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Mariño-Ocampo N, Rodríguez DF, Guerra Díaz D, Zúñiga-Núñez D, Duarte Y, Fuentealba D, Zacconi FC. Direct Oral FXa Inhibitors Binding to Human Serum Albumin: Spectroscopic, Calorimetric, and Computational Studies. Int J Mol Sci 2023; 24:ijms24054900. [PMID: 36902328 PMCID: PMC10002493 DOI: 10.3390/ijms24054900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/26/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023] Open
Abstract
Direct FXa inhibitors are an important class of bioactive molecules (rivaroxaban, apixaban, edoxaban, and betrixaban) applied for thromboprophylaxis in diverse cardiovascular pathologies. The interaction of active compounds with human serum albumin (HSA), the most abundant protein in blood plasma, is a key research area and provides crucial information about drugs' pharmacokinetics and pharmacodynamic properties. This research focuses on the study of the interactions between HSA and four commercially available direct oral FXa inhibitors, applying methodologies including steady-state and time-resolved fluorescence, isothermal titration calorimetry (ITC), and molecular dynamics. The HSA complexation of FXa inhibitors was found to occur via static quenching, and the complex formation in the ground states affects the fluorescence of HSA, with a moderate binding constant of 104 M-1. However, the ITC studies reported significantly different binding constants (103 M-1) compared with the results obtained through spectrophotometric methods. The suspected binding mode is supported by molecular dynamics simulations, where the predominant interactions were hydrogen bonds and hydrophobic interactions (mainly π-π stacking interactions between the phenyl ring of FXa inhibitors and the indole moiety of Trp214). Finally, the possible implications of the obtained results regarding pathologies such as hypoalbuminemia are briefly discussed.
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Affiliation(s)
- Nory Mariño-Ocampo
- Escuela de Química, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
| | - Diego F. Rodríguez
- Escuela de Química, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
| | - Daniel Guerra Díaz
- Escuela de Química, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
| | - Daniel Zúñiga-Núñez
- Escuela de Química, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
| | - Yorley Duarte
- Center for Bioinformatics and Integrative Biology, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago 8370035, Chile
| | - Denis Fuentealba
- Escuela de Química, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
- Correspondence: (D.F.); (F.C.Z.)
| | - Flavia C. Zacconi
- Escuela de Química, Facultad de Química y de Farmacia, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
- Centro de Investigaciones en Nanotecnología y Materiales Avanzados, CIEN-UC, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile
- Center for Nanomedicine, Diagnostic & Drug Development (ND3), Universidad de Talca, Talca 3460000, Chile
- Correspondence: (D.F.); (F.C.Z.)
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Santagata D, Cammà G, Donadini MP, Squizzato A, Ageno W. Current and emerging drug strategies for the prevention of venous thromboembolism in acutely ill medical inpatients. Expert Opin Pharmacother 2022; 23:1651-1665. [PMID: 36154548 DOI: 10.1080/14656566.2022.2128757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common complication in patients hospitalized for acute medical illnesses. Therefore, medical inpatients require a careful VTE and bleeding risk assessment to drive optimal strategies for VTE prevention. Low molecular weight heparin and fondaparinux have long been used for inhospital prophylaxis for patients at increased risk of VTE. The selection of patients who require post-discharge prophylaxis, and the role of direct oral anticoagulants remain debated. New molecules currently under development may contribute to improve the risk benefit of VTE prevention in this setting. AREAS COVERED This text summarizes the evidence on approved treatments and on other drugs for the prevention of VTE in acutely ill medical patients. The main focus is on their pharmacological proprieties, clinical efficacy and safety, and the current license approved by the FDA (Food and Drug Administration) and EMA (European Medicines Agency), giving the readers a way to compare available drugs to date. The trials presented consider both inhospital and extended prophylaxis. EXPERT OPINION Thanks to the potentially favorable safety profile, factor XI inhibitors may play a role in the prevention of VTE in this setting. The expert opinion section discusses pharmacological properties, prophylaxis trials, and potential clinical applications of this novel class of drugs.
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Affiliation(s)
- D Santagata
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Via Gucciardini 9, 21100, Varese and Como, Italy
| | - G Cammà
- Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Curore, Largo Francesco Vito 1, 00139, Rome, Italy
| | - M P Donadini
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Via Gucciardini 9, 21100, Varese and Como, Italy
| | - A Squizzato
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Via Ravona 20 San Fermo della Battaglia (Como), 22042 Como, Italy
| | - W Ageno
- Department of Medicine and Surgery, Research Center on Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Via Gucciardini 9, 21100, Varese and Como, Italy
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El-Masry AA, El-Wasseef DR, Eid M, Shehata IA, Zeid AM. Development of three ecological spectroscopic methods for analysis of betrixaban either alone or in mixture with lercanidipine: greenness assessment. R Soc Open Sci 2022; 9:211457. [PMID: 35127114 PMCID: PMC8808099 DOI: 10.1098/rsos.211457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/05/2022] [Indexed: 05/03/2023]
Abstract
Three eco-friendly spectrophotometric methods were developed for determination of the novel anticoagulant drug, betrixaban (BTX). The first method (method A) was based on direct analysis of BTX at 229.4 nm on the zero-order spectrum using methanol as the optimum solvent. While the second method (method B) was based on measuring difference absorption value (ΔA) of BTX at 335 nm, which was obtained from pH-induced spectral difference (difference spectra of BTX in 0.1 M NaOH versus 0.1 M HCl). The third method (method C) was based on measurement of the first-derivative amplitudes of BTX and its co-administered Ca channel blocker lercanidipine (LER) at 304 and 229 nm for simultaneous assay of BTX and LER, respectively. All methods were linear over concentration ranges of 1.0-20.0 and 8.0-80.0 µg ml-1 for BTX in methods A and B, respectively, and of 1.0-20.0 and 1.0-25.0 µg ml-1 for BTX and LER, respectively, in method C. The three methods were fully validated and assessed for greenness by three metrics: analytical eco-scale, green analytical procedure index and Analytical GREEnness metrics. The results indicated the validity and greenness of the proposed methods. Moreover, the methods were applied to assay the studied analytes in their dosage forms with high percentage of recovery and low percentage of relative s.d. values.
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Affiliation(s)
- Amal A. El-Masry
- Department of Medicinal Chemistry, Faculty of Pharmacy, Mansoura University, 35516 Mansoura, Egypt
| | - Dalia R. El-Wasseef
- Department of Medicinal Chemistry, Faculty of Pharmacy, Mansoura University, 35516 Mansoura, Egypt
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Delta University for Science and Technology, 35712, Gamasa, Egypt
| | - Manal Eid
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, 35516 Mansoura, Egypt
| | - Ihsan A. Shehata
- Department of Medicinal Chemistry, Faculty of Pharmacy, Mansoura University, 35516 Mansoura, Egypt
| | - Abdallah M. Zeid
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Mansoura University, 35516 Mansoura, Egypt
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Grześk G, Rogowicz D, Wołowiec Ł, Ratajczak A, Gilewski W, Chudzińska M, Sinkiewicz A, Banach J. The Clinical Significance of Drug-Food Interactions of Direct Oral Anticoagulants. Int J Mol Sci 2021; 22:8531. [PMID: 34445237 PMCID: PMC8395160 DOI: 10.3390/ijms22168531] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiovascular diseases are the most common cause of death in the world. For almost 60 years, vitamin K antagonists (VKAs) were the mainstay of anticoagulation therapy, but in recent years direct oral anticoagulants (DOACs) have become the anticoagulant treatment of choice. DOACs were initially considered drugs with no significant food interactions; however, clinical observations from daily practice have proved otherwise as interactions with food ingredients have been reported. Food, dietary supplements or herbs may contain substances that, when administered concomitantly with DOACs, can potentially affect the plasma concentration of the drugs. The aim of this paper was to evaluate the clinical significance of drug-food interactions of DOACs, such as dabigatran, rivaroxaban, apixaban, edoxaban and betrixaban. Patients treated with anticoagulants should avoid products containing St. John's wort and take special care with other food ingredients. As the interest in dietary supplements is on the rise, healthcare providers can contribute to the development of well-designed clinical trials on interactions between DOACs and food, and distribute sufficient knowledge about the proper use of these supplements among patients.
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Affiliation(s)
- Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Daniel Rogowicz
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Łukasz Wołowiec
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Agnieszka Ratajczak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Wojciech Gilewski
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Małgorzata Chudzińska
- Department of Nutrition and Dietetics, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dębowa 3 Street, 85-626 Bydgoszcz, Poland;
| | - Anna Sinkiewicz
- Department of Otolaryngology, Audiology and Phoniatrics, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland;
| | - Joanna Banach
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
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Lee JJ, Memar Montazerin S, Shojaei F, Chi G. Current Opinion on the use of Direct Oral Anticoagulants for the Prophylaxis of Venous Thromboembolism among Medical Inpatients. Ther Clin Risk Manag 2021; 17:471-487. [PMID: 34079269 PMCID: PMC8165214 DOI: 10.2147/tcrm.s271439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/12/2021] [Indexed: 01/09/2023] Open
Abstract
Venous thromboembolism (VTE) is a known cause of morbidity and mortality, especially among acutely ill medical patients. Although VTE prophylaxis is part of post-discharge clinical care in surgical patients, there is controversy regarding its use in acutely ill medical patients and the current guideline statements suggest against its routine use. Recent clinical trials (APEX, MAGELLAN and MARINER) compared the safety and efficacy of direct oral anticoagulants (including betrixaban and rivaroxaban) with the standard of the care, enoxaparin, to identify the risk–benefit tradeoff. In this review, we summarized the key findings from these trials and substudies and recent updates in society guidelines regarding VTE prevention. In addition, we discussed the potential barriers, cost-effectiveness, and COVID-19 with respect to the implementation of extended-duration or post-discharge usage of direct oral anticoagulants.
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Affiliation(s)
- Jane J Lee
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Sahar Memar Montazerin
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Fahimehalsadat Shojaei
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gerald Chi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Siriez R, Dogné JM, Gosselin R, Laloy J, Mullier F, Douxfils J. Comprehensive review of the impact of direct oral anticoagulants on thrombophilia diagnostic tests: Practical recommendations for the laboratory. Int J Lab Hematol 2020; 43:7-20. [PMID: 32946681 DOI: 10.1111/ijlh.13342] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/28/2022]
Abstract
There is a laboratory and clinical need to know the impact of direct oral anticoagulants (DOACs) on diagnostic tests to avoid misinterpretation of results. Although the regulatory labelling documents provide some information about the influences of each DOAC on diagnostic tests, these are usually limited to some of the most common tests and no head to head comparison is available. In this paper, we report the impact of DOACs on several thrombophilia tests, including assessment of antithrombin, protein S and protein C activity assays, detection of activated protein C resistance and assays used for lupus anticoagulant. Results are compared and discussed with data obtained from literature. The final goal of this comprehensive review is to provide practical recommendations for laboratories to avoid misdiagnosis due to oral direct factor Xa (FXa) or IIa (FIIa) inhibitors. Overall, oral direct FXa (apixaban, betrixaban, edoxaban and rivaroxaban) and FIIa (dabigatran) antagonists may affect clot-based thrombophilia diagnostic tests resulting in false-positive or false-negative results. An effect on FIIa-based thrombophilia diagnostic tests is observed with dabigatran but not with anti-FXa DOACs and conversely for FXa-based thrombophilia diagnostic tests. No impact was observed with antigenic/chromogenic methods for the assessment of protein S and C activity. In conclusion, interpretation of thrombophilia diagnostic tests results should be done with caution in patients on DOACs. The use of a device/chemical compound able to remove or antagonize the effect of DOACs or the development of new diagnostic tests insensitive to DOACs should be considered to minimize the risk of false results.
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Affiliation(s)
- Romain Siriez
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Robert Gosselin
- Thrombosis and Hemostasis Center, Davis Health System, University of California, Sacramento, California
| | - Julie Laloy
- Department of Pharmacy, Namur Nanosafety Center (NNC),, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - François Mullier
- Laboratory Hematology, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), CHU UCL Namur, Université catholique de Louvain, Namur, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
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Affiliation(s)
- Toshihiro Sugiyama
- Department of Orthopaedic Surgery, Saitama Medical University , Saitama, Japan
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8
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Affiliation(s)
- Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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Ageno W, Lopes RD, Yee MK, Hernandez A, Hull RD, Goldhaber SZ, Gibson CM, Cohen AT. Net-clinical benefit of extended prophylaxis of venous thromboembolism with betrixaban in medically ill patients aged 80 or more. J Thromb Haemost 2019; 17:2089-2098. [PMID: 31392827 DOI: 10.1111/jth.14600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 07/03/2019] [Accepted: 08/05/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Extended-duration thromboprophylaxis with betrixaban reduces the risk of venous thromboembolism (VTE) without increasing major bleeding rates in acutely ill medical patients as compared to standard duration enoxaparin. We aimed to assess the risk-benefit of betrixaban in patients aged ≥ 80 years enrolled in the APEX trial. METHODS APEX was a randomized, double-blind trial in which patients hospitalized for acute medical illnesses received enoxaparin 40 mg qd for 10 ± 4 days or oral betrixaban 80 mg qd for 35 to 42 days. The primary efficacy outcome was VTE, the principal safety outcome was major bleeding. Net clinical benefit (NCB) was defined by the occurrence of VTE or major bleeding. RESULTS Of 7513 patients enrolled in the APEX trial, 2781 (37%) were aged ≥ 80 years. In this subgroup, VTE or major bleeding occurred in 7.0% of betrixaban patients and in 8.4% of enoxaparin patients, for a relative risk in the NCB of 0.82 (95% confidence interval 0.62-1.10). The relative risk reduction obtained with betrixaban was similar between those aged ≥ 80 years and patients younger than 80 years (5.0% and 6.7%, respectively, NCB 0.75, 0.58-0.96, P = .024), with no significant interaction across age groups (P = .33). CONCLUSIONS Event rates were higher in medically ill patients aged ≥ 80 years enrolled in the APEX study than in patients younger than 80 years. The predefined NCB was reduced with extended betrixaban therapy in both groups with no signs of age-related interactions. However, the primary efficacy endpoint was not achieved with betrixaban for patients 80 years of age or older.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Renato D Lopes
- Duke University and Duke Clinical Research Institute, Durham, North Carolina
| | - Megan K Yee
- Boston Clinical Research Institute, Newton, Massachusetts
| | - Adrian Hernandez
- Duke University and Duke Clinical Research Institute, Durham, North Carolina
| | - Russell D Hull
- R.A.H Faculty of Medicine, Division of Cardiology, University of Calgary, Calgary, AB, Canada
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, London, UK
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Carpenter E, Singh D, Dietrich E, Gums J. Andexanet alfa for reversal of factor Xa inhibitor-associated anticoagulation. Ther Adv Drug Saf 2019; 10:2042098619888133. [PMID: 31807265 PMCID: PMC6880028 DOI: 10.1177/2042098619888133] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/18/2019] [Indexed: 12/02/2022] Open
Abstract
Background: Review of clinical data on andexanet alfa for the reversal of factor Xa (FXa)
inhibitor associated anticoagulation. Data sources: In the present review, we identified articles via PubMed
using the combined keywords andexanet alfa, apixaban, enoxaparin, edoxaban,
and rivaroxaban. Additional online searches via PubMed,
Google Scholar, and Lexicomp were conducted for both prescribing and cost
information. Portola Pharmaceuticals was contacted for information used for
United States Food and Drug Administration approval of andexanet alfa. Study selection and data extraction: English-language clinical trials and reviews published between January 2008
and April 2019 were included for review. Bibliographies of selected articles
were reviewed manually for relevant publications, focusing on reversal
strategies for apixaban, enoxaparin, edoxaban, or rivaroxaban associated
anticoagulation using andexanet alfa. Review articles were excluded. Data synthesis: The safety and tolerability of andexanet alfa were evaluated in one phase I,
two phase II, and one phase III clinical trials. The use of andexanet alfa
for reversing FXa inhibitor-associated anticoagulation were evaluated in the
phase III ANNEXA-4 study. Conclusions: Studies evaluating laboratory parameters for coagulation show that andexanet
alfa rapidly neutralizes the anticoagulant effects of apixaban, enoxaparin,
edoxaban, and rivaroxaban. Clinical studies show that andexanet alfa
improves markers related to coagulation, and reverses major bleeding in
healthy volunteers and patients with life-threatening bleeding. Interruption
of anticoagulation may result in thromboembolic and ischemic events. The use
of andexanet alfa requires close monitoring for signs and symptoms of
thromboembolic events, ischemic events, and cardiac arrest. Furthermore,
anticoagulation should be resumed following the administration of andexanet
alfa as soon as medically appropriate.
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Affiliation(s)
- Elise Carpenter
- Parkview Regional Medical Center, 11109 Parkview Plaza Dr, Fort Wayne, IN 46845, USA
| | - Divita Singh
- Howard University College of Pharmacy, Washington, DC, USA
| | - Eric Dietrich
- University of Florida College of Pharmacy, Gainesville, FL, USA
| | - John Gums
- University of Florida College of Pharmacy, Gainesville, FL, USA
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Kustos SA, Fasinu PS. Direct-Acting Oral Anticoagulants and Their Reversal Agents-An Update. Medicines (Basel) 2019; 6:medicines6040103. [PMID: 31618893 PMCID: PMC6963825 DOI: 10.3390/medicines6040103] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/10/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
Background: Over the last ten years, a new class of drugs, known as the direct-acting oral anticoagulants (DOACs), have emerged at the forefront of anticoagulation therapy. Like the older generation anticoagulants, DOACs require specific reversal agents in cases of life-threatening bleeding or the need for high-risk surgery. Methods: Published literature was searched, and information extracted to provide an update on DOACS and their reversal agents. Results: The DOACs include the direct thrombin inhibitor—dabigatran, and the factor Xa inhibitors—rivaroxaban, apixaban, edoxaban, and betrixaban. These DOACs all have a rapid onset of action and each has a predictable therapeutic response requiring no monitoring, unlike the older anticoagulants, such as warfarin. Two reversal agents have been approved within the last five years: idarucizumab for the reversal of dabigatran, and andexanet alfa for the reversal of rivaroxaban and apixaban. Additionally, ciraparantag, a potential “universal” reversal agent, is currently under clinical development. Conclusions: A new generation of anticoagulants, the DOACs, and their reversal agents, are gaining prominence in clinical practice, having demonstrated superior efficacy and safety profiles. They are poised to replace traditional anticoagulants including warfarin.
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Affiliation(s)
- Stephanie A Kustos
- Department of Pharmaceutical Sciences, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA.
| | - Pius S Fasinu
- Department of Pharmaceutical Sciences, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA.
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12
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Laskier V, Guy H, Fisher M, Neuman WR, Bucior I, Cohen AT, Ren S. Effectiveness and safety of betrixaban extended prophylaxis for venous thromboembolism compared with standard-duration prophylaxis intervention in acute medically ill patients: a systematic literature review and network meta-analysis. J Med Econ 2019; 22:1063-1072. [PMID: 31314619 DOI: 10.1080/13696998.2019.1645679] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Aims: To determine the clinical effectiveness and safety of venous thromboembolism (VTE) prophylaxis using US- and Europe-approved anticoagulants relative to extended-duration VTE prophylaxis with betrixaban. Low molecular weight heparins (LMWHs), unfractionated heparin (UFH), fondaparinux sodium and placebo were each compared to betrixaban, as standard-duration VTE prophylaxis for hospitalized, non-surgical patients with acute medical illness at risk of VTE. Materials and methods: A systematic literature review was conducted up to June 2019 to identify randomized controlled trials (RCTs) of VTE prophylaxis in hospitalized, non-surgical patients with acute medical illness at risk of VTE. Studies that reported the occurrence of VTE events (including death) and, where possible, major bleeding, from treatment initiation to 20-50 days thereafter were retrieved and extracted. A Bayesian fixed effect network meta-analysis was used to estimate efficacy and safety of betrixaban compared with standard-duration VTE prophylaxis. Results: Seven RCTs were analyzed which compared betrixaban, LMWHs, UFH, fondaparinux sodium, or placebo. There were significantly higher odds (median odds [95% credible interval]) of VTE with LMWHs (1.38 [1.12-1.70]), UFH (1.60 [1.05-2.46]), and placebo (2.37 [1.55-3.66]) compared with betrixaban. There were significantly higher odds of VTE-related death with placebo (7.76 [2.14-34.40]) compared with betrixaban. No significant differences were observed for the odds of major bleeding with all comparators, VTE-related death with any active standard-duration VTE prophylaxis, or of VTE with fondaparinux sodium, compared with betrixaban. Limitations and conclusions: In this indirect comparison, betrixaban was shown to be an effective regimen with relative benefits compared with LMWHs and UFH. This indicates that betrixaban could reduce the burden of VTE in at-risk hospitalized patients with acute medical illness who need extended prophylaxis, though without direct comparative evidence, stronger conclusions cannot be drawn.
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Affiliation(s)
| | - Holly Guy
- Health Economics, FIECON Ltd , St Albans , UK
| | - Mark Fisher
- Health Economics, FIECON Ltd , St Albans , UK
| | - W Richey Neuman
- Medical Affairs, Portola Pharmaceuticals, Inc , South San Francisco , CA , USA
| | - Iwona Bucior
- Medical Affairs, Portola Pharmaceuticals, Inc , South San Francisco , CA , USA
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St. Thomas' Hospitals, King's College London , London , UK
| | - Shijie Ren
- HEDS, ScHARR, The University of Sheffield , Sheffield , UK
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13
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Yee MK, Gibson CM, Nafee T, Kerneis M, Daaboul Y, Korjian S, Chi G, AlKhalfan F, Hernandez AF, Hull RD, Cohen AT, Goldhaber SZ. Characterization of Major and Clinically Relevant Non-Major Bleeds in the APEX Trial. TH Open 2019; 3:e103-e108. [PMID: 31249989 PMCID: PMC6524922 DOI: 10.1055/s-0039-1685496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/25/2019] [Indexed: 12/17/2022] Open
Abstract
Background
Among medically ill patients treated with thromboprophylaxis, betrixaban was not associated with an increase in major bleeding compared with enoxaparin, but an increase in clinically relevant non-major (CRNM) bleeding was observed. The aim of this analysis is to describe the severity and clinical consequences of major and CRNM bleeding in the APEX trial.
Methods
The APEX trial randomized 7,513 hospitalized acutely ill medical patients to receive either enoxaparin for 6 to 14 days or betrixaban for 35 to 42 days. Subjects receiving a concomitant strong p-glycoprotein inhibitor or with creatinine clearance <30 mL/min were administered a reduced dose of study drug.
Results
A total of 25 (0.7%) and 21 (0.6%) major bleeds occurred in the betrixaban and enoxaparin arms, respectively (
p
= NS) and a total of 91 (2.5%) and 38 (1.0%) CRNM bleeds occurred in the betrixaban and enoxaparin arm (
p
< 0.001), respectively. Most major bleeds were considered moderate or severe and most CRNM bleeds were considered mild and moderate (
p
= NS). One fatal major bleed occurred in each treatment arm. Rates of major or CRNM bleeds resulting in new or prolonged hospitalization (major: 44.0 vs. 28.6%; CRNM: 12.1 vs. 21.1%) or study treatment interruption or cessation (major: 72.0 vs. 71.4%; CRNM: 71.3 vs. 68.4%) were similar between treatment arms (
p
= NS).
Conclusions
In the APEX trial, CRNM bleeds were mild or moderate in nature and had less of a clinical impact than major bleeds. The severity and clinical sequela of bleeds in the betrixaban arm were comparable to those in the enoxaparin arm.
Clinical Trial Registration
URL:
http://www.clinicaltrials.gov
.; Unique identifier: NCT01583218.
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Affiliation(s)
- Megan K Yee
- Boston Clinical Research Institute, Newton, Massachusetts, United States
| | - C Michael Gibson
- Boston Clinical Research Institute, Newton, Massachusetts, United States
| | - Tarek Nafee
- Boston Clinical Research Institute, Newton, Massachusetts, United States
| | - Mathieu Kerneis
- PERFUSE Study Group, Division of Cardiovascular, Departments of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Yazan Daaboul
- PERFUSE Study Group, Division of Cardiovascular, Departments of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Serge Korjian
- PERFUSE Study Group, Division of Cardiovascular, Departments of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Gerald Chi
- PERFUSE Study Group, Division of Cardiovascular, Departments of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Fahad AlKhalfan
- PERFUSE Study Group, Division of Cardiovascular, Departments of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Adrian F Hernandez
- Duke University and Duke Clinical Research Institute, Durham, North Carolina, United States
| | - Russell D Hull
- Division of Cardiology, R.A.H. Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, London, United Kingdom
| | - Samuel Z Goldhaber
- Division of Cardiovascular, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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14
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Abstract
Despite significant advances in strategies and compliance with venous thromboembolism (VTE) prophylaxis, hospital-acquired VTE remains a leading cause of preventable deaths in acute medically ill patients. A majority of venous thromboembolic events occur posthospital discharge when risk factors persist and pharmacoprophylactic regimens have been completed. Until recently, there has been an unmet need for safe and effective extended-duration VTE prevention. Three major trials evaluated this concept, but excess bleeding outweighed the benefit of reduced thromboembolic events. Betrixaban is an oral direct factor Xa inhibitor recently approved for extended-duration VTE prophylaxis in acute medically ill patients at risk for thromboembolism based on results from the Phase III APEX study. This article reviews the pharmacology and supporting data for betrixaban.
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Affiliation(s)
| | - Jean M Connors
- Department of Hematology, Brigham & Women's Hospital, Boston, MA, 02115, USA
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15
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Andexxa--an antidote for apixaban and rivaroxaban. Med Lett Drugs Ther 2018; 60:99-101. [PMID: 29913471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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16
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Abstract
Objective: To evaluate the efficacy, safety, and clinical implication of betrixaban for prophylaxis of venous thromboembolism (VTE) in patients with acute medical illness. Data Sources: A search for clinical trials was performed from January 2006 to January 2017 in English language using Clinicaltrials.gov and PubMed/MEDLINE. The following search terms were used: betrixaban, pharmacokinetics, pharmacology, and drug safety. Study Selection: The following limits were used to access the clinical trials: controlled clinical trial, randomized clinical trial, clinical trial, clinical trial phase II, and clinical trial phase III. The search was narrowed to include only humans. Data Extraction: The search criteria resulted in 6 clinical trials assessing the safety and efficacy of betrixaban. Additionally, references from publications assessing the safety and efficacy of betrixaban in atrial fibrillation, treatment and prevention of VTE, and extended duration VTE prophylaxis were assessed. Data Synthesis: Prior to 2017, no anticoagulant therapy had been approved for extended VTE prophylaxis in acutely ill medical patients. Betrixaban is the first direct oral anticoagulant approved for VTE prophylaxis in adult, acutely ill patients at risk for thromboembolisms. Based on the APEX trial, betrixaban 80 mg administered daily for 35 to 42 days was compared to enoxaparin administered daily for 6 to 14 days. In 7441 patients, fewer VTEs were seen in the betrixaban compared to enoxaparin with no significant difference in adverse reactions. Conclusion: Based on clinical trials, betrixaban appears to be safe and effective in preventing VTE in acutely ill patients who are at risk of developing VTE.
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Affiliation(s)
- Grazia Murphy
- Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Yasmin Grace
- Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Sadaf Chaudry
- Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Rita Chamoun
- Palm Beach Atlantic University, West Palm Beach, FL, USA
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17
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Affiliation(s)
- Konstantinos N Aronis
- Division of Cardiology, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Elaine M Hylek
- Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA
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18
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Garland SG, DeRemer CE, Smith SM, Gums JG. Betrixaban: A New Oral Factor Xa Inhibitor for Extended Venous Thromboembolism Prophylaxis in High-Risk Hospitalized Patients. Ann Pharmacother 2018; 52:554-561. [PMID: 29338293 DOI: 10.1177/1060028018754383] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To review the pharmacology, pharmacokinetics, efficacy, and safety of the factor Xa (FXa) inhibitor betrixaban for extended-duration prophylaxis of acute medically ill patients with venous thromboembolism (VTE) risk factors. DATA SOURCES A MEDLINE/PubMed (January 1990 to October 2017) search was conducted using the following keywords: betrixaban, PRT054021, FXa inhibitor, novel oral anticoagulant, NOAC, direct oral anticoagulant, DOAC, and target specific oral anticoagulant, TSOAC. References of identified articles were searched by hand for additional relevant citations. STUDY SELECTION AND DATA EXTRACTION We included English-language articles evaluating betrixaban pharmacology, pharmacokinetics, efficacy, or safety in human subjects for VTE prophylaxis. DATA SYNTHESIS Betrixaban is a FXa inhibitor that decreases prothrombinase activity and thrombin generation. Betrixaban efficacy and safety has been compared with that of enoxaparin for prophylaxis of VTE in acutely ill medical patients. In the APEX trial and substudies, extended-duration betrixaban was superior in efficacy to standard-duration enoxaparin in patients at high risk for VTE, including those with elevated D-dimer levels (≥2× upper limit of normal) and of older age (≥75 years). Betrixaban is noninferior to enoxaparin in rates of major bleeding, but the former is associated with more clinically relevant nonmajor bleeding events. CONCLUSION Betrixaban is the first oral agent approved for extended-duration VTE prophylaxis in acutely ill hospitalized patients. Extended-duration thromboprophylaxis with betrixaban reduces the risk of VTE compared with standard-duration thromboprophylaxis with enoxaparin but is associated with increased risk of bleeding.
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Affiliation(s)
| | | | | | - John G Gums
- 1 University of Florida, Gainesville, FL, USA
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19
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Gibson CM, Jennings LK, Chi G, Yee MK, Halaby R, Nafee T, AlKhalfan F, Kerneis M, Korjian S, Daaboul Y, Goldhaber SZ, Hull RD, Hernandez AF, Cohen AT, Harrington RA. Association of D-dimer Levels with Clinical Event Rates and the Efficacy of Betrixaban versus Enoxaparin in the APEX Trial. TH Open 2018; 2:e16-e24. [PMID: 31249924 PMCID: PMC6524856 DOI: 10.1055/s-0037-1615288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 11/20/2017] [Indexed: 11/12/2022] Open
Abstract
Background Elevated D-dimer concentrations are associated with an increased risk of venous thromboembolism (VTE). However, they may also provide prognostic value. The present analysis sought to study the association of D-dimer levels with VTE event rates and the efficacy of betrixaban versus enoxaparin in the APEX trial. Methods Hospitalized acutely medically ill subjects ( n = 7,513) were randomized in a double-dummy double-blind fashion to either extended-duration oral betrixaban (80 mg once daily for 35-42 days) or standard dose subcutaneous enoxaparin (40 mg once daily for 10 ± 4 days) for venous thromboprophylaxis. D-dimer was assessed using a central core laboratory measurement. Results For every 0.25 µg/mL increase in D-dimer concentration, there was a 2% increase in the relative risk of experiencing the primary efficacy endpoint (asymptomatic deep vein thrombosis [DVT], symptomatic DVT, nonfatal pulmonary embolism, or VTE-related death) in both the betrixaban ( p < 0.001) and enoxaparin ( p < 0.001) treatment arms. Among D-dimer-positive (≥ 2 × upper limit of normal; corresponding to ≥ 1.00 µg/mL) subjects, extended-duration betrixaban reduced the risk of experiencing the primary efficacy outcome (5.4% [ n = 124] vs. 7.6% [ n = 170]; odds ratio = 0.69; 95% confidence interval: 0.55-0.88; absolute risk reduction = 2.2%, number needed to treat = 46, p = 0.003). There was no interaction between D-dimer and the treatment effect ( p int = 0.53). Conclusion Extended-duration betrixaban was superior to standard-duration enoxaparin, irrespective of D-dimer level at baseline. To prevent one VTE event, 46 D-dimer-positive patients would need to be treated with betrixaban.
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Affiliation(s)
- C. Michael Gibson
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Lisa K. Jennings
- CirQuest Labs, The University of Tennessee Health Science Center, Memphis, Tennessee, United States
| | - Gerald Chi
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Megan K. Yee
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Rim Halaby
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Tarek Nafee
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Fahad AlKhalfan
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Mathieu Kerneis
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Serge Korjian
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Yazan Daaboul
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Samuel Z. Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Russel D. Hull
- Division of Cardiology, Faculty of Medicine, University of Calgary, Alberta, Canada
| | - Adrian F. Hernandez
- Division of Cardiology, Duke University and Duke Clinical Research Institute, Durham, North Carolina, United States
| | - Alexander T. Cohen
- Department of Haematological Medicine, Guy's and St. Thomas' Hospitals, King's College London, London, United Kingdom
| | - Robert A. Harrington
- Department of Medicine, Stanford University, Stanford, California, United States
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20
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Marszalek J, Mehrsefat S, Chi G. The risk of stroke among acutely ill hospitalized medical patients: lessons from recent trials on extended-duration thromboprophylaxis. Expert Rev Hematol 2017; 10:679-684. [PMID: 28617144 DOI: 10.1080/17474086.2017.1343662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Data from recent randomized controlled trials indicate that the incidence of stroke among acutely ill medical patients is unexpectedly high and approximates 1% at 90 days. Preliminary data suggest that betrixaban may reduce ischemic stroke in patients without atrial fibrillation. There is an unmet demand for stroke risk stratification schemes targeting hospitalized medical patients. The prognostic value of biomarkers such as natriuretic peptides and D-dimer in predicting short-term stroke remains uncertain. Future research should focus on identifying the high-risk subsets in which the benefit of anticoagulation significantly outweighs the associated hemorrhagic risk. Clinical trials: NCT00457002, NCT00571649, NCT01583218.
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Affiliation(s)
- Jolanta Marszalek
- a Department of Neurology , University of Arkansas for Medical Sciences , Little Rock , AR , USA
| | - Sara Mehrsefat
- b Division of Pulmonary and Critical Care Medicine , Johns Hopkins University , Baltimore , MD , USA
| | - Gerald Chi
- c Division of Cardiovascular Medicine, Department of Medicine , Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , MA , USA
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21
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Affiliation(s)
- Daniel J Quinlan
- From Department of Radiology, Kings College Hospital, London, United Kingdom (D.J.Q.); and Population Health Research Institute, Hamilton Health Sciences and Department of Medicine, McMaster University, Ontario, Canada (J.W.E., R.G.H.).
| | - John W Eikelboom
- From Department of Radiology, Kings College Hospital, London, United Kingdom (D.J.Q.); and Population Health Research Institute, Hamilton Health Sciences and Department of Medicine, McMaster University, Ontario, Canada (J.W.E., R.G.H.)
| | - Robert G Hart
- From Department of Radiology, Kings College Hospital, London, United Kingdom (D.J.Q.); and Population Health Research Institute, Hamilton Health Sciences and Department of Medicine, McMaster University, Ontario, Canada (J.W.E., R.G.H.)
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22
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Abstract
Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a common and potentially preventable cause of morbidity and mortality. Unfractionated heparin, low-molecular-weight heparin, and warfarin have been the cornerstone of VTE prevention and treatment but are being replaced by recently approved non-vitamin K antagonist oral anticoagulants (NOACs): dabigatran, rivaroxaban, apixaban, and edoxaban. The NOACs are at least as effective and as safe as heparins and warfarin for VTE prevention and treatment and are more convenient because they have a low propensity for food and drug interactions and are given in fixed doses without routine coagulation monitoring. The remaining limitations of currently available NOACs include their dependence on renal and hepatic function for clearance, and the lack of an approved antidote. Betrixaban is a new NOAC with distinct pharmacological characteristics: minimal renal clearance, minimal hepatic metabolism, and long half-life. It has undergone successful Phase II studies in orthopedic thromboprophylaxis, and in stroke prevention in atrial fibrillation. Currently, it is being evaluated in a Phase III trial of extended thromboprophylaxis in medical patients (APEX study). In this article, we describe the development of betrixaban, review its pharmacological profile, discuss the results of clinical trials, and examine its potential for VTE prevention and treatment.
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Affiliation(s)
- Noel C Chan
- Population Health Research Institute, Hamilton, ON, Canada ; Department of Haematology, Monash Medical Center, Clayton, VIC, Australia
| | - Vinai Bhagirath
- Population Health Research Institute, Hamilton, ON, Canada ; Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada ; Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada ; Department of Medicine, McMaster University, Hamilton, ON, Canada
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