor XI/XIa Inhibition: The Arsenal in Development for a New Therapeutic Target in Cardio- and Cerebrovascular Disease. J Cardiovasc Dev Dis 2022; 9:437. [PMID: 36547434 PMCID: PMC9781521 DOI: 10.3390/jcdd9120437] [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: 10/14/2022] [Revised: 11/25/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022] Open
Abstract
Despite major advancements in the development of safer and more effective anticoagulant agents, bleeding complications remain a significant concern in the treatment of thromboembolic diseases. Improvements in our understanding of the coagulation pathways highlights the notion that the contact pathway-specifically factor XI (FXI)-has a greater role in the etiopathogenesis of thrombosis than in physiological hemostasis. As a result, a number of drugs targeting FXI are currently in different stages of testing and development. This article aims to review the different strategies directed towards FXI-inhibition with a brief summation of the agents in clinical development, and to comment on the therapeutic areas that could be explored for potential indications. Therapeutics targeting FXI/FXIa inhibition have the potential to usher in a new era of anticoagulation therapy.
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Affiliation(s)
- Juan J. Badimon
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Gines Escolar
- Department of Hematopathology, Hospital Clinic, 08036 Barcelona, Spain
| | - M. Urooj Zafar
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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Deaminative-cleaved S. monotuberculatus fucosylated glycosaminoglycan: Structural elucidation and anticoagulant activity. Carbohydr Polym 2022; 298:120072. [DOI: 10.1016/j.carbpol.2022.120072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 08/04/2022] [Accepted: 09/01/2022] [Indexed: 01/01/2023]
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Moellmer SA, Puy C, McCarty OJT. HK is the apple of FXI's eye. J Thromb Haemost 2022; 20:2485-2487. [PMID: 36271466 PMCID: PMC9589922 DOI: 10.1111/jth.15842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 07/29/2022] [Accepted: 08/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Samantha A. Moellmer
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Cristina Puy
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Owen J. T. McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
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12
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Li T, Liu J, Wu W. Factor XI, a potential target for anticoagulation therapy for venous thromboembolism. Front Cardiovasc Med 2022; 9:975767. [PMID: 36386334 PMCID: PMC9659736 DOI: 10.3389/fcvm.2022.975767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 10/11/2022] [Indexed: 11/25/2022] Open
Abstract
Venous thromboembolism (VTE) is a common cause of mortality and disability in hospitalized patients, and anticoagulation is an essential therapeutic option. Despite the increasing use of direct oral anticoagulants, complications and adverse drug reactions still occur in patients with VTE. Within 5 years, 20% of patients with VTE experience recurrence, and 50% of patients with deep vein thrombosis develop post-thrombotic syndrome. Furthermore, bleeding due to anticoagulants is a side effect that must be addressed. Therefore, safer and more effective anticoagulant strategies with higher patient compliance are urgently needed. Available epidemiological evidence and animal studies have shown that factor XI (FXI) inhibitors can reduce thrombus size and loosen the thrombus structure with a relatively low risk of bleeding, suggesting that FXI has an important role in thrombus stabilization and is a safer target for anticoagulation. Recent clinical trial data have also shown that FXI inhibitors are as effective as enoxaparin and apixaban in preventing VTE, but with a significantly lower incidence of bleeding. Furthermore, FXI inhibitors can be administered daily or monthly; therefore, the monitoring interval can be longer. Additionally, FXI inhibitors can prolong the activated partial thromboplastin time without affecting prothrombin time, which is an easy and common test used in clinical testing, providing a cost-effective monitoring routine for patients. Consequently, the inhibition of FXI may be an effective strategy for the prevention and treatment of VTE. Enormous progress has been made in the research strategies for FXI inhibitors, with abelacimab already in phase III clinical trials and most other inhibitors in phase I or II trials. In this review, we discuss the challenges of VTE therapy, briefly describe the structure and function of FXI, summarize the latest FXI/activated FXI (FXIa) inhibitor strategies, and summarize the latest developments in clinical trials of FXI/FXIa inhibitors.
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Affiliation(s)
- Tingting Li
- National Center for Clinical Laboratories, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital, National Center of Gerontology, Beijing, China
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiang Liu
- Department of Nephrology, Metabolic Vascular Disease Key Laboratory, Sichuan Clinical Research Center for Nephropathy, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Weihua Wu
- Department of Nephrology, Metabolic Vascular Disease Key Laboratory, Sichuan Clinical Research Center for Nephropathy, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- *Correspondence: Weihua Wu
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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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14
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Nopp S, Kraemmer D, Ay C. Factor XI Inhibitors for Prevention and Treatment of Venous Thromboembolism: A Review on the Rationale and Update on Current Evidence. Front Cardiovasc Med 2022; 9:903029. [PMID: 35647061 PMCID: PMC9133368 DOI: 10.3389/fcvm.2022.903029] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022] Open
Abstract
Although anticoagulation therapy has evolved from non-specific drugs (i.e., heparins and vitamin K antagonists) to agents that directly target specific coagulation factors (i.e., direct oral anticoagulants, argatroban, fondaparinux), thrombosis remains a leading cause of death worldwide. Direct oral anticoagulants (i.e., factor IIa- and factor Xa-inhibitors) now dominate clinical practice because of their favorable pharmacological profile and ease of use, particularly in venous thromboembolism (VTE) treatment and stroke prevention in atrial fibrillation. However, despite having a better safety profile than vitamin K antagonists, their bleeding risk is not insignificant. This is true for all currently available anticoagulants, and a high bleeding risk is considered a contraindication to anticoagulation. As a result, ongoing research focuses on developing future anticoagulants with an improved safety profile. Several promising approaches to reduce the bleeding risk involve targeting the intrinsic (or contact activation) pathway of coagulation, with the ultimate goal of preventing thrombosis without impairing hemostasis. Based on epidemiological data on hereditary factor deficiencies and preclinical studies factor XI (FXI) emerged as the most promising candidate target. In this review, we highlight unmet clinical needs of anticoagulation therapy, outlay the rationale and evidence for inhibiting FXI, discuss FXI inhibitors in current clinical trials, conduct an exploratory meta-analysis on their efficacy and safety, and provide an outlook on the potential clinical application of these novel anticoagulants.
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Affiliation(s)
| | | | - Cihan Ay
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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15
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Li T, Ma H, Li H, Tang H, Huang J, Wei S, Yuan Q, Shi X, Gao C, Mi S, Zhao L, Zhong S, Liu Y. Physicochemical Properties and Anticoagulant Activity of Purified Heteropolysaccharides from Laminaria japonica. Molecules 2022; 27:3027. [PMID: 35566376 PMCID: PMC9102426 DOI: 10.3390/molecules27093027] [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: 03/31/2022] [Revised: 05/03/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023] Open
Abstract
Laminaria japonica is widely consumed as a key food and medicine. Polysaccharides are one of the most plentiful constituents of this marine plant. In this study, several polysaccharide fractions with different charge numbers were obtained. Their physicochemical properties and anticoagulant activities were determined by chemical and instrumental methods. The chemical analysis showed that Laminaria japonica polysaccharides (LJPs) and the purified fractions LJP0, LJP04, LJP06, and LJP08 mainly consisted of mannose, glucuronic acid, galactose, and fucose in different mole ratios. LJP04 and LJP06 also contained minor amounts of xylose. The polysaccharide fractions eluted by higher concentration of NaCl solutions showed higher contents of uronic acid and sulfate group. Biological activity assays showed that LJPs LJP06 and LJP08 could obviously prolong the activated partial thromboplastin time (APTT), indicating that they had strong anticoagulant activity. Furthermore, we found that LJP06 exerted this activity by inhibiting intrinsic factor Xase with higher selectivity than other fractions, which may have negligible bleeding risk. The sulfate group may play an important role in the anticoagulant activity. In addition, the carboxyl group and surface morphology of these fractions may affect their anticoagulant activities. The results provide information for applications of L. japonica polysaccharides, especially LJP06 as anticoagulants in functional foods and therapeutic agents.
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Affiliation(s)
- Tingting Li
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Haiqiong Ma
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Hong Li
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Hao Tang
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Jinwen Huang
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Shiying Wei
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Qingxia Yuan
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Xiaohuo Shi
- Key Laboratory of Precise Synthesis of Functional Molecules of Zhejiang Province, School of Science, Westlake University, Hangzhou 310024, China;
| | - Chenghai Gao
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Shunli Mi
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Longyan Zhao
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Shengping Zhong
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
| | - Yonghong Liu
- Institute of Marine Drugs, Guangxi University of Chinese Medicine, Nanning 530200, China; (T.L.); (H.M.); (H.L.); (H.T.); (J.H.); (S.W.); (Q.Y.); (C.G.); (S.M.)
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16
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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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17
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Gailani D. Factor XI as a target for preventing venous thromboembolism. J Thromb Haemost 2022; 20:550-555. [PMID: 35023278 PMCID: PMC9540353 DOI: 10.1111/jth.15628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 01/10/2023]
Affiliation(s)
- David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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18
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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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19
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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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20
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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: 6] [Impact Index Per Article: 2.0] [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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21
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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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22
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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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23
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Zanardi TA, Korbmacher B, Boone L, Engelhardt JA, Wang Y, Burel S, Prill B, Aghajan M, Guo S, Henry SP. Safety, Pharmacokinetic, and Pharmacodynamic Evaluation of a 2'-(2-Methoxyethyl)-D-ribose Antisense Oligonucleotide-Triantenarry N-Acetyl-galactosamine Conjugate that Targets the Human Transmembrane Protease Serine 6. J Pharmacol Exp Ther 2021; 377:51-63. [PMID: 33431610 DOI: 10.1124/jpet.120.000222] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/05/2021] [Indexed: 01/29/2023] Open
Abstract
Cellular uptake of antisense oligonucleotides (ASOs) is one of the main determinants of in vivo activity and potency. A significant advancement in improving uptake into cells has come through the conjugation of ASOs to triantenarry N-acetyl-galactosamine (GalNAc3), a ligand for the asialoglycoprotein receptor on hepatocytes. The impact for antisense oligonucleotides, which are already taken up into hepatocytes, is a 10-fold improvement in potency in mice and up to a 30-fold potency improvement in humans, resulting in overall lower effective dose and exposure levels. 2'-Methoxyethyl-modified antisense oligonucleotide conjugated to GalNAc3 (ISIS 702843) is specific for human transmembrane protease serine 6 and is currently in clinical trials for the treatment of β-thalassemia. This report summarizes a chronic toxicity study of ISIS 702843 in nonhuman primates (NHPs), including pharmacokinetic and pharmacology assessments. Suprapharmacologic doses of ISIS 702843 were well tolerated in NHPs after chronic dosing, and the data indicate that the overall safety profile is very similar to that of the unconjugated 2'-(2-methoxyethyl)-D-ribose (2'-MOE) ASOs. Notably, the GalNAc3 moiety did not cause any new toxicities nor exacerbate the known nonspecific class effects of the 2'-MOE ASOs. This observation was confirmed with multiple GalNAc3-MOE conjugates by querying a data base of monkey studies containing both GalNAc3-conjugated and unconjugated 2'-MOE ASOs. SIGNIFICANCE STATEMENT: This report documents the potency, pharmacology, and overall tolerability profile of a triantenarry N-acetyl-galactosamine (GalNAc3)-conjugated 2'-(2-methoxyethyl)-D-ribose (2'-MOE) antisense oligonucleotide (ASO) specific to transmembrane protease serine 6 after chronic treatment in the cynomolgus monkey. Collective analysis of 15 independent GalNAc3-conjugated and unconjugated 2'-MOE ASOs shows the consistency in the dose response and character of hepatic and platelet tolerability across sequences that will result in much larger safety margins for the GalNAc3-conjugated 2'-MOE ASOs when compared with the unconjugated 2'-MOE ASOs given the increased potency.
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Affiliation(s)
- Thomas A Zanardi
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Birgit Korbmacher
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Laura Boone
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Jeffrey A Engelhardt
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Yanfeng Wang
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Sebastien Burel
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Bobby Prill
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Mariam Aghajan
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Shuling Guo
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
| | - Scott P Henry
- Ionis Pharmaceuticals, Carlsbad, California (T.A.Z., J.A.E., Y.W., S.B., B.P., M.A., S.G., S.P.H.), and Covance Preclinical Services GmbH, Munster, Germany (B.K., L.B.)
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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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Hobson JJ, Rannard SP, Owen A, Liptrott NJ. Safety assessment of a new nanoemulsion-based drug-delivery system reveals unexpected drug-free anticoagulant activity. Nanomedicine (Lond) 2020; 15:1361-1373. [PMID: 32484393 DOI: 10.2217/nnm-2019-0447] [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: 11/21/2022] Open
Abstract
Aim: A preclinical safety assessment of a novel nanoemulsion drug-delivery system, initially developed to improve the posology of efavirenz (EFV), was conducted with a specific focus on possible immunological and hematological complications. Materials & methods: Assessment of common acute toxicities, such as complement activation and cytokine secretion, was performed using validated assays known to have good correlation with in vivo end points. Results & conclusion: Compared with a standard aqueous solution of EFV, the EFV nanoemulsion showed no significant effect on immune cell function or phenotype. Prolongation of activated partial thromboplastin time was observed for EFV-loaded nanoemulsions (88% at 4 μg/ml) as well as unloaded nanoemulsions (52%) highlighting the potential for drug-free anticoagulant activity and warranting further investigation of the mechanism and utility of these materials.
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Affiliation(s)
- James J Hobson
- Department of Chemistry, University of Liverpool, Liverpool, L69 7ZD, UK
| | - Steve P Rannard
- Department of Chemistry, University of Liverpool, Liverpool, L69 7ZD, UK
| | - Andrew Owen
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, L69 3GF, UK.,European Nanomedicine Characterisation Laboratory, University of Liverpool, Liverpool, L7 3NY, UK
| | - Neill J Liptrott
- Department of Molecular & Clinical Pharmacology, University of Liverpool, Liverpool, L69 3GF, UK.,European Nanomedicine Characterisation Laboratory, University of Liverpool, Liverpool, L7 3NY, UK
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Therapeutic strategies for thrombosis: new targets and approaches. Nat Rev Drug Discov 2020; 19:333-352. [PMID: 32132678 DOI: 10.1038/s41573-020-0061-0] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 12/19/2022]
Abstract
Antiplatelet agents and anticoagulants are a mainstay for the prevention and treatment of thrombosis. However, despite advances in antithrombotic therapy, a fundamental challenge is the side effect of bleeding. Improved understanding of the mechanisms of haemostasis and thrombosis has revealed new targets for attenuating thrombosis with the potential for less bleeding, including glycoprotein VI on platelets and factor XIa of the coagulation system. The efficacy and safety of new agents are currently being evaluated in phase III trials. This Review provides an overview of haemostasis and thrombosis, details the current landscape of antithrombotic agents, addresses challenges with preventing thromboembolic events in patients at high risk and describes the emerging therapeutic strategies that may break the inexorable link between antithrombotic therapy and bleeding risk.
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Weitz JI, Bauersachs R, Becker B, Berkowitz SD, Freitas MCS, Lassen MR, Metzig C, Raskob GE. Effect of Osocimab in Preventing Venous Thromboembolism Among Patients Undergoing Knee Arthroplasty: The FOXTROT Randomized Clinical Trial. JAMA 2020; 323:130-139. [PMID: 31935028 PMCID: PMC6990695 DOI: 10.1001/jama.2019.20687] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
IMPORTANCE The efficacy of factor XIa inhibition for thromboprophylaxis is unknown. Osocimab is a long-acting, fully human monoclonal antibody that inhibits factor XIa. OBJECTIVE To compare different doses of osocimab with enoxaparin and apixaban for thromboprophylaxis in patients who have undergone knee arthroplasty. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label, adjudicator-blinded, phase 2 noninferiority trial with observer blinding for osocimab doses, conducted at 54 hospitals in 13 countries. Adult patients undergoing unilateral knee arthroplasty were randomized from October 2017 through August 2018 and followed up until January 2019. INTERVENTIONS Single intravenous osocimab postoperative doses of 0.3 mg/kg (n = 107), 0.6 mg/kg (n = 65), 1.2 mg/kg (n = 108), or 1.8 mg/kg (n = 106); preoperative doses of 0.3 mg/kg (n = 109) or 1.8 mg/kg (n = 108); or 40 mg of subcutaneous enoxaparin once daily (n = 105) or 2.5 mg of oral apixaban twice daily (n = 105) for at least 10 days or until venography. MAIN OUTCOMES AND MEASURES The primary outcome was venous thromboembolism incidence between 10 and 13 days postoperatively (assessed by mandatory bilateral venography performed 10 to 13 days after surgery or confirmed symptomatic deep vein thrombosis or pulmonary embolism). A 5% noninferiority margin compared with enoxaparin was chosen. The primary safety outcome of major or clinically relevant nonmajor bleeding was assessed until 10 to 13 days postoperatively. RESULTS Of 813 randomized participants (mean [SD] age, 66.5 years [8.2 years]; body mass index, 32.7 [5.7]; and 74.2% women), 600 were included in the per-protocol population used for the primary analysis. The primary outcome occurred in 18 patients (23.7%) receiving 0.3 mg/kg, 8 (15.7%) receiving 0.6 mg/kg, 13 (16.5%) receiving 1.2 mg/kg, and 14 (17.9%) receiving 1.8 mg/kg of osocimab postoperatively; 23 (29.9%) receiving 0.3 mg/kg and 9 (11.3%) receiving 1.8 mg/kg of osocimab preoperatively; 20 (26.3%) receiving enoxaparin; and 12 (14.5%) receiving apixaban. Osocimab given postoperatively met criteria for noninferiority compared with enoxaparin with risk differences (1-sided 95% CIs) of 10.6% (95% CI, -1.2% to ∞) at the 0.6-mg/kg dose; 9.9% (95% CI, -0.9% to ∞) at the 1.2-mg/kg dose, and 8.4% (95% CI, -2.6 to ∞) at the 1.8-mg/kg dose. The preoperative dose of 1.8 mg/kg of osocimab met criteria for superiority compared with enoxaparin with a risk difference of 15.1%; 2-sided 90% CI, 4.9% to 25.2%). Postoperative and preoperative doses of 0.3 mg/kg of osocimab did not meet the prespecified criteria for noninferiority, with risk differences (1-sided 95% CIs) of 2.6% (95% CI, -8.9% to ∞) and -3.6% (95% CI, -15.5% to ∞), respectively. Major or clinically relevant nonmajor bleeding was observed in up to 4.7% of those receiving osocimab, 5.9% receiving enoxaparin, and 2% receiving apixaban. CONCLUSIONS AND RELEVANCE Among patients undergoing knee arthroplasty, postoperative osocimab 0.6 mg/kg, 1.2 mg/kg, and 1.8 mg/kg met criteria for noninferiority compared with enoxaparin, and the preoperative 1.8-mg/kg dose of osocimab met criteria for superiority compared with enoxaparin for the primary outcome of incidence of venous thromboembolism at 10 to 13 days postoperatively. Further studies are needed to establish efficacy and safety of osocimab relative to standard thromboprophylaxis. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03276143.
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Affiliation(s)
- Jeffrey I. Weitz
- Department of Medicine and Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Rupert Bauersachs
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | | | | | | | - Michael R. Lassen
- Department of Orthopedics, Spine Section, Zealand University Hospital, Koege, Denmark
| | | | - Gary E. Raskob
- University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City
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From multi-target anticoagulants to DOACs, and intrinsic coagulation factor inhibitors. Blood Rev 2020; 39:100615. [DOI: 10.1016/j.blre.2019.100615] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/08/2019] [Accepted: 08/27/2019] [Indexed: 01/10/2023]
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Al-Horani RA. Factor XI(a) inhibitors for thrombosis: an updated patent review (2016-present). Expert Opin Ther Pat 2019; 30:39-55. [PMID: 31847619 DOI: 10.1080/13543776.2020.1705783] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Anticoagulation without bleeding is an ideal goal in treating thrombosis, however, this goal has not been achieved. All current anticoagulants are associated with significant bleeding which limits their safe use. Genetic and pharmacological findings indicate that factor XIa is a key player in thrombosis, yet it is a relatively marginal one in hemostasis. Thus, factor XIa and its zymogen offer a unique opportunity to develop anticoagulants with low bleeding risk.Areas covered: A survey of patent literature has retrieved more than 50 patents on the discovery of novel therapeutics targeting factor XI(a) since 2016. Small molecules, monoclonal antibodies, oligonucleotides, and polypeptides have been developed to inhibit factor XI(a). Many inhibitors are in early development and few have been evaluated in clinical trials.Expert opinion: Factor XI(a) is being actively pursued as a drug target for the development of effective and safer anticoagulants. Although many patents claiming factor XI(a) inhibitors were filed prior to 2016, recent literature reveals a moderately declining trend. Nevertheless, more agents have entered different levels of clinical trials. These agents exploit diverse mechanistic strategies for inhibition. Although further development is warranted, reaching one or more of these agents to the clinic will transform the anticoagulation therapy.
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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, USA
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Schaefer M, Buchmueller A, Dittmer F, Straßburger J, Wilmen A. Allosteric Inhibition as a New Mode of Action for BAY 1213790, a Neutralizing Antibody Targeting the Activated Form of Coagulation Factor XI. J Mol Biol 2019; 431:4817-4833. [PMID: 31655039 DOI: 10.1016/j.jmb.2019.09.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 07/26/2019] [Accepted: 09/10/2019] [Indexed: 12/20/2022]
Abstract
Factor XI (FXI), the zymogen of activated FXI (FXIa), is an attractive target for novel anticoagulants because FXI inhibition offers the potential to reduce thrombosis risk while minimizing the risk of bleeding. BAY 1213790, a novel anti-FXIa antibody, was generated using phage display technology. Crystal structure analysis of the FXIa-BAY 1213790 complex demonstrated that the tyrosine-rich complementarity-determining region 3 loop of the heavy chain of BAY 1213790 penetrated deepest into the FXIa binding epitope, forming a network of favorable interactions including a direct hydrogen bond from Tyr102 to the Gln451 sidechain (2.9 Å). The newly discovered binding epitope caused a structural rearrangement of the FXIa active site, revealing a novel allosteric mechanism of FXIa inhibition by BAY 1213790. BAY 1213790 specifically inhibited FXIa with a binding affinity of 2.4 nM, and in human plasma, prolonged activated partial thromboplastin time and inhibited thrombin generation in a concentration-dependent manner.
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Affiliation(s)
- Martina Schaefer
- Bayer AG, Research and Development, Pharmaceuticals, Structural Biology, 13342 Berlin, Germany.
| | - Anja Buchmueller
- Bayer AG, Research and Development, Pharmaceuticals, Cardiovascular, 42096 Wuppertal, Germany
| | - Frank Dittmer
- Bayer AG, Product Supply, Pharmaceuticals, Quality Control, 51368 Leverkusen, Germany
| | - Julia Straßburger
- Bayer AG, Research and Development, Pharmaceuticals, Cardiovascular, 42096 Wuppertal, Germany
| | - Andreas Wilmen
- Bayer AG, Research and Development, Pharmaceuticals, Protein Engineering and Assays, 50829 Cologne, Germany
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Wang Y, Zhang H, Jiang JM, Zheng D, Tan HS, Tang LM, Xu HX. Multiorgan toxicity induced by EtOH extract of Fructus Psoraleae in Wistar rats. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2019; 58:152874. [PMID: 30889421 DOI: 10.1016/j.phymed.2019.152874] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 02/10/2019] [Accepted: 02/23/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND The fruits of Psoralea corylifolia L. (Fructus Psoraleae, FP) has a long history and a wide range of applications in the treatment of osteoporosis and leukoderma. Although it is well known that FP could cause hepatotoxicity and reproductive toxicity, less is known about its potential toxicity on multiple organs. PURPOSE This study aims to determine the multiorgan toxicity of EtOH extract of FP (EEFP) and to investigate the underlying mechanisms through a systematic evaluation in Wistar rats. STUDY DESIGN AND METHODS Wistar rats were orally administered with the EEFP at doses of 1.5, 1.0 and 0.5 g/kg for 28 days. Histopathologic and clinicopathologic analyses were performed, and the hormone levels in serum and the mRNA levels of enzymes related to the production of steroid hormones in adrenal glands were detected. The area of each band of adrenal glands and the steroid levels in the adrenal glands were also measured. RESULTS After the treatment, both the histopathologic and clinicopathologic examination showed that EEFP caused liver, prostate, seminal vesicle and adrenal gland damage. Among the enzymes involved in the regulation of adrenal steroid hormone production, NET, VMAT2, and CYP11B1 were upregulated, while CYP17A1 was downregulated. Among the adrenal steroid hormones, COR and NE were upregulated, while levels of DHT and serum ACRH and CRH decreased. CONCLUSION Our results indicated that adrenal gland, prostate, and seminal vesicles could also be the target organs of FP-induced toxicity. Abnormal enzyme and hormone production related to the hypothalamic pituitary adrenal (HPA) axis caused by the EEFP may be the potential toxic mechanism for changes in the adrenal gland and secondary sex organs of male rats.
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Affiliation(s)
- Yu Wang
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, PR China; Engineering Research Center of Shanghai Colleges for TCM New Drug Discovery, Shanghai 201203, PR China
| | - Hong Zhang
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, PR China; Engineering Research Center of Shanghai Colleges for TCM New Drug Discovery, Shanghai 201203, PR China
| | - Jia-Ming Jiang
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, PR China; Engineering Research Center of Shanghai Colleges for TCM New Drug Discovery, Shanghai 201203, PR China
| | - Dan Zheng
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, PR China; Engineering Research Center of Shanghai Colleges for TCM New Drug Discovery, Shanghai 201203, PR China
| | - Hong-Sheng Tan
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, PR China; Engineering Research Center of Shanghai Colleges for TCM New Drug Discovery, Shanghai 201203, PR China
| | - Li-Ming Tang
- Pharmacology and Toxicology Department, Shanghai Institute for Food and Drug Control, Shanghai 201203, PR China.
| | - Hong-Xi Xu
- School of Pharmacy, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, PR China; Engineering Research Center of Shanghai Colleges for TCM New Drug Discovery, Shanghai 201203, PR China.
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Thomas D, Thelen K, Kraff S, Schwers S, Schiffer S, Unger S, Yassen A, Boxnick S. BAY 1213790, a fully human IgG1 antibody targeting coagulation factor XIa: First evaluation of safety, pharmacodynamics, and pharmacokinetics. Res Pract Thromb Haemost 2019; 3:242-253. [PMID: 31011708 PMCID: PMC6462747 DOI: 10.1002/rth2.12186] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 12/15/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Coagulation factor XI (FXI) contributes to the development of thrombosis but appears to play only a minor role in hemostasis and is therefore an attractive anticoagulant drug target. OBJECTIVES To evaluate the safety, pharmacodynamic, and pharmacokinetic properties of BAY 1213790, a fully human immunoglobulin (Ig) G1 antibody targeting activated coagulation FXI (FXIa), in healthy men. METHODS In this phase 1, single-blind, parallel-group, placebo-controlled, dose-escalation study, 83 healthy Caucasian men were randomized 4:1 to receive a single 60-minute intravenous infusion of BAY 1213790 (0.015-10 mg/kg) or placebo. Adverse events, pharmacodynamic parameters (including activated partial thromboplastin time [aPTT]) and pharmacokinetic parameters were determined. Volunteers were followed up for 150 days. RESULTS BAY 1213790 demonstrated favorable safety and tolerability; there were no observed cases of bleeding or clinically relevant antidrug antibody formation. One volunteer (1.2%) experienced an infusion reaction. Following intravenous administration of BAY 1213790, dose-dependent increases in aPTT (maximal mean increase relative to baseline: 1.85 [conventional method] and 2.17 [kaolin-triggered method]) and rotational thromboelastometry whole blood clotting time were observed, as well as dose-dependent reductions in FXI activity. Bleeding times did not increase following administration of BAY 1213790 and were similar for all dose cohorts, including placebo. Measurable and dose-dependent increases in systemic exposure were detected for all doses of BAY 1213790 of 0.06 mg/kg or higher. CONCLUSIONS Based on these safety, pharmacodynamic, and pharmacokinetic results, further evaluation of BAY 1213790 in patients with, or at risk of, thrombosis is warranted.
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Affiliation(s)
- Dirk Thomas
- Experimental Medicine CV/HEM, Research & DevelopmentBayer AGWuppertalGermany
| | - Kirstin Thelen
- Clinical PK CV, Research & DevelopmentBayer AGWuppertalGermany
| | - Stefanie Kraff
- Clinical PK CV, Research & DevelopmentBayer AGWuppertalGermany
| | - Stephan Schwers
- Experimental Medicine CV/HEM, Research & DevelopmentBayer AGWuppertalGermany
| | - Sonja Schiffer
- Experimental Medicine CV/HEM, Research & DevelopmentBayer AGWuppertalGermany
| | - Sigrun Unger
- Research & Clinical Sciences Statistics, Research & DevelopmentBayer AGWuppertalGermany
| | - Ashraf Yassen
- Clinical Pharmacometrics, Research & DevelopmentBayer AGWuppertalGermany
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Székely O, Borgi M, Lip GYH. Factor XI inhibition fulfilling the optimal expectations for ideal anticoagulation. Expert Opin Emerg Drugs 2019; 24:55-61. [DOI: 10.1080/14728214.2019.1591368] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Orsolya Székely
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Marco Borgi
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Gregory Y. H. Lip
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
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The contact system at the crossroads of various key patho- physiological functions: Update on present understanding, laboratory exploration and future perspectives. Transfus Apher Sci 2019; 58:216-222. [PMID: 30954379 DOI: 10.1016/j.transci.2019.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The contact system initiates the intrinsic pathway of coagulation and is started by Factor XII activation, which then activates prekallicrein to kallicrein and Factor XI to Factor XIa and, in the presence of high molecular weight kininogen, forms a "contact phase activation loop", that amplifies Factor XII activation. FXII deficiency is not associated with bleeding tendencies, but when the blood clots, the thrombus is less dense, thus favoring antithrombotic protection. Activated Factor XII inhibition emerges as an efficient target for preventing thrombo-embolic diseases without inducing a hemorrhagic risk. Activated Factor XII exhibits other activities, in that it can activate complement and provoke inflammation, contributing to innate immunity. It also stimulates fibrinolysis through uPA activation from scu-PA. Among the other components of the contact phase, Factor XI has a more important role in coagulation pathways and can directly activate FX, FVIII and FV, in a FIX independent pathway. Its deficiency is associated with a mild bleeding diathesis ("pseudo-hemophilia" or hemophilia C), with a variable incidence among kindreds. Recently, the occurrence of thrombotic events the same day following infusion of immunoglobulin concentrates has been demonstrated to be caused by the presence of trace amounts of activated Factor XI, pointing out the key role of this factor for thrombogenicity. Prekallicrein can be activated at the endothelial surface in the presence of high molecular weight kininogen, whose cleavage generates bradykinins and contributes to vessel tonicity and inflammation. The contact phase, through its activation loop, is then an important physiological system, which can initiate and regulate various biological functions and is at the crossroads of various biological activities. Many of the body's physiological functions are intimately linked between them, making the global approach of special usefulness for understanding the interactions which can result from any abnormality of one of them. New pharmaceutical drugs targeting a defined activity need to be investigated for all the possible interferences or side effects. In this article we aim to present and summarize the present understanding of contact phase system activation and regulation, its involvement in various physiological functions, and the laboratory tools for its exploration.
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Al-Horani RA, Afosah DK. Recent advances in the discovery and development of factor XI/XIa inhibitors. Med Res Rev 2018; 38:1974-2023. [PMID: 29727017 PMCID: PMC6173998 DOI: 10.1002/med.21503] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/09/2018] [Accepted: 04/04/2018] [Indexed: 12/12/2022]
Abstract
Factor XIa (FXIa) is a serine protease homodimer that belongs to the intrinsic coagulation pathway. FXIa primarily catalyzes factor IX activation to factor IXa, which subsequently activates factor X to factor Xa in the common coagulation pathway. Growing evidence suggests that FXIa plays an important role in thrombosis with a relatively limited contribution to hemostasis. Therefore, inhibitors targeting factor XI (FXI)/FXIa system have emerged as a paradigm-shifting strategy so as to develop a new generation of anticoagulants to effectively prevent and/or treat thromboembolic diseases without the life-threatening risk of internal bleeding. Several inhibitors of FXI/FXIa proteins have been discovered or designed over the last decade including polypeptides, active site peptidomimetic inhibitors, allosteric inhibitors, antibodies, and aptamers. Antisense oligonucleotides (ASOs), which ultimately reduce the hepatic biosynthesis of FXI, have also been introduced. A phase II study, which included patients undergoing elective primary unilateral total knee arthroplasty, revealed that a specific FXI ASO effectively protects patients against venous thrombosis with a relatively limited risk of bleeding. Initial findings have also demonstrated the potential of FXI/FXIa inhibitors in sepsis, listeriosis, and arterial hypertension. This review highlights various chemical, biochemical, and pharmacological aspects of FXI/FXIa inhibitors with the goal of advancing their development toward clinical use.
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Affiliation(s)
- Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, Louisiana 70125
| | - Daniel K. Afosah
- Department of Medicinal Chemistry and Institute for Structural Biology, Drug Discovery and Development, Virginia Commonwealth University, Richmond, Virginia 23219
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Quan ML, Pinto DJP, Smallheer JM, Ewing WR, Rossi KA, Luettgen JM, Seiffert DA, Wexler RR. Factor XIa Inhibitors as New Anticoagulants. J Med Chem 2018; 61:7425-7447. [PMID: 29775297 DOI: 10.1021/acs.jmedchem.8b00173] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
With the introduction of thrombin and factor Xa inhibitors to the oral anticoagulant market, significant improvements in both efficacy and safety have been achieved. Early clinical and preclinical data suggest that inhibitors of factor XIa can provide a still safer alternative, with expanded efficacy for arterial indications. This Perspective provides an overview of target rationale and details of the discovery and development of inhibitors of factor XIa as next generation antithrombotic agents.
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Affiliation(s)
- Mimi L Quan
- Research and Development , Bristol-Myers Squibb Company , P.O. Box 5400, Princeton , New Jersey 08543 , United States
| | - Donald J P Pinto
- Research and Development , Bristol-Myers Squibb Company , P.O. Box 5400, Princeton , New Jersey 08543 , United States
| | - Joanne M Smallheer
- Research and Development , Bristol-Myers Squibb Company , P.O. Box 5400, Princeton , New Jersey 08543 , United States
| | - William R Ewing
- Research and Development , Bristol-Myers Squibb Company , P.O. Box 5400, Princeton , New Jersey 08543 , United States
| | - Karen A Rossi
- Research and Development , Bristol-Myers Squibb Company , P.O. Box 5400, Princeton , New Jersey 08543 , United States
| | - Joseph M Luettgen
- Research and Development , Bristol-Myers Squibb Company , P.O. Box 5400, Princeton , New Jersey 08543 , United States
| | - Dietmar A Seiffert
- Research and Development , Bristol-Myers Squibb Company , P.O. Box 5400, Princeton , New Jersey 08543 , United States
| | - Ruth R Wexler
- Research and Development , Bristol-Myers Squibb Company , P.O. Box 5400, Princeton , New Jersey 08543 , United States
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Shang F, Gao N, Yin R, Lin L, Xiao C, Zhou L, Li Z, Purcell SW, Wu M, Zhao J. Precise structures of fucosylated glycosaminoglycan and its oligosaccharides as novel intrinsic factor Xase inhibitors. Eur J Med Chem 2018; 148:423-435. [DOI: 10.1016/j.ejmech.2018.02.047] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 01/24/2018] [Accepted: 02/14/2018] [Indexed: 12/20/2022]
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van Montfoort M, Meijers J. Anticoagulation beyond direct thrombin and factor Xa inhibitors: indications for targeting the intrinsic pathway? Thromb Haemost 2017; 110:223-32. [DOI: 10.1160/th12-11-0803] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 05/07/2013] [Indexed: 11/05/2022]
Abstract
SummaryAntithrombotic drugs like vitamin K antagonists and heparin have been the gold standard for the treatment and prevention of thromboembolic disease for many years. Unfortunately, there are several disadvantages of these antithrombotic drugs: they are accompanied by serious bleeding problems, it is necessary to monitor the therapeutic window, and there are various interactions with food and other drugs. This has led to the development of new oral anticoagulants, specifically inhibiting either thrombin or factor Xa. In terms of effectiveness, these drugs are comparable to the currently available anticoagulants; however, they are still associated with issues such as bleeding, reversal of the drug and complicated laboratory monitoring. Vitamin K antagonists, heparin, direct thrombin and factor Xa inhibitors have in common that they target key proteins of the haemostatic system. In an attempt to overcome these difficulties we investigated whether the intrinsic coagulation factors (VIII, IX, XI, XII, prekallikrein and high-molecular-weight kininogen) are superior targets for anticoagulation. We analysed epidemiological data concerning thrombosis and bleeding in patients deficient in one of the intrinsic pathway proteins. Furthermore, we discuss several thrombotic models in intrinsic coagulation factor-deficient animals. The combined results suggest that intrinsic coagulation factors could be suitable targets for anticoagulant drugs.
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40
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Fischer PM. Design of Small-Molecule Active-Site Inhibitors of the S1A Family Proteases as Procoagulant and Anticoagulant Drugs. J Med Chem 2017; 61:3799-3822. [DOI: 10.1021/acs.jmedchem.7b00772] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Peter M. Fischer
- School of Pharmacy and Centre for Biomolecular Sciences, University of Nottingham, Nottingham NG7 2RD, U.K
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Mustonen EK, Palomäki T, Pasanen M. Oligonucleotide-based pharmaceuticals: Non-clinical and clinical safety signals and non-clinical testing strategies. Regul Toxicol Pharmacol 2017; 90:328-341. [PMID: 28966105 DOI: 10.1016/j.yrtph.2017.09.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 12/21/2022]
Abstract
Antisense oligonucleotides, short interfering RNAs (siRNAs) and aptamers are oligonucleotide-based pharmaceuticals with a promising role in targeted therapies. Currently, five oligonucleotide-based pharmaceuticals have achieved marketing authorization in Europe or USA and many more are undergoing clinical testing. However, several safety concerns have been raised in non-clinical and clinical studies. Oligonucleotides share properties with both chemical and biological pharmaceuticals and therefore they pose challenges also from the regulatory point of view. We have analyzed the safety data of oligonucleotides and evaluated the applicability of current non-clinical toxicological guidelines for assessing the safety of oligonucleotide-based pharmaceuticals. Oligonucleotide-based pharmaceuticals display a similar toxicological profile, exerting adverse effects on liver and kidney, evoking hematological alterations, as well as causing immunostimulation and prolonging the coagulation time. It is possible to extrapolate some of these effects from non-clinical studies to humans. However, evaluation strategies for genotoxicity testing of "non-natural" oligonucleotides should be revised. Additionally, the selective use of surrogates and prediction of clinical endpoints for non-clinically observed immunostimulation is complicated by its multiple potential manifestations, demanding improvements in the testing strategies. Utilizing more relevant and mechanistic-based approaches and taking better account of species differences, could possibly improve the prediction of relevant immunological/proinflammatory effects in humans.
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Affiliation(s)
- Enni-Kaisa Mustonen
- University of Eastern Finland, Faculty of Health Sciences, School of Pharmacy, P.O. Box 1627, 70211 Kuopio, Finland
| | | | - Markku Pasanen
- University of Eastern Finland, Faculty of Health Sciences, School of Pharmacy, P.O. Box 1627, 70211 Kuopio, Finland.
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Gómez-Outes A, García-Fuentes M, Suárez-Gea ML. Discovery methods of coagulation-inhibiting drugs. Expert Opin Drug Discov 2017; 12:1195-1205. [DOI: 10.1080/17460441.2017.1384811] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Antonio Gómez-Outes
- Division of Pharmacology and Clinical Drug Evaluation, Medicines for Human Use, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Minerva García-Fuentes
- Division of Pharmacology and Clinical Drug Evaluation, Medicines for Human Use, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Mª Luisa Suárez-Gea
- Division of Pharmacology and Clinical Drug Evaluation, Medicines for Human Use, Spanish Agency for Medicines and Medical Devices (AEMPS), Madrid, Spain
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Wheeler AP, Gailani D. The Intrinsic Pathway of Coagulation as a Target for Antithrombotic Therapy. Hematol Oncol Clin North Am 2017; 30:1099-114. [PMID: 27637310 DOI: 10.1016/j.hoc.2016.05.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Plasma coagulation in the activated partial thromboplastin time assay is initiated by sequential activation of coagulation factors XII, XI, and IX. While this series of proteolytic reactions is not an accurate model for hemostasis in vivo, there is mounting evidence that factor XI and factor XII contribute to thrombosis, and that inhibiting them can produce an antithrombotic effect with a small effect on hemostasis. This article discusses the contributions of components of the intrinsic pathway to thrombosis in animal models and humans, and results of early clinical trials of drugs targeting factors IX, XI, and XII.
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Affiliation(s)
- Allison P Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, C-3321A Medical Center North, 1161 21st Avenue, Nashville, TN 37232, USA; Department of Pediatrics, Vanderbilt University, 397 Preston Research Building, 2220 Pierce Ave, Nashville, TN 37232, USA.
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, C-3321A Medical Center North, 1161 21st Avenue, Nashville, TN 37232, USA; Hematology/Oncology Division, Department of Medicine, Vanderbilt University, 777 Preston Research Building, 2220 Pierce Avenue, Nashville, TN 37232, USA
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Henry SP, Narayanan P, Shen L, Bhanot S, Younis HS, Burel SA. Assessment of the Effects of 2'-Methoxyethyl Antisense Oligonucleotides on Platelet Count in Cynomolgus Nonhuman Primates. Nucleic Acid Ther 2017; 27:197-208. [PMID: 28541820 DOI: 10.1089/nat.2017.0666] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Decreases in platelet (PLT) counts observed in nonhuman primates (NHPs) given 2'-O-methoxyethyl modified antisense inhibitors (2'-MOE ASOs) have been reported, but the incidence and severity of the change vary considerably between sequences, studies, and animals. This article will broadly illustrate the spectrum of effects on PLT count in NHPs. From queries of an NHP safety database representing over 102 independent 2'-MOE ASOs, from 61 studies and >2200 NHPs, two patterns of PLT changes emerged. The first is a consistent and reproducible decrease in group mean values, observed with about 30% of the compounds, in which PLT count typically remains ≥150K cells/μL. The second is a sporadic decrease in PLTs to <50K cells/μL (2%-4% incidence at doses >5 mg/kg) that is often not reproducible. In both cases, the reduction in PLT count is dose dependent and reversible. The human relevance of PLT change observed in NHPs was investigated using ISIS 404173. In a chronic NHP study (20 mg/kg/wk for 26 weeks), a gradual decrease in group mean PLT count was observed at ≥10 mg/kg/wk, which plateaued by 13 weeks generally within the normal range and was maintained through 26 weeks of treatment. However, PLT counts <50K cells/μL occurred in 1 of 16 NHP at 10 mg/kg/wk and 3 of 16 NHP at 20 mg/kg/wk. In a 26-week double-blind, placebo-controlled Phase 2 trial, 62 patients were treated with 200 mg/wk ISIS 404173 (∼3.3 mg/kg/wk) there was an increased incidence of PLT count >30% decreased compared to baseline but no incidence of PLT <75K cells/μL. Based on these data, the consistent, self-limiting PLT reduction seen in NHP may translate to humans, but these changes appear to be of limited clinical significance. However, NHPs appear to overpredict the incidence of sporadic PLT <50K cells/μL compared to humans.
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Affiliation(s)
- Scott P Henry
- Development, IONIS Pharmaceuticals , Carlsbad, California
| | | | - Lijiang Shen
- Development, IONIS Pharmaceuticals , Carlsbad, California
| | - Sanjay Bhanot
- Development, IONIS Pharmaceuticals , Carlsbad, California
| | - Husam S Younis
- Development, IONIS Pharmaceuticals , Carlsbad, California
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Heestermans M, van Vlijmen BJ. Oligonucleotides targeting coagulation factor mRNAs: use in thrombosis and hemophilia research and therapy. Thromb J 2017; 15:7. [PMID: 28286423 PMCID: PMC5341404 DOI: 10.1186/s12959-017-0130-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 02/27/2017] [Indexed: 02/08/2023] Open
Abstract
Small interfering (si) RNAs and antisense oligonucleotides (ASOs; here for simplicity reasons, both referred to as oligonucleotides) are small synthetic RNA or DNA molecules with a sequence complementary to a (pre)mRNA. Although the basic mechanisms of action between siRNAs and ASO are distinct, a sequence-specific interaction of the both oligonucleotides with the target (pre)mRNA alters the target's fate, which includes highly effective sequence-specific blockade of translation and consequently depletion of the corresponding protein. For a number of years, these oligonucleotides have been used as a tool in biological research to study gene function in vitro. More recently, safe and specific delivery of these oligonucleotides to the liver of mammals has been achieved and optimized. This not only allowed their use for in vivo gene studies in physiology and disease, but also opened the opportunity for the development of a new generation of RNA-specific drugs for therapeutic purposes. In 2013, the first oligonucleotide product targeting RNA from the hepatic cholesterol pathway was approved. For blood coagulation, a large portion of key proteins are produced in the liver, and thereby siRNAs and ASOs can also be used as appropriate tools to target these proteins in vivo. In this review, we describe the first use of oligonucleotides for this purpose from zebrafish to primates. As the use of oligonucleotides allows avoidance of early lethality associated with full deficiency of several coagulation factors, it has proved to be of value for studying these proteins in physiology and disease. Currently, oligonucleotides are tested as therapeutics, with the ultimate goal to beneficially modulate the hemostatic balance in thrombosis and hemophilia patients. We discuss both the preclinical and clinical studies of a number of siRNAs and ASOs with the potential to be introduced as drugs for prophylactic and/or treatment of thrombosis or hemophilia. We conclude that for the coagulation field, oligonucleotides are of value for research purposes, and now the moment has come to fulfill their promise as therapeutics.
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Affiliation(s)
- Marco Heestermans
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Bart J.M. van Vlijmen
- Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine, Division of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Lavery KS, Rhodes C, Mcgraw A, Eppihimer MJ. Anti-thrombotic technologies for medical devices. Adv Drug Deliv Rev 2017; 112:2-11. [PMID: 27496703 DOI: 10.1016/j.addr.2016.07.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/03/2016] [Accepted: 07/26/2016] [Indexed: 01/08/2023]
Abstract
Thrombosis associated with medical devices may lead to dramatic increases in morbidity, mortality and increased health care costs. Innovative strategies are being developed to reduce this complication and provide a safe biocompatible interface between device and blood. This article aims to describe the biological phenomena underlying device-associated thrombosis, and surveys the literature describing current and developing technologies designed to overcome this challenge. To reduce thrombosis, biomaterials with varying topographical properties and incorporating anti-thrombogenic substances on their surface have demonstrated potential. Overall, there is extensive literature describing technical solutions to reduce thrombosis associated with medical devices, but clinical results are required to demonstrate significant long-term benefits.
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Affiliation(s)
- Karen S Lavery
- Preclinical Sciences, Boston Scientific Corporation, 100 Boston Scientific Way, Marlborough, MA 01752-1234, United States
| | - Candace Rhodes
- Preclinical Sciences, Boston Scientific Corporation, 100 Boston Scientific Way, Marlborough, MA 01752-1234, United States
| | - Adam Mcgraw
- Preclinical Sciences, Boston Scientific Corporation, 100 Boston Scientific Way, Marlborough, MA 01752-1234, United States
| | - Michael J Eppihimer
- Preclinical Sciences, Boston Scientific Corporation, 100 Boston Scientific Way, Marlborough, MA 01752-1234, United States
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Crooke ST, Baker BF, Witztum JL, Kwoh TJ, Pham NC, Salgado N, McEvoy BW, Cheng W, Hughes SG, Bhanot S, Geary RS. The Effects of 2'-O-Methoxyethyl Containing Antisense Oligonucleotides on Platelets in Human Clinical Trials. Nucleic Acid Ther 2017; 27:121-129. [PMID: 28145801 PMCID: PMC5467133 DOI: 10.1089/nat.2016.0650] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A thorough analysis of clinical trial data in the Ionis integrated safety database (ISDB) was performed to determine if there is a class effect on platelet numbers and function in subjects treated with 2′-O-methoxyethyl (2′MOE)-modified antisense oligonucleotides (ASOs). The Ionis ISDB includes over 2,600 human subjects treated with 16 different 2′MOE ASOs in placebo-controlled and open-label clinical trials over a range of doses up to 624 mg/week and treatment durations as long as 4.6 years. This analysis showed that there is no class generic effect on platelet numbers and no incidence of confirmed platelet levels below 50 K/μL in subjects treated with 2′MOE ASOs. Only 7 of 2,638 (0.3%) subjects treated with a 2′MOE ASO experienced a confirmed postbaseline (BSLN) platelet count between 100 and 50 K/μL. Three of sixteen 2′MOE ASOs had >10% incidence of platelet decreases >30% from BSLN, suggesting that certain sequences may associate with clinically insignificant platelet declines. Further to these results, we found no evidence that 2′MOE ASOs alter platelet function, as measured by the lack of clinically relevant bleeding in the presence or absence of other drugs that alter platelet function and/or number and by the results from trials conducted with the factor XI (FXI) ASO.
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Affiliation(s)
| | | | - Joseph L. Witztum
- Department of Medicine, University of California San Diego, School of Medicine, La Jolla, California
| | | | | | | | | | - Wei Cheng
- Ionis Pharmaceuticals, Inc., Carlsbad, California
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Zhong C, Zhang L, Chen L, Deng L, Li R. Coagulation factor XI vaccination: an alternative strategy to prevent thrombosis. J Thromb Haemost 2017; 15:122-130. [PMID: 27813324 DOI: 10.1111/jth.13561] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 10/24/2016] [Indexed: 12/22/2022]
Abstract
Essentials Coagulation Factor (F) XI is a safe target for the development of antithrombotics. We designed an antigen comprising the human FXI catalytic domain and diphtheria toxin T domain. Antigen immunization reduced plasma FXI activity by 54% and prevented thrombosis in mice. FXI vaccination can serve as an effective strategy for thrombosis prevention. SUMMARY Background Coagulation factor XI serves as a signal amplifier in the intrinsic coagulation pathway. Blockade of FXI by mAbs or small-molecule inhibitors inhibits thrombosis without causing severe bleeding, which is an inherent risk of currently available antithrombotic agents. Objectives To design an FXI vaccine and assess its efficacy in inhibiting FXI activity and preventing thrombosis. Methods An FXI antigen was generated by fusing the catalytic domain of human FXI to the C-terminus of the transmembrane domain of diphtheria toxin. The anti-FXI antibody response, plasma FXI activity and antithrombotic efficacy in mice immunized with the FXI antigen were examined. Results The antigen elicited a significant antibody response against mouse FXI, and reduced the plasma FXI activity by 54.0% in mice. FXI vaccination markedly reduced the levels of coagulation and inflammation in a mouse model of inferior vena cava stenosis. Significant protective effects were also observed in mouse models of venous thrombosis and pulmonary embolism. Conclusions Our data demonstrate that FXI vaccination can serve as an effective strategy for thrombosis prevention.
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Affiliation(s)
- C Zhong
- State Key Laboratory of Microbial Metabolism and School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - L Zhang
- State Key Laboratory of Microbial Metabolism and School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - L Chen
- State Key Laboratory of Microbial Metabolism and School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
| | - L Deng
- Shanghai HyCharm Inc., Shanghai, China
| | - R Li
- State Key Laboratory of Microbial Metabolism and School of Life Sciences & Biotechnology, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, Shanghai, China
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Abstract
INTRODUCTION Anticoagulants are the mainstay for prevention and/or treatment of thrombotic disorders. Each clinically used anticoagulant is associated with significant adverse consequences, especially bleeding. Factor XIa (FXIa), a key factor involved in the amplification of procoagulation signal, has been suggested as a major target for anticoagulant drug discovery because of reduced risk of bleeding. AREAS COVERED Our literature search uncovered dozens of industrial and academic patents on the discovery of novel FXIa/FXI inhibitors. Small peptidomimetics, sulfated glycosaminoglycan mimetics, polypeptides, antisense oligonucleotides, and monoclonal antibodies have been developed as inhibitors of FXIa. Although many agents are in early discovery/development phases, the activity and safety of a few have been evaluated in various animal models and in humans. EXPERT OPINION FXIa is a promising drug target for development of effective anticoagulants with limited bleeding complications. Literature reveals a major trend in the number of patent applications over the last three years. These inhibitors exploit different approaches for target inhibition. Allosteric modulation of FXIa and biosynthetic inhibition of FXI are mechanistically unique. Despite initial results in patients undergoing knee anthroplasty as with antisense oligonucleotides, major advances should be realized, particularly with respect to pharmacokinetics, for FXI/FXIa inhibitors to enter the clinic.
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Affiliation(s)
- Rami A Al-Horani
- a Department of Medicinal Chemistry & Institute for Structural Biology , Drug Discovery and Development, Virginia Commonwealth University , Richmond , VA 23219 , USA
| | - Umesh R Desai
- a Department of Medicinal Chemistry & Institute for Structural Biology , Drug Discovery and Development, Virginia Commonwealth University , Richmond , VA 23219 , USA
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Miller CM, Harris EN. Antisense Oligonucleotides: Treatment Strategies and Cellular Internalization. RNA & DISEASE 2016; 3:e1393. [PMID: 28374018 PMCID: PMC5376066 DOI: 10.14800/rd.1393] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The clinical applicaton of antisense oligonucleotides (ASOs) is becoming more of a reality as several drugs have been approved for the treatment of human disorders and many others are in various phases in development and clinical trials. ASOs are short DNA/RNA oligos which are heavily modified to increase their stability in biological fluids and retain the properties of creating RNA-RNA and DNA-RNA duplexes that knock-down or correct genetic expression. This review outlines several strategies that ASOs utilize for the treatment of various congenital diseases and syndromes that develop with aging. In addition, we discuss some of the mechanisms for specific non-targeted ASO internalization within cells.
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Affiliation(s)
- Colton M. Miller
- Department of Biochemistry, University of Nebraska - Lincoln, 1901 Vine St. Lincoln NE 68588 USA
| | - Edward N. Harris
- Department of Biochemistry, University of Nebraska - Lincoln, 1901 Vine St. Lincoln NE 68588 USA
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