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Seiffge DJ, Meinel T, Purrucker JC, Kaesmacher J, Fischer U, Wilson D, Wu TY. Recanalisation therapies for acute ischaemic stroke in patients on direct oral anticoagulants. J Neurol Neurosurg Psychiatry 2021; 92:534-541. [PMID: 33542084 PMCID: PMC8053326 DOI: 10.1136/jnnp-2020-325456] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/12/2020] [Accepted: 12/23/2020] [Indexed: 02/06/2023]
Abstract
Direct oral anticoagulants (DOACs) have emerged as primary therapeutic option for stroke prevention in patients with atrial fibrillation. However, patients may have ischaemic stroke despite DOAC therapy and there is uncertainty whether those patients can safely receive intravenous thrombolysis or mechanical thrombectomy. In this review, we summarise and discuss current knowledge about different approaches to select patient. Time since last DOAC intake-as a surrogate for anticoagulant activity-is easy to use but limited by interindividual variability of drug pharmacokinetics and long cut-offs (>48 hours). Measuring anticoagulant activity using drug-specific coagulation assays showed promising safety results. Large proportion of patients at low anticoagulant activity seem to be potentially treatable but there remains uncertainty about exact safe cut-off values and limited assay availability. The use of specific reversal agents (ie, idarucizumab or andexanet alfa) prior to thrombolysis is a new emerging option with first data reporting safety but issues including health economics need to be elucidated. Mechanical thrombectomy appears to be safe without any specific selection criteria applied. In patients on DOAC therapy with large vessel occlusion, decision for intravenous thrombolysis should not delay thrombectomy (eg, direct thrombectomy or immediate transfer to a thrombectomy-capable centre recommended). Precision medicine using a tailored approach combining clinicoradiological information (ie, penumbra and vessel status), anticoagulant activity and use of specific reversal agents only if necessary seems a reasonable choice.
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Affiliation(s)
- David J Seiffge
- Stroke Research Center, Queen Square Institute of Neurology, London, UK
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | | | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric RadiologyUniversity Institute of Diagnostic and Interventional of Neuroradiology, University Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital University Hospital Berne, Bern, Switzerland
| | - Duncan Wilson
- Stroke Research Center, Queen Square Institute of Neurology, London, UK
- Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Teddy Y Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
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Yoo HHB, Nunes‐Nogueira VS, Fortes Villas Boas PJ. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database Syst Rev 2020; 2:CD010222. [PMID: 32030721 PMCID: PMC7004894 DOI: 10.1002/14651858.cd010222.pub4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke. The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardiopulmonary reserve, classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncology patients). Traditionally, all PEs are anticoagulated in a similar manner independent of their location, or number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by a possible unnecessary use of anticoagulants. Patients with isolated SSPE, or incidental PE, may have a more benign clinical presentation compared to those with proximal PEs. However, the clinical significance in patients, and their prognosis, needs to be studied to evaluate whether anticoagulation therapy is required. This is the second update of the Cochrane systematic review published in 2014. OBJECTIVES To assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and AMED databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 26 November 2019. We also undertook reference checking to identify additional studies. SELECTION CRITERIA We included randomised controlled trials of anticoagulation therapy versus control in patients with SSPE or incidental SSPE. DATA COLLECTION AND ANALYSIS Two review authors inspected all citations identified to ensure reliable assessment. If relevant studies were identified, we planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS We did not identify any studies that met the inclusion criteria. AUTHORS' CONCLUSIONS There is no evidence from randomised controlled trials to assess the effectiveness and safety of anticoagulation therapy versus control in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. Well-conducted research is required before informed practice decisions can be made.
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Affiliation(s)
- Hugo HB Yoo
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Vania Santos Nunes‐Nogueira
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
| | - Paulo J Fortes Villas Boas
- Botucatu Medical School, São Paulo State University‐UNESPDepartment of Internal MedicineBotucatuSão PauloBrazil18618‐687
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Kawabori M, Niiya Y, Iwasaki M, Mabuchi S, Ozaki H, Matsubara K, Houkin K. Characteristics of Symptomatic Intracerebral Hemorrhage in Patient Receiving Direct Oral Anticoagulants: Comparison with Warfarin. J Stroke Cerebrovasc Dis 2018; 27:1338-1342. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.12.020] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/03/2017] [Accepted: 12/17/2017] [Indexed: 11/16/2022] Open
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Huo M. New oral anticoagulants in venous thromboembolism prophylaxis in orthopaedic patients: Are they really better? Thromb Haemost 2017; 106:45-57. [DOI: 10.1160/th10-10-0653] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2010] [Accepted: 04/15/2011] [Indexed: 01/13/2023]
Abstract
SummaryProphylaxis against venous thromboembolism (VTE) is considered standard of care. Appropriate chemoprophylaxis for VTE has been mandated by the United States government agencies and consumer groups. However, controversies exist regarding the most clinically relevant and safe chemoprophylaxis protocols in patients undergoing joint replacement surgery. Thus, this paper reviews the clinical efficacy and safety of newer oral anticoagulants. A literature search was performed for oral anticoagulants in advanced stages of development using PubMed and abstracts from thrombosis meetings. Most clinical trial data have demonstrated equal or superior efficacy in venographic endpoints in comparison to low-molecular-weight heparins (LMWH). However, bleeding complications have been reported to occur with oral anticoagulants as frequently as or more frequently than with LMWH. Other potential complications reported include liver enzyme elevation and cardiac irregularities. It remains to be established whether newer oral anticoagulants will be better alternatives to the current standard-ofcare in real-life medical clinical practice.
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Piovella F, Iosub DI. Extended non-vitamin K antagonist oral anticoagulation therapy for prevention of recurrent venous thromboembolism. Thromb Res 2016; 152:87-92. [PMID: 28017344 DOI: 10.1016/j.thromres.2016.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/07/2016] [Accepted: 12/03/2016] [Indexed: 10/20/2022]
Abstract
Evidence from the use of traditional therapy (low-molecular-weight heparin/vitamin K antagonists) for venous thromboembolism (VTE) treatment and prevention suggests that extending treatment beyond the acute phase reduces recurrence. More recently, several non-vitamin K antagonist oral anticoagulants (NOACs) have been approved in the acute setting; accumulating evidence suggests continuing treatment with these agents beyond 12months offers additional benefits to patients with VTE. This review examines the evidence for NOAC use in longer-duration anticoagulation treatment, and discusses guidelines from major societies. Clinical data from the phase III extension studies for apixaban, dabigatran and rivaroxaban are presented, and the clinical and economic costs and benefits are examined. Evidence from other therapy areas utilising extended treatment regimens highlights the possible impact of factors relevant to extended anticoagulation therapy. Phase IV studies of NOACs are presented. US and European guidelines advise long-term therapy in certain instances, taking into account evidence on NOAC use in VTE accumulated recently. They support NOAC use where they have been selected as the initial therapy choice and therapy needs to be extended beyond 3months. The phase III extension studies demonstrate the benefits of extended NOAC use versus treatment cessation, with reduced recurrence rates versus placebo, although associated with a potential moderate increase in bleeding risk. Phase IV data are also emerging, with the recent XALIA study showing that a broad range of patients with VTE can benefit from continued rivaroxaban treatment; ongoing research will yield data on long-term use of the other NOACs in routine clinical practice.
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Affiliation(s)
- Franco Piovella
- Fondazione I.R.C.C.S. Policlinico San Matteo, viale Camillo Golgi, 19, 27100 Pavia, Italy.
| | - Diana I Iosub
- Fondazione I.R.C.C.S. Policlinico San Matteo, viale Camillo Golgi, 19, 27100 Pavia, Italy
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Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke. AF-related strokes cause greater disability and mortality than those in patients without AF, and are associated with a significant clinical and economic burden in Mexico. Antithrombotic therapy reduces stroke risk in patients with AF and is recommended for all patients except those classified as having a low stroke risk. However, its use is suboptimal all around the world; one study showed that only 4 % of Mexican patients with AF who presented with ischemic stroke were in the therapeutic range for anticoagulation. Vitamin K antagonists (VKAs) such as warfarin or acenocoumarin have long been the only oral anticoagulants for stroke prevention in AF. Although effective, VKAs have disadvantages, including the need for regular coagulation monitoring and dose adjustment. Interactions with numerous common medications and foods contribute to the risk of serious bleeding and thrombotic events in VKA-treated patients. Thus novel oral anticoagulants (NOACs), more properly called direct oral anticoagulants (DOACs), such as dabigatran etexilate, rivaroxaban, apixaban, and edoxaban (not available in Mexico), have been developed. These offer the convenience of fixed-dose treatment without the need for monitoring, and have few drug or food interactions. Pivotal phase III trials have demonstrated that these agents are at least as effective as warfarin in preventing stroke and are associated with a reduced risk of intracranial hemorrhage. With apixaban approved in Mexico in April 2013, clinicians now have the choice of three novel DOACs as alternatives to warfarin. However, it is yet to be established which of these agents should be the first choice, and treatment decisions are likely to depend on the individual patient's characteristics.
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Abstract
BACKGROUND Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke.The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardio-pulmonary (C/P) reserve the classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncologic patients).Traditionally, all PEs are anticoagulated in a similar manner independent of the location, number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by possible unnecessary use of anticoagulants.Patients with isolated SSPE or incidental PE may have a more benign clinical presentation compared with those with proximal PEs. However, the clinical significance in patients and their prognosis have to be studied to evaluate whether anticoagulation therapy is required.This review is an update of a Cochrane systematic review first published in 2014. OBJECTIVES To assess the effectiveness and safety of anticoagulation therapy versus no intervention in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. SEARCH METHODS The Cochrane Vascular Trials Search Co-ordinator searched the Specialised Register (last searched December 2015) and CENTRAL (2015, Issue 11). MEDLINE, EMBASE, LILACS and clinical trials databases were also searched. SELECTION CRITERIA Randomised controlled trials of anticoagulation therapy versus no intervention in patients with SSPE or incidental SSPE. DATA COLLECTION AND ANALYSIS Two review authors inspected all citations to ensure reliable selection. We planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS No studies were identified that met the inclusion criteria. AUTHORS' CONCLUSIONS There is no randomised controlled trial evidence for the effectiveness and safety of anticoagulation therapy versus no intervention in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE, and therefore we can not draw any conclusions. Well-conducted research is required before informed practice decisions can be made.
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Affiliation(s)
- Hugo H B Yoo
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista, Distrito de Rubiao Junior, s/n, Campus de Botucatu, Botucatu, Sao Paulo, Brazil, 18618-970
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Wilson D, Charidimou A, Shakeshaft C, Ambler G, White M, Cohen H, Yousry T, Al-Shahi Salman R, Lip GYH, Brown MM, Jäger HR, Werring DJ. Volume and functional outcome of intracerebral hemorrhage according to oral anticoagulant type. Neurology 2015; 86:360-6. [PMID: 26718576 DOI: 10.1212/wnl.0000000000002310] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/03/2015] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To compare intracerebral hemorrhage (ICH) volume and clinical outcome of non-vitamin K oral anticoagulants (NOAC)-associated ICH to warfarin-associated ICH. METHODS In this multicenter cross-sectional observational study of patients with anticoagulant-associated ICH, consecutive patients with NOAC-ICH were compared to those with warfarin-ICH selected from a population of 344 patients with anticoagulant-associated ICH. ICH volume was measured by an observer blinded to clinical details. Outcome measures were ICH volume and clinical outcome adjusted for confounding factors. RESULTS We compared 11 patients with NOAC-ICH to 52 patients with warfarin-ICH. The median ICH volume was 2.4 mL (interquartile range [IQR] 0.3-5.4 mL) for NOAC-ICH vs 8.9 mL (IQR 4.0-21.3 mL) for warfarin-ICH (p = 0.0028). In univariate linear regression, use of warfarin (difference in cube root volume 1.61; 95% confidence interval [CI] 0.69 to 2.53) and lobar ICH location (compared with nonlobar ICH; difference in cube root volume 1.52; 95% CI 2.20 to 0.85) were associated with larger ICH volumes. In multivariable linear regression adjusting for confounding factors (sex, hypertension, previous ischemic stroke, white matter disease burden, and premorbid modified Rankin Scale score [mRS]), warfarin use remained independently associated with larger ICH (cube root) volumes (coefficient 0.64; 95% CI 0.24 to 1.25; p = 0.042). Ordered logistic regression showed an increased odds of a worse clinical outcome (as measured by discharge mRS) in warfarin-ICH compared with NOAC-ICH: odds ratio 4.46 (95% CI 1.10 to 18.14; p = 0.037). CONCLUSIONS In this small prospective observational study, patients with NOAC-associated ICH had smaller ICH volumes and better clinical outcomes compared with warfarin-associated ICH.
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Affiliation(s)
- Duncan Wilson
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Andreas Charidimou
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Clare Shakeshaft
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Gareth Ambler
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Mark White
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Hannah Cohen
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Tarek Yousry
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Rustam Al-Shahi Salman
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Gregory Y H Lip
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Martin M Brown
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - Hans Rolf Jäger
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK
| | - David J Werring
- From the Stroke Research Group (D.W., A.C., M.M.B., D.J.W.) and the Department of Brain Repair and Rehabilitation (D.W., A.C., C.S., M.W., T.Y., H.R.J., D.J.W.), UCL Institute of Neurology; Department of Statistical Science (G.A.), UCL; Lysholm Department of Neuroradiology (M.W., T.Y., H.R.J.), National Hospital for Neurology and Neurosurgery (D.W., A.C., M.M.B., D.J.W.), London; University College London Hospitals NHS Foundation Trust (H.C.); Division of Clinical Neurosciences (R.A.-S.S.), Centre for Clinical Brain Sciences, School of Clinical Sciences, University of Edinburgh; and University of Birmingham Centre for Cardiovascular Sciences (G.Y.H.L.), City Hospital, UK.
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Bapat P, Pinto LSR, Lubetsky A, Berger H, Koren G. Rivaroxaban transfer across the dually perfused isolated human placental cotyledon. Am J Obstet Gynecol 2015; 213:710.e1-6. [PMID: 26164691 DOI: 10.1016/j.ajog.2015.06.065] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 05/21/2015] [Accepted: 06/30/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The purpose of this study was to determine the rate and extent of rivaroxaban transfer across the term human placenta and determine whether passive diffusion was the primary mechanism involved in this transfer. STUDY DESIGN The transplacental pharmacokinetics of rivaroxaban was determined with the ex-vivo placenta perfusion model. Rivaroxaban was added to the maternal or fetal circulation only (250 ng/mL). Additional experiments were conducted under equilibrative conditions with the addition of rivaroxaban to both the maternal and fetal circulations (250 ng/mL). Rivaroxaban concentrations were measured with the use of liquid chromatography-tandem mass spectrometry. RESULTS There was rapid transfer of rivaroxaban across the human placenta in both the maternal-to-fetal and fetal-to-maternal directions, as evidenced by transfer ratios of 0.69 (interquartile range, 0.58-0.73; n = 5) and 0.69 (interquartile range, 0.67-0.71; n = 2), respectively, after 3 hours. Under equilibrative conditions (n = 2), rivaroxaban concentrations remained relatively constant, which suggests that rivaroxaban crosses the placenta down a concentration gradient. CONCLUSION This is the first direct evidence of rivaroxaban transfer across the term human placenta from both the mother-to-fetus and fetus-to-mother directions. Our results document that unbound rivaroxaban rapidly crosses the placental barrier via passive diffusion. However, because rivaroxaban is highly bound to plasma proteins (up to 95%), this suggests that the amount of unbound drug that may reach the fetus is likely much lower. Additional studies will need to explore its safety before administering rivaroxaban to a pregnant woman.
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Affiliation(s)
- Priya Bapat
- Motherisk Program, Division of Clinical Pharmacology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Angelika Lubetsky
- Motherisk Program, Division of Clinical Pharmacology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Howard Berger
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto, ON, Canada
| | - Gideon Koren
- Motherisk Program, Division of Clinical Pharmacology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Pharmacology and Toxicology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Abstract
BACKGROUND Acute pulmonary embolism (PE) is a common cause of death, accounting for 50,000 to 200,000 deaths annually. It is the third most common cause of mortality among the cardiovascular diseases, after coronary artery disease and stroke.The advent of multi-detector computed tomographic pulmonary angiography (CTPA) has allowed better assessment of PE regarding visualisation of the peripheral pulmonary arteries, increasing its rate of diagnosis. More cases of peripheral PEs, such as isolated subsegmental PE (SSPE) and incidental PE, have thereby been identified. These two conditions are usually found in patients with few or none of the classic PE symptoms such as haemoptysis or pleuritic pain, acute dyspnoea or circulatory collapse. However, in patients with reduced cardio-pulmonary (C/P) reserve the classic PE symptoms can be found with isolated SSPEs. Incidental SSPE is found casually in asymptomatic patients, usually by diagnostic imaging performed for other reasons (for example routine CT for cancer staging in oncologic patients).Traditionally, all PEs are anticoagulated in a similar manner independent of the location, number and size of the thrombi. It has been suggested that many patients with SSPE may be treated without benefit, increasing adverse events by possible unnecessary use of anticoagulants.Patients with isolated SSPE or incidental PE may have a more benign clinical presentation compared with those with proximal PEs. However, the clinical significance in patients and their prognosis have to be studied to evaluate whether anticoagulation therapy is required. OBJECTIVES To assess the effectiveness and safety of anticoagulation therapy versus no intervention in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2013) and CENTRAL (2013, Issue 9). MEDLINE, EMBASE, LILACS and clinical trials databases were also searched (October 2013). SELECTION CRITERIA Randomised controlled trials of anticoagulation therapy versus no intervention in patients with SSPE or incidental SSPE. DATA COLLECTION AND ANALYSIS Two review authors inspected all citations to ensure reliable selection. We planned for two review authors to independently extract data and to assess the methodological quality of identified trials using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS No studies were identified that met the inclusion criteria. AUTHORS' CONCLUSIONS There is no randomised controlled trial evidence for the effectiveness and safety of anticoagulation therapy versus no intervention in patients with isolated subsegmental pulmonary embolism (SSPE) or incidental SSPE, and therefore we can not draw any conclusions. Well-conducted research is required before informed practice decisions can be made.
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Affiliation(s)
- Hugo H B Yoo
- Department of Internal Medicine, Botucatu Medical School, UNESP - Univ Estadual Paulista, Distrito de Rubiao Junior, s/n, Campus de Botucatu, Botucatu, Sao Paulo, Brazil, 18618-970
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11
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Mueck W, Schwers S, Stampfuss J. Rivaroxaban and other novel oral anticoagulants: pharmacokinetics in healthy subjects, specific patient populations and relevance of coagulation monitoring. Thromb J 2013; 11:10. [PMID: 23809871 PMCID: PMC3726366 DOI: 10.1186/1477-9560-11-10] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/09/2013] [Indexed: 02/08/2023] Open
Abstract
Unlike traditional anticoagulants, the more recently developed agents rivaroxaban, dabigatran and apixaban target specific factors in the coagulation cascade to attenuate thrombosis. Rivaroxaban and apixaban directly inhibit Factor Xa, whereas dabigatran directly inhibits thrombin. All three drugs exhibit predictable pharmacokinetic and pharmacodynamic characteristics that allow for fixed oral doses in a variety of settings. The population pharmacokinetics of rivaroxaban, and also dabigatran, have been evaluated in a series of models using patient data from phase II and III clinical studies. These models point towards a consistent pharmacokinetic and pharmacodynamic profile, even when extreme demographic factors are taken into account, meaning that doses rarely need to be adjusted. The exception is in certain patients with renal impairment, for whom pharmacokinetic modelling provided the rationale for reduced doses as part of some regimens. Although not routinely required, the ability to measure plasma concentrations of these agents could be advantageous in emergency situations, such as overdose. Specific pharmacokinetic and pharmacodynamic characteristics must be taken into account when selecting an appropriate assay for monitoring. The anti-Factor Xa chromogenic assays now available are likely to provide the most appropriate means of determining plasma concentrations of rivaroxaban and apixaban, and specific assays for dabigatran are in development.
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Affiliation(s)
- Wolfgang Mueck
- Bayer Pharma AG, Clinical Pharmacology, D-42096 Wuppertal, Germany.
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12
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Yoo HHB, Queluz THAT, El Dib RP. Anticoagulant treatment for subsegmental pulmonary embolism. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd010222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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13
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Abstract
Direct oral factor IIa inhibitors represent a new class of anticoagulants for the prevention and treatment of venous and selected arterial thomboembolisms. Dabigatran etexilate is the most studied and promising of the oral direct thrombin inhibitors. Preclinical and early-phase clinical studies show it to have a predictable and reliable pharmacokinetic and pharmacodynamic profile, whereas advanced phase 3 trials prove it to be noninferior to traditional anticoagulants in selective conditions for the prevention and treatment of venous and arterial thromboembolism. Other advantages of this drug, including a lack of interaction with cytochrome P450 enzymes or with food and drugs, rapid onset of action, good safety profile, lack of need for routine monitoring, broad therapeutic window, and fixed-dose administration, make this a competitive oral anticoagulant.
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Affiliation(s)
- Catherine J Lee
- Department of Medicine, Lenox Hill Hospital, New York, NY 10075, USA
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14
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Apostolakis S, Lip GYH, Lane DA, Shantsila E. The Quest for New Anticoagulants: From Clinical Development to Clinical Practice. Cardiovasc Ther 2010; 29:e12-22. [DOI: 10.1111/j.1755-5922.2010.00160.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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15
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Molecular structure, lipophilicity, solubility, absorption, and polar surface area of novel anticoagulant agents. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/j.theochem.2009.09.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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17
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Abstract
Thrombosis, both venous and arterial, is a major cause of morbidity and mortality worldwide. Consequently, there is an ongoing search for new antithrombotic drugs, particularly novel antiplatelet agents and anticoagulants. A better understanding of the biochemical pathways involved in platelet activation and coagulation and of the links between these systems and the impact of thrombosis on inflammation has led to the identification of new targets for antithrombotic drugs. This paper focuses on these new targets and new antiplatelet drugs and anticoagulants and describes the major advances in the continuing search for more potent antithrombotic drugs that have limited effects on hemostasis.
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Affiliation(s)
- P L Gross
- Department of Medicine, McMaster University and Henderson Research Centre, Hamilton, Ontario, Canada
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18
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Van Huis CA, Casimiro-Garcia A, Bigge CF, Cody WL, Dudley DA, Filipski KJ, Heemstra RJ, Kohrt JT, Leadley RJ, Narasimhan LS, McClanahan T, Mochalkin I, Pamment M, Thomas Peterson J, Sahasrabudhe V, Schaum RP, Edmunds JJ. Exploration of 4,4-disubstituted pyrrolidine-1,2-dicarboxamides as potent, orally active Factor Xa inhibitors with extended duration of action. Bioorg Med Chem 2009; 17:2501-11. [PMID: 19231206 DOI: 10.1016/j.bmc.2009.01.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 01/22/2009] [Accepted: 01/26/2009] [Indexed: 11/27/2022]
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19
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20
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Spyropoulos AC. Brave new world: The current and future use of novel anticoagulants. Thromb Res 2008; 123 Suppl 1:S29-35. [DOI: 10.1016/j.thromres.2008.08.010] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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21
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Shiraishi T, Kadono S, Haramura M, Kodama H, Ono Y, Iikura H, Esaki T, Koga T, Hattori K, Watanabe Y, Sakamoto A, Yoshihashi K, Kitazawa T, Esaki K, Ohta M, Sato H, Kozono T. Factor VIIa inhibitors: Target hopping in the serine protease family using X-ray structure determination. Bioorg Med Chem Lett 2008; 18:4533-7. [DOI: 10.1016/j.bmcl.2008.07.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 07/09/2008] [Accepted: 07/11/2008] [Indexed: 10/21/2022]
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22
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Affiliation(s)
- George C Velmahos
- John F. Burke Professor of Surgery, Harvard Medical School, Chief, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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23
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Imaeda Y, Kuroita T, Sakamoto H, Kawamoto T, Tobisu M, Konishi N, Hiroe K, Kawamura M, Tanaka T, Kubo K. Discovery of imidazo[1,5-c]imidazol-3-ones: weakly basic, orally active factor Xa inhibitors. J Med Chem 2008; 51:3422-36. [PMID: 18507371 DOI: 10.1021/jm701548u] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The coagulation enzyme factor Xa (FXa) has been recognized as a promising target for the development of new antithrombotic agents. We previously found compound 1 to be an orally bioavailable FXa inhibitor in fasted monkeys; however, 1 showed poor bioavailability in rats and fed monkeys. To work out the pharmacokinetic problems, we focused our synthetic efforts on the chemical conversion of the 4-(imidazo[1,2- a]pyridin-5-yl)piperazine moiety of 1 to imidazolylpiperidine derivatives (fused and nonfused), which resulted in the discovery of the weakly basic imidazo[1,5- c]imidazol-3-one 3q as a potent and selective FXa inhibitor. Compound 3q showed favorable oral bioavailability in rats and monkeys under both fasted and fed conditions and antithrombotic efficacy in a rat model of venous thrombosis after oral administration, without a significant increase in bleeding time (unlike warfarin). On the basis of these promising properties, compound 3q was selected for further evaluation.
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Affiliation(s)
- Yasuhiro Imaeda
- Pharmaceutical Research Division, Takeda Pharmaceutical Co., Ltd., 2-17-85, Jusohonmachi, Yodogawa-ku, Osaka 532-8686, Japan.
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24
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Gross PL, Weitz JI. New anticoagulants for treatment of venous thromboembolism. Arterioscler Thromb Vasc Biol 2008; 28:380-6. [PMID: 18296593 DOI: 10.1161/atvbaha.108.162677] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Anticoagulant therapy is the cornerstone of treatment of venous thromboembolism (VTE). Such treatment is divided into 2 stages: Rapid initial anticoagulation is given to minimize the risk of thrombus extension and fatal pulmonary embolism, whereas extended anticoagulation is aimed at preventing recurrent VTE, thereby reducing the risk of postphlebitic syndrome. With currently available drugs, immediate anticoagulation can only be achieved with parenteral agents, such as heparin, low-molecular-weight heparin, or fondaparinux. Extended treatment usually involves the administration of vitamin K antagonists, such as warfarin. Emerging anticoagulants have the potential to streamline VTE treatment. These agents include idraparinux, a long-acting synthetic pentasaccharide that is given subcutaneously on a once-weekly basis, and new oral anticoagulants that target thrombin or factor Xa. This article (1) reviews the pharmacology of these agents, (2) outlines their potential strengths and weaknesses, (3) describes the results of clinical trials with these new drugs, and (4) identifies the evolving role of new anticoagulants in the management of VTE.
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Affiliation(s)
- Peter L Gross
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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25
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Imaeda Y, Miyawaki T, Sakamoto H, Itoh F, Konishi N, Hiroe K, Kawamura M, Tanaka T, Kubo K. Discovery of sulfonylalkylamides: A new class of orally active factor Xa inhibitors. Bioorg Med Chem 2008; 16:2243-60. [DOI: 10.1016/j.bmc.2007.11.073] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Revised: 11/22/2007] [Accepted: 11/27/2007] [Indexed: 10/22/2022]
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26
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Young RJ, Borthwick AD, Brown D, Burns-Kurtis CL, Campbell M, Chan C, Charbaut M, Chung CW, Convery MA, Kelly HA, Paul King N, Kleanthous S, Mason AM, Pateman AJ, Patikis AN, Pinto IL, Pollard DR, Senger S, Shah GP, Toomey JR, Watson NS, Weston HE. Structure and property based design of factor Xa inhibitors: Pyrrolidin-2-ones with biaryl P4 motifs. Bioorg Med Chem Lett 2008; 18:23-7. [DOI: 10.1016/j.bmcl.2007.11.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2007] [Revised: 11/06/2007] [Accepted: 11/08/2007] [Indexed: 11/29/2022]
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27
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Kohrt JT, Bigge CF, Bryant JW, Casimiro-Garcia A, Chi L, Cody WL, Dahring T, Dudley DA, Filipski KJ, Haarer S, Heemstra R, Janiczek N, Narasimhan L, McClanahan T, Peterson JT, Sahasrabudhe V, Schaum R, Van Huis CA, Welch KM, Zhang E, Leadley RJ, Edmunds JJ. The discovery of (2R,4R)-N-(4-chlorophenyl)-N- (2-fluoro-4-(2-oxopyridin-1(2H)-yl)phenyl)-4-methoxypyrrolidine-1,2-dicarboxamide (PD 0348292), an orally efficacious factor Xa inhibitor. Chem Biol Drug Des 2007; 70:100-12. [PMID: 17683371 DOI: 10.1111/j.1747-0285.2007.00539.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Herein, we report the discovery of novel, proline-based factor Xa inhibitors containing a neutral P1 chlorophenyl pharmacophore. Through the additional incorporation of 1-(4-amino-3-fluoro-phenyl)-1H-pyridin-2-one 22, as a P4 pharmacophore, we discovered compound 7 (PD 0348292). This compound is a selective, orally bioavailable, efficacious FXa inhibitor that is currently in phase II clinical trials for the treatment and prevention of thrombotic disorders.
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Affiliation(s)
- Jeffrey T Kohrt
- Michigan Laboratories, Ann Arbor Campus, Pfizer Global Research and Development, 2800 Plymouth Road, Ann Arbor, MI 48105, USA.
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