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Jannati S, Patnaik R, Banerjee Y. Beyond Anticoagulation: A Comprehensive Review of Non-Vitamin K Oral Anticoagulants (NOACs) in Inflammation and Protease-Activated Receptor Signaling. Int J Mol Sci 2024; 25:8727. [PMID: 39201414 PMCID: PMC11355043 DOI: 10.3390/ijms25168727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 09/02/2024] Open
Abstract
Non-vitamin K oral anticoagulants (NOACs) have revolutionized anticoagulant therapy, offering improved safety and efficacy over traditional agents like warfarin. This review comprehensively examines the dual roles of NOACs-apixaban, rivaroxaban, edoxaban, and dabigatran-not only as anticoagulants, but also as modulators of inflammation via protease-activated receptor (PAR) signaling. We highlight the unique pharmacotherapeutic properties of each NOAC, supported by key clinical trials demonstrating their effectiveness in preventing thromboembolic events. Beyond their established anticoagulant roles, emerging research suggests that NOACs influence inflammation through PAR signaling pathways, implicating factors such as factor Xa (FXa) and thrombin in the modulation of inflammatory responses. This review synthesizes current evidence on the anti-inflammatory potential of NOACs, exploring their impact on inflammatory markers and conditions like atherosclerosis and diabetes. By delineating the mechanisms by which NOACs mediate anti-inflammatory effects, this work aims to expand their therapeutic utility, offering new perspectives for managing inflammatory diseases. Our findings underscore the broader clinical implications of NOACs, advocating for their consideration in therapeutic strategies aimed at addressing inflammation-related pathologies. This comprehensive synthesis not only enhances understanding of NOACs' multifaceted roles, but also paves the way for future research and clinical applications in inflammation and cardiovascular health.
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Affiliation(s)
- Shirin Jannati
- Yajnavalkaa Banerrji Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai Health, Dubai P.O. Box 505055, United Arab Emirates; (S.J.); (R.P.)
| | - Rajashree Patnaik
- Yajnavalkaa Banerrji Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai Health, Dubai P.O. Box 505055, United Arab Emirates; (S.J.); (R.P.)
| | - Yajnavalka Banerjee
- Yajnavalkaa Banerrji Research Group, College of Medicine and Health Sciences, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai Health, Dubai P.O. Box 505055, United Arab Emirates; (S.J.); (R.P.)
- Centre for Medical Education, University of Dundee, Dundee DD1 4HN, UK
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Migliorini F, Maffulli N, Velaj E, Bell A, Kämmer D, Hildebrand F, Hofmann UK, Eschweiler J. Antithrombotic prophylaxis following total hip arthroplasty: a level I Bayesian network meta-analysis. J Orthop Traumatol 2024; 25:1. [PMID: 38194191 PMCID: PMC10776533 DOI: 10.1186/s10195-023-00742-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 12/11/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Several clinical investigations have compared different pharmacologic agents for the prophylaxis of venous thromboembolism (VTE). However, no consensus has been reached. The present investigation compared enoxaparin, fondaparinux, aspirin and non-vitamin K antagonist oral anticoagulants (NOACs) commonly used as prophylaxis following total hip arthroplasty (THA). A Bayesian network meta-analysis was performed, setting as outcomes of interest the rate of deep venous thrombosis (DVT), pulmonary embolism (PE) and major and minor haemorrhages. METHODS This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension statement for reporting systematic reviews incorporating network meta-analyses of healthcare interventions. All randomised controlled trials (RCTs) comparing two or more drugs used for the prophylaxis of VTE following THA were accessed. PubMed, Web of Science and Google Scholar databases were accessed in March 2023 with no time constraint. RESULTS Data from 31,705 patients were extracted. Of these, 62% (19,824) were women, with age, sex ratio, and body mass index (BMI) being comparable at baseline. Apixaban 5 mg, fondaparinux, and rivaroxaban 60 mg were the most effective in reducing the rate of DVT. Dabigatran 220 mg, apixaban 5 mg, and aspirin 100 mg were the most effective in reducing the rate of PE. Apixaban 5 mg, ximelagatran 2 mg and aspirin 100 mg were associated with the lowest rate of major haemorrhages, while rivaroxaban 2.5 mg, apixaban 5 mg and enoxaparin 40 mg were associated with the lowest rate of minor haemorrhages. CONCLUSION Administration of apixaban 5 mg demonstrated the best balance between VTE prevention and haemorrhage control following THA. Level of evidence Level I, network meta-analysis of RCTs.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany.
- Department of Orthopedics and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, 39100, Bolzano, Italy.
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany.
| | - Nicola Maffulli
- Department of Medicine and Psychology, University of Rome "La Sapienza", Rome, Italy
- School of Pharmacy and Bioengineering, Keele University Faculty of Medicine, Stoke on Trent, ST4 7QB, UK
- Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, Queen Mary University of London, London, E1 4DG, UK
| | - Erlis Velaj
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Andreas Bell
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Daniel Kämmer
- Department of Orthopaedic and Trauma Surgery, Eifelklinik St.Brigida, 52152, Simmerath, Germany
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ulf Krister Hofmann
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Medical Centre, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Halle (Saale), Germany
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Sarkar M, Madabhavi IV, Quy PN, Govindagoudar MB. COVID-19 vaccine-induced immune thrombotic thrombocytopenia: A review. Ann Thorac Med 2022; 17:1-13. [PMID: 35198043 PMCID: PMC8809131 DOI: 10.4103/atm.atm_404_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/21/2021] [Indexed: 11/18/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible and pathogenic coronavirus responsible for the pandemic coronavirus disease 19 (COVID-19). It has significant impact on human health and public safety along with negative social and economic consequences. Vaccination against SARS-CoV-2 is likely the most effective approach to sustainably control the global COVID-19 pandemic. Vaccination is highly effective in reducing the risk of severe COVID-19 disease. Mass-scale vaccination will help us in attaining herd immunity and will lessen the negative impact of the disease on public health, social and economic conditions. The present pandemic stimulated the development of several effective vaccines based on different platforms. Although the vaccine is safe and efficacious, rare cases of thrombosis and thrombocytopenia following the use of vaccination with the ChAdOx1 CoV-19 vaccine (AstraZeneca, University of Oxford, and Serum Institute of India) or the Ad26.COV2.S vaccine (Janssen/Johnson & Johnson) have been reported globally. This review focussed on the definition, epidemiology, pathogenesis, clinical features, diagnosis, and management of vaccine associated thrombosis.
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Affiliation(s)
- Malay Sarkar
- Department of Pulmonary Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Irappa V. Madabhavi
- Department of Medical and Pediatric Oncology, Kerudi Cancer Hospital, Bagalkot, Karnataka, India
- Department of Medical Oncology, J N Medical College, Belagavi, Karnataka, India
| | - Pham Nguyen Quy
- Department of Medical Oncology, Kyoto Miniren Central Hospita, Ukyoku, Kyoto, Japan
| | - Manjunath B. Govindagoudar
- Department of Pulmonary and Critical Care, Pt B. D. Sharma, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
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Lichota A, Szewczyk EM, Gwozdzinski K. Factors Affecting the Formation and Treatment of Thrombosis by Natural and Synthetic Compounds. Int J Mol Sci 2020; 21:E7975. [PMID: 33121005 PMCID: PMC7663413 DOI: 10.3390/ijms21217975] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/13/2022] Open
Abstract
Venous thromboembolism (VTE) refers to deep vein thrombosis (DVT), whose consequence may be a pulmonary embolism (PE). Thrombosis is associated with significant morbidity and mortality and is the third most common cardiovascular disease after myocardial infarction and stroke. DVT is associated with the formation of a blood clot in a deep vein in the body. Thrombosis promotes slowed blood flow, hypoxia, cell activation, and the associated release of many active substances involved in blood clot formation. All thrombi which adhere to endothelium consist of fibrin, platelets, and trapped red and white blood cells. In this review, we summarise the impact of various factors affecting haemostatic disorders leading to blood clot formation. The paper discusses the causes of thrombosis, the mechanism of blood clot formation, and factors such as hypoxia, the involvement of endothelial cells (ECs), and the activation of platelets and neutrophils along with the effects of bacteria and reactive oxygen species (ROS). Mechanisms related to the action of anticoagulants affecting coagulation factors including antiplatelet drugs have also been discussed. However, many aspects related to the pathogenesis of thrombosis still need to be clarified. A review of the drugs used to treat and prevent thrombosis and natural anticoagulants that occur in the plant world and are traditionally used in Far Eastern medicine has also been carried out.
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Affiliation(s)
- Anna Lichota
- Department of Pharmaceutical Microbiology and Microbiological Diagnostic, Faculty of Pharmacy, Medical University of Lodz, 90-235 Lodz, Poland; (A.L.); (E.M.S.)
| | - Eligia M. Szewczyk
- Department of Pharmaceutical Microbiology and Microbiological Diagnostic, Faculty of Pharmacy, Medical University of Lodz, 90-235 Lodz, Poland; (A.L.); (E.M.S.)
| | - Krzysztof Gwozdzinski
- Department of Molecular Biophysics, Faculty of Biology and Environmental Protection, University of Lodz, 90-236 Lodz, Poland
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Tsuji N, Honda Y, Kamisato C, Morishima Y, Shibano T, Fukuda T. Comparison of antithrombotic efficacy between edoxaban, a direct factor Xa inhibitor, and fondaparinux, an indirect factor Xa inhibitor under low and high shear rates. Thromb Haemost 2017; 106:1062-8. [DOI: 10.1160/th11-07-0451] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 08/17/2011] [Indexed: 11/05/2022]
Abstract
SummaryEdoxaban is an oral, direct factor Xa (FXa) inhibitor under late-phase clinical development. This study compared the antithrombotic efficacy of edoxaban with that of an indirect FXa inhibitor, fondaparinux, in in vivo venous and arterial thrombosis models and in ex vivo perfusion chamber thrombosis model under low and high shear rates in rats. Venous and arterial thrombi were induced by platinum wire insertion into the inferior vena cava and by application of FeCl3 to the carotid artery, respectively. The perfusion chamber thrombus was formed by blood perfusion into a collagen-coated capillary at 150 s-1 (low shear rate) and 1,600 s-1 (high shear rate). Effective doses of edoxaban that reduced thrombus formation by 50% (ED50) in venous and arterial thrombosis models were 0.076 and 0.093 mg/kg/h, respectively. In contrast, ED50 of fondaparinux in the arterial thrombosis model (>10 mg/kg/h) was markedly higher compared to ED50 in the venous thrombosis model (0.021 mg/kg/h). In the perfusion chamber thrombosis model, the ratio of ED50 under high shear rate (1.13 mg/kg/h) to that under low shear rate (0.63 mg/kg/h) for edoxaban was 1.9, whereas that for fondaparinux was more than 66. While the efficacy of fondaparinux markedly decreased in arterial thrombosis and in a high-shear state, edoxaban exerted consistent antithrombotic effects regardless of flow conditions. These results suggest that shear rate is a key factor in different antithrombotic effects between edoxaban and fondaparinux.
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Permsuwan U, Chaiyakunapruk N, Nathisuwan S, Sukonthasarn A. Cost-Effectiveness Analysis of Fondaparinux vs Enoxaparin in Non-ST Elevation Acute Coronary Syndrome in Thailand. Heart Lung Circ 2015; 24:860-8. [PMID: 25837019 DOI: 10.1016/j.hlc.2015.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 02/02/2015] [Accepted: 02/20/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Non-ST elevation acute coronary syndrome (NSTE-ACS) imposes a significant health and economic burden on a society. Anticoagulants are recommended as standard therapy by various clinical practice guidelines. Fondaparinux was introduced and evaluated in a number of large randomised, controlled trials. This study therefore aimed to determine the cost-effectiveness of fondaparinux versus enoxaparin in the treatment of NSTE-ACS in Thailand. METHODS A two-part construct model comprising a one-year decision tree and a Markov model was developed to capture short and long-term costs and outcomes from the perspective of provider and society. Effectiveness data were derived from OASIS-5 trial while bleeding rates were derived from the Thai Acute Coronary Syndrome Registry (TACSR). Costs data were based on a Thai database and presented in the year of 2013. Both costs and outcomes were discounted by 3% annually. A series of sensitivity analyses were performed. RESULTS The results showed that compared with enoxaparin, fondaparinux was a cost-saving strategy (lower cost with slightly higher effectiveness). Cost of revascularisation with major bleeding had a greater impact on the amount of cost saved both from societal and provider perspectives. With a threshold of 160,000 THB ((4,857.3 USD) per QALY in Thailand, fondaparinux was about 99% more cost-effective compared with enoxaparin. CONCLUSION Fondaparinux should be considered as a cost-effective alternative when compared to enoxaparin for NSTE-ACS based on Thailand's context, especially in the era of limited healthcare resources.
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Affiliation(s)
| | - Nathorn Chaiyakunapruk
- School of Pharmacy, Monash University Malaysia, Malaysia; Center of Pharmaceutical Outcomes Research (CPOR), Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand; School of Population Health, University of Queensland, Brisbane, Australia; School of Pharmacy, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Apichard Sukonthasarn
- Department of Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Knepper J, Horne D, Obi A, Wakefield TW. A systematic update on the state of novel anticoagulants and a primer on reversal and bridging. J Vasc Surg Venous Lymphat Disord 2013; 1:418-26. [PMID: 26992768 DOI: 10.1016/j.jvsv.2013.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Revised: 04/20/2013] [Accepted: 04/20/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Current prevention and treatment of venous thromboembolism (VTE) includes familiar agents that have been in use for many years, including unfractionated heparin, low-molecular-weight heparin (LMWH), and vitamin K antagonists (VKAs). A number of novel oral anticoagulants are currently developed or are in stages of development to either replace VKAs in concert with initial heparin or LMWH, or to replace both heparin/LMWH and VKAs totally as monotherapy. These agents hold the promise of not requiring monitoring, being safer in terms of bleeding risk than current agents, and being of equal or improved efficacy compared with established anticoagulants. METHODS In the following report, we systematically review the oral agents currently approved or closest to approval for both VTE and atrial fibrillation treatment, focusing on the treatment of VTE: dabigatran, rivaroxaban, and apixaban. RESULTS Findings of clinical use and comparisons to standard care of these agents are summarized in depth, by succinctly reviewing all major randomized controlled trials. Mechanistic and functional differences are reviewed, as Dabigatran targets activated factor II (factor IIa), while rivaroxaban and apixaban target activated factor X (factor Xa). We also discuss the inability at the present time to reliably reverse the anticoagulant effects of these agents, provide a suggested strategy for reversal, and finally discuss an approach to bridging these agents when other procedures are required while currently taking one of these three agents. CONCLUSIONS These agents, while still with many unanswered questions, demonstrate great promise in the prevention and treatment of VTE.
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Affiliation(s)
- Jordan Knepper
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich.
| | - Danielle Horne
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Andrea Obi
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas W Wakefield
- Department of Surgery, Section of Vascular Surgery, University of Michigan, Ann Arbor, Mich
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Abstract
The devastating consequences of venous thromboembolism have forever provided the impetus to explore safe and effective treatment strategies. To date, the pathophysiology and mechanism of thrombosis have been extensively studied and details of new thrombophilic conditions are continually being discovered. Although there has been extensive research detailing various predispositions to thrombosis, uncertainties regarding their appropriate management continue. This review aims to highlight the various challenges involved in identifying those at risk; provide appropriate management options; and lastly present the current views on the development of new anticoagulants that are competing to replace the traditional agents.
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Affiliation(s)
- T Sarvananthan
- The Hillingdon Hospital Foundation Trust and Northwest London Hospitals, London, UK
| | - S Das
- The Hillingdon Hospital Foundation Trust and Northwest London Hospitals, London, UK
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Knepper J, Ramacciotti E, Wakefield TW. Novel anticoagulants: a discussion of clinical use in the treatment and prevention of venous thromboembolism. Phlebology 2011; 26:3-7. [PMID: 21239724 DOI: 10.1258/phleb.2010.010023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Traditional therapeutic oral anticoagulation strategies often require invasive dosing or monitoring. Vitamin K antagonists (VKAs) have a large number of interactions, delayed onset requires frequent dose monitoring, and they have a small margin between therapeutic dose and bleeding complications. Novel oral anticoagulants, such as dabigatran, rivaroxaban and apixaban, are being developed to prevent those VKAs drawbacks. Besides oral bioavailability, those compounds are designed to require minimal to no monitoring and have a favourable safety profile. This review reports efficacy and safety data of these compounds throughout clinical development, as well as new approaches for oral pharmacological management of venous thromboembolism.
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Affiliation(s)
- J Knepper
- Conrad Jobst Vascular Research Laboratories, Section of Vascular Surgery, University of Michigan Medical Center, A570D, MSRB II, 1150 W. Medical Center Dr, Ann Arbor, MI 48109, USA.
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Martin MJ, Blair KS, Curry TK, Singh N. Vena Cava Filters: Current Concepts and Controversies for the Surgeon. Curr Probl Surg 2010; 47:524-618. [DOI: 10.1067/j.cpsurg.2010.03.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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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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Study of sulfated derivatives of polyhydroxy compounds as inhibitors of blood coagulation. Russ Chem Bull 2010. [DOI: 10.1007/s11172-010-0067-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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