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Abstract
Although rare in children, venous thromboembolism (VTE) is markedly more likely in hospitalized patients, particularly with the use of central venous access devices. Dabigatran etexilate (Pradaxa®) is one of the first direct non-vitamin K antagonist oral anticoagulants (DOAC) approved for use in pediatric patients. It is approved in the EU and USA for the treatment of VTE in patients who have been treated with a parenteral anticoagulant for ≥ 5 days, and for the prevention of recurrent VTE. In an open-label, phase 2b/3 clinical trial in pediatric patients with acute VTE treated for ≈ 3 months, dabigatran etexilate was non-inferior to standard of care (SOC) treatment for the primary composite endpoint of complete thrombus resolution, freedom from recurrent VTE and VTE-related death. In a single-arm phase 3 safety study, few patients experienced recurrent VTE with ≤ 12 months of anticoagulation with dabigatran etexilate. Dabigatran etexilate was generally well tolerated in both studies; bleeding events were mostly minor and, in the phase 2b/3 study, occurred at a similar incidence to SOC. Although further data will be useful, dabigatran etexilate is a valuable and convenient treatment option in pediatric VTE.
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Tang Z, Ren Y, Liu F. Identify thrombin inhibitor with novel skeleton based on virtual screening study. J Biomol Struct Dyn 2020; 40:499-507. [PMID: 32876545 DOI: 10.1080/07391102.2020.1815580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Virtual screening refers to the screening of active compounds based on a small-molecule database. This procedure can rapidly select active compounds with pharmaceutical properties from millions of molecules, thus considerably reducing the number of experimental screening compounds and cost of drug development and shortening the research cycle. In this paper, a pharmacophore screening method was used for virtual screening to determine new scaffold compounds with potential anticoagulant activities. The pharmacophore model (Model_01-20) was constructed in SYBYL-X 2.0 based on dabigatran derivatives (D1-D9) with micromolar to nanomolar activities and tested by decoy test method. Model_01 was selected to screen more than 1600 million compounds in the Zinc 12.0 database. Furtherly, molecular docking analysis and ADME prediction were conducted on more than 100,000 screened compounds. Finally, two compounds (Z-19 and Z-29) were selected for anticoagulant activity test in vitro, Compound Z-29 with tryptophan aurone structure was found possess anticoagulant effect and its IC50 = 22.9 ± 6.88 μM. ADME prediction results show that compound Z-29 features a high intestinal absorption rate, which is valuable for further in-depth research. The research results of this paper can be used for further structural modification and optimisation to guide the design and provide new ideas and methods for the discovery of new thrombin inhibitors.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Zhipeng Tang
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, Shanghai, China
| | - Yujie Ren
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, Shanghai, China
| | - Fei Liu
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, Shanghai, China
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Wang N, Chen L, Li N, Xu G, Qi F, Zhu L, Liu W. Predicted effect of ticagrelor on the pharmacokinetics of dabigatran etexilate using physiologically based pharmacokinetic modeling. Sci Rep 2020; 10:9717. [PMID: 32546773 PMCID: PMC7298054 DOI: 10.1038/s41598-020-66557-x] [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: 12/27/2019] [Accepted: 05/22/2020] [Indexed: 11/16/2022] Open
Abstract
Dabigatran etexilate (DABE) is a direct oral anticoagulant (DOAC) and may be combined with ticagrelor, a P2Y12 inhibitor with antiplatelet effects. This combination of antiplatelet drugs and anticoagulants would increases the risk of bleeding in patients. In addition, the potential drug interaction may further increase the risk of bleeding. At present, there is scarce research to clarify the results of the interaction between the two. Therefore, we conducted this study to identify the potential impact of ticagrelor on the pharmacokinetics of DABE using physiologically based pharmacokinetic (PBPK) modeling. The models reasonably predicted the concentration-time profiles of dabigatran (DAB), the transformation form after DABE absorption, and ticagrelor. For pharmacokinetic drug-drug interaction (DDI), exposure to DAB at steady state was increased when co-administrated with ticagrelor. The Cmax and AUC0-t of DAB were raised by approximately 8.7% and 7.1%, respectively. Meanwhile, a stable-state ticagrelor co-administration at 400 mg once-daily increased the Cmax and AUC0-t of DAB by approximately 12.8% and 18.8%, respectively. As conclusions, Ticagrelor slightly increased the exposure of DAB. It is possible to safely use ticagrelor in a double or triple antithrombotic regimen containing DABE, only considering the antithrombotic efficacy, but not need to pay much attention on the pharmacokinetic DDI.
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Affiliation(s)
- Nan Wang
- Pharmacy Department, Tianjin Third Central Hospital, Tianjin, China.,Tianjin Key Laboratory of Artificial Cell, Tianjin, China.,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
| | - Lu Chen
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Na Li
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Gaoqi Xu
- Pharmacy Department, Zhejiang Cancer Hospital, Hangzhou, China
| | - Fang Qi
- Pharmaceutical College, Tianjin Medical University, Tianjin, China
| | - Liqin Zhu
- Pharmacy Department, Tianjin First Center Hospital, Tianjin, China.
| | - Wensheng Liu
- Pharmacy Department, Tianjin Third Central Hospital, Tianjin, China. .,Tianjin Key Laboratory of Artificial Cell, Tianjin, China. .,Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China.
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Stepanović-Petrović R, Nastić K. Direct oral anticoagulants: A new chapter in anticoagulation therapy. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2005249s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Thromboembolic events are the leading cause of morbidity and mortality worldwide. From the second half of the 20th century, vitamin K antagonists (VKAs), warfarin and acenocoumarol, were the only anticoagulants taken orally. The major reform in anticoagulation therapy was made by the advent of direct oral anticoagulants (DOACs), about 10 years ago. Direct thrombin inhibitor (dabigatran) and direct inhibitors of factor Xa (rivaroxaban, apixaban, edoxaban, and betrixaban) have demonstrated favorable risk/benefit ratio. Compared to warfarin, DOACs are associated with a predictable pharmacokinetic profile, lower severe bleeding complications, particularly intracranial hemorrhages, and minimal drug interactions. Moreover, DOACs achieve a rapid onset of action and have shown comparable efficacy with warfarin and low molecular weight heparin (LMWH) in clinical trials. As a result, DOACs are now replacing VKAs and LMWH for many indications including stroke and systemic embolism prevention in nonvalvular atrial fibrillation, prevention, and treatment of venous thromboembolism and thromboprophylaxis following total knee/hip replacement surgery. In addition, rivaroxaban (in combination with aspirin alone or aspirin and clopidogrel) is used in the prevention of atherothrombotic events following acute coronary syndrome with elevated cardiac biomarkers. In case of severe bleeding complications under DOACs treatment, antidotes are available; idarucizumab for dabigatran reversal and andexanet alfa for rivaroxaban and apixaban.
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LC-MS/MS method for simultaneous determination of rivaroxaban and metformin in rat plasma: application to pharmacokinetic interaction study. Bioanalysis 2019; 11:2269-2281. [PMID: 31845601 DOI: 10.4155/bio-2019-0230] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Aim: A reliable, sensitive and simple LC-MS/MS method has been established and validated for the quantitation of rivaroxaban (RIV) and metformin (MET) in rat plasma. Results: The procedure of method validation was conducted according to the guiding principles of EMA and US FDA. At the same time, the method was applied to pharmacokinetic interactions study between RIV and MET for the first time. When RIV and MET coadministered to rats, pharmacokinetic parameters of MET like AUC(0-t), AUC(0-∞) and Cmax had statistically significant increased. tmax of RIV was prolonged without affecting t1/2 obviously and Cmax was inhibited significantly (p < 0.05) by comparison to the single group. Conclusion: The results indicated that drug-drug interactions occurred when the coadministration of RIV and MET.
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Rautio J, Meanwell NA, Di L, Hageman MJ. The expanding role of prodrugs in contemporary drug design and development. Nat Rev Drug Discov 2018; 17:559-587. [DOI: 10.1038/nrd.2018.46] [Citation(s) in RCA: 325] [Impact Index Per Article: 54.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Papadopoulos DV, Kostas-Agnantis I, Gkiatas I, Tsantes AG, Ziara P, Korompilias AV. The role of new oral anticoagulants in orthopaedics: an update of recent evidence. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2017; 27:573-582. [DOI: 10.1007/s00590-017-1940-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 03/05/2017] [Indexed: 12/27/2022]
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DI Benedetto P, Vetrugno L, DE Franceschi D, Gisonni R, Causero A, Rocca GD. Patient compliance with new oral anticoagulants after major orthopaedic surgery: rivaroxaban and dabigatran compared with subcutaneous injection of fondaparinux. JOINTS 2017; 4:214-221. [PMID: 28217657 DOI: 10.11138/jts/2016.4.4.214] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE the main purpose of our study was to compare patient compliance with the orally administered new oral anticoagulants (NOCs) dabigatran and rivaroxaban compared with subcutaneously injected fondaparinux after major orthopaedic surgery, and to assess patient preference for the oral vs subcutaneous administration route. METHODS prophylactic antithrombotic drug therapy with dabigatran (group D; GD, n=32 patients), rivaroxaban (group R; GR, n=38 patients) or fondaparinux (group F; GF, n=30 patients), to prevent deep vein thrombosis, was started immediately after surgery in 100 patients submitted to total hip arthroplasty. RESULTS the patients had a mean age of 68.7±11 years and 62% were female. In GD, 87.5% of patients indicated that they preferred oral intake of medications to subcutaneous injection (12.5%). In GR, 84.2% declared a preference for oral administration over subcutaneous injection (15.8%). In GF, a surprisingly high proportion of patients (73.3%; p < 0.001) declared that they preferred subcutaneous administration of medications over the oral route (26.7%). Overall, the rate of compliance with antithrombotic drug therapy was very high, at 99%. CONCLUSIONS intake of the NOAs dabigatran and rivaroxaban following hospital discharge is entirely the responsibility of the patient; a high level of patient compliance with these drugs must therefore be demonstrated in order for them to become well accepted within the medical community. The results of this study showed a very high level of compliance both with orally and subcutaneously administered drugs. LEVEL OF EVIDENCE Level I, randomized clinical study.
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Affiliation(s)
- Paolo DI Benedetto
- Department of Orthopaedic Surgery, University Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Udine, Udine, Italy
| | - Dania DE Franceschi
- Department of Orthopaedic Surgery, University Hospital of Udine, Udine, Italy
| | - Renato Gisonni
- Department of Orthopaedic Surgery, University Hospital of Udine, Udine, Italy
| | - Araldo Causero
- Department of Orthopaedic Surgery, University Hospital of Udine, Udine, Italy
| | - Giorgio Della Rocca
- Department of Anesthesia and Intensive Care Medicine, University Hospital of Udine, Udine, Italy
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Design, synthesis and antithrombotic evaluation of novel non-peptide thrombin inhibitors. Bioorg Med Chem 2017; 25:458-470. [DOI: 10.1016/j.bmc.2016.11.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/05/2016] [Accepted: 11/08/2016] [Indexed: 11/21/2022]
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Ho PJ, Siordia JA. Dabigatran approaching the realm of heparin-induced thrombocytopenia. Blood Res 2016; 51:77-87. [PMID: 27382551 PMCID: PMC4931941 DOI: 10.5045/br.2016.51.2.77] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 06/14/2016] [Accepted: 06/14/2016] [Indexed: 02/02/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is a serious, immune mediated complication of exposure to unfractionated or low-molecular-weight heparin. Though rare, it is a condition associated with high morbidity and mortality that requires immediate change to alternative anticoagulants for the prevention of life-threatening thrombosis. The direct thrombin inhibitors lepirudin and argatroban are currently licensed for the treatment of HIT. Dabigatran, a novel oral anticoagulant (NOAC) with a similar mechanism of action and effective use in other indications, has recently been proposed as another therapeutic option in cases of HIT. This review serves as an introduction to using dabigatran for this purpose, detailing the clinical aspects of its administration, evidence of its performance compared to other anticoagulants, and the preliminary reports of HIT successfully treated with dabigatran. As the literature on this develops, it will need to include clinical trials that directly evaluate dabigatran against the other NOACs and current treatment options.
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Affiliation(s)
- Patricia J Ho
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Juan A Siordia
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
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An evidence summary of the management of patients taking direct oral anticoagulants (DOACs) undergoing dental surgery. Int J Oral Maxillofac Surg 2016; 45:618-30. [DOI: 10.1016/j.ijom.2015.12.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 10/05/2015] [Accepted: 12/11/2015] [Indexed: 11/19/2022]
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Johnston S. A New Generation of Antiplatelet, and Anticoagulant Medication and the Implications for the Dental Surgeon. ACTA ACUST UNITED AC 2016; 42:840-2, 845-6, 849-50 passim. [PMID: 26749792 DOI: 10.12968/denu.2015.42.9.840] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The management of dental patients taking either antiplatelet medication, anticoagulant medication or both has been well established in the previous literature. Recently, new generations of drugs have emerged which are becoming increasingly common, including direct thrombin inhibitors, factor X inhibitors and a new class of oral thienopyridines. The implications of these drugs for the dental surgeon are not yet fully known. Awareness remains low and there is very little information available within the literature on safe use during surgery. This review paper aims to provide some guidance for dental practitioners performing invasive procedures. CPD/CLINICAL RELEVANCE: A new generation of anticoagulant and antiplatelet drugs have serious implications for patients undergoing surgery and their use is increasing.
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Dabigatran Etexilate: A Review of Its Use in the Treatment of Acute Venous Thromboembolism and Prevention of Venous Thromboembolism Recurrence. Drugs 2014; 74:1785-800. [DOI: 10.1007/s40265-014-0304-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bates D, Dalton B, Gilmour J, Kapler J. Venous thromboembolism due to suspected interaction between rivaroxaban and nevirapine. Can J Hosp Pharm 2013; 66:125-9. [PMID: 23616677 DOI: 10.4212/cjhp.v66i2.1235] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Duane Bates
- , BScPharm, ACPR, is a Clinical Practice Leader, Medicine, in the Department of Pharmacy, Foothills Medical Centre, Alberta Health Services, Calgary, Alberta
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Steiner T, Böhm M, Dichgans M, Diener HC, Ell C, Endres M, Epple C, Grond M, Laufs U, Nickenig G, Riess H, Röther J, Schellinger PD, Spannagl M, Veltkamp R. Recommendations for the emergency management of complications associated with the new direct oral anticoagulants (DOACs), apixaban, dabigatran and rivaroxaban. Clin Res Cardiol 2013; 102:399-412. [PMID: 23669868 DOI: 10.1007/s00392-013-0560-7] [Citation(s) in RCA: 134] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 03/21/2013] [Indexed: 02/07/2023]
Abstract
Dabigatran, apixaban, and rivaroxaban have been approved for primary and secondary stroke prevention in patients with atrial fibrillation. However, questions have arisen about how to manage emergency situations, such as when thrombolysis would be required for acute ischemic stroke or for the managing intracranial or gastrointestinal bleedings. We summarize the current literature and provide recommendations for the management of these situations. Peak plasma levels of the direct oral anticoagulants (DOACs) apixaban, dabigatran, or rivaroxaban are observed about 2-4 h after intake. Elimination of dabigatran is mainly dependent on renal function. Consequently, if renal function is impaired, there is a risk of drug accumulation that is highest for dabigatran followed by rivaroxaban and then apixaban and thus dosing recommendations are different. To date, no bedside tests are available that reliably assess the anticoagulatory effect of DOACs, nor are specific antidotes available. We recommend performing the following tests if DOAC intake is unknown: dabigatran-associated bleeding risk is minimized or can be neglected if thrombin time, Hemoclot test, or Ecarin clotting time is normal. Apixaban and rivaroxaban effects can be ruled out if findings from the anti-factor Xa activity test are normal. High plasma levels of DOAC are also mostly excluded if PTT and PTZ are normal four or more hours after DOAC intake. However, normal values of global coagulation tests are not sufficient if thrombolysis is indicated for treating acute stroke. The decision for or against thrombolysis is an individual decision; in these cases, thrombolysis use is off-label. In case of bleeding, prothrombin complex concentrates seems to be the most plausible treatment. For severe gastrointestinal bleeding with life-threatening blood loss, the bleeding source needs to be identified and treated by invasive measures. Use of procoagulant drugs (antifibrinolytics) might also be considered. However, there is very limited clinical experience with these products in conjunction with DOAC.
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Affiliation(s)
- T Steiner
- Neurologische Klinik, Klinikum Frankfurt Höchst, Frankfurt am Main, Germany.
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