Inhibition of Prekallikrein for Hereditary Angioedema

BACKGROUND

Hereditary angioedema is characterized by recurrent and unpredictable swellings that are disabling and potentially fatal. Selective inhibition of plasma prekallikrein production by antisense oligonucleotide treatment (donidalorsen) may reduce the frequency of attacks and the burden of disease.

METHODS

In this phase 2 trial, we randomly assigned, in a 2:1 ratio, patients with hereditary angioedema with C1 inhibitor deficiency to receive four subcutaneous doses of either donidalorsen (80 mg) or placebo, with one dose administered every 4 weeks. The primary end point was the time-normalized number of investigator-confirmed angioedema attacks per month (attack rate) between week 1 (baseline) and week 17. Secondary end points included quality of life, as measured with the Angioedema Quality of Life Questionnaire (scores range from 0 to 100, with higher scores indicating worse quality of life), and safety.

RESULTS

A total of 20 patients were enrolled, of whom 14 were randomly assigned to receive donidalorsen and 6 to receive placebo. The mean monthly rate of investigator-confirmed angioedema attacks was 0.23 (95% confidence interval [CI], 0.08 to 0.39) among patients receiving donidalorsen and 2.21 (95% CI, 0.58 to 3.85) among patients receiving placebo (mean difference, -90%; 95% CI, -96 to -76; P<0.001). The mean change from baseline to week 17 in the Angioedema Quality of Life Questionnaire score was -26.8 points in the donidalorsen group and -6.2 points in the placebo group (mean difference, -20.7 points; 95% CI, -32.7 to -8.7). The incidence of mild-to-moderate adverse events was 71% among patients receiving donidalorsen and 83% among those receiving placebo.

CONCLUSIONS

Among patients with hereditary angioedema, donidalorsen treatment resulted in a significantly lower rate of angioedema attacks than placebo in this small, phase 2 trial. (Funded by Ionis Pharmaceuticals; ISIS 721744-CS2 ClinicalTrials.gov number, NCT04030598.).

Antisense Inhibition of Prekallikrein to Control Hereditary Angioedema

Hereditary angioedema is characterized by recurrent and unpredictable episodes of subcutaneous and mucosal swelling that can be life threatening. IONIS-PKK-L_Rx is a ligand-conjugated antisense oligonucleotide designed for receptor-mediated delivery to hepatocytes. In a compassionate-use pilot study, two patients with severe bradykinin-mediated angioedema were initially administered weekly subcutaneous injections of the unconjugated parent drug, IONIS-PKK_Rx, for 12 to 16 weeks, after which they received IONIS-PKK-L_Rx at a dose of 80 mg every 3 to 4 weeks for 7 to 8 months. Treatment was accompanied by a reduction in the angioedema attack rate. (Funded by Amsterdam UMC.).

Identification and characterization of plasma kallikrein-kinin system inhibitors from salivary glands of the blood-sucking insectTriatoma infestans

Two plasma kallikrein-kinin system inhibitors in the salivary glands of the kissing bug Triatoma infestans, designated triafestin-1 and triafestin-2, have been identified and characterized. Reconstitution experiments showed that triafestin-1 and triafestin-2 inhibit the activation of the kallikrein-kinin system by inhibiting the reciprocal activation of factor XII and prekallikrein, and subsequent release of bradykinin. Binding analyses showed that triafestin-1 and triafestin-2 specifically interact with factor XII and high molecular weight kininogen in a Zn2+-dependent manner, suggesting that they specifically recognize Zn2+-induced conformational changes in factor XII and high molecular weight kininogen. Triafestin-1 and triafestin-2 also inhibit factor XII and high molecular weight kininogen binding to negatively charged surfaces. Furthermore, they interact with both the N-terminus of factor XII and domain D5 of high molecular weight kininogen, which are the binding domains for biological activating surfaces. These results suggest that triafestin-1 and triafestin-2 inhibit activation of the kallikrein-kinin system by interfering with the association of factor XII and high molecular weight kininogen with biological activating surfaces, resulting in the inhibition of bradykinin release in an animal host during insect blood-feeding.

[Effect of compound Chinese drug bailong on the expression of tumor suppressor genes and relationship with prekallikrein activator signal pathway in human gastric carcinoma BGC82-3 cell line]

OBJECTIVE

To study the effect of compound Chinese drug Bailong on the transcription of Cyclin Dependent Kinase Inhibitor (CKI) p16INK4a, p21 and Rb, c-myc genes, and the relationship between gene expression and cAMP-PKA pathway.

METHODS

Using the traditional molecular biology methods (cell synchronization, molecular hybridization--Western blotting, Northern blotting, etc.) examine the gene expression.

RESULTS

Bailong promoted the expression (both mRNA and protein) of p16INK4a obviously in G1 phase cells. When prekallikrein (PKA) inhibitor was added in the cells which were treated by Bailong, the mRNA and protein level of p16INK4a decreased. It was shown that the inhibited proliferation of BGC82-3 cell by Bailong may come from the enhanced p16INK4a gene expression in G1 phase. Being same as p16INK4a, tumor suppressor genes Rb, p21 and oncogene c-myc expression were all affected by Bailong. When PKA inhibitor was added, the results were reversed.

CONCLUSION

Bailong can affect many anticancer genes (including p16INK4a, p21 and Rb genes) and oncogenes (including c-myc) transcription by regulating cAMP-PKA pathway.

Studies on kochiae fructus. III. Antinociceptive and antiinflammatory effects of 70% ethanol extract and its component, momordin Ic from dried fruits of Kochia scoparia L

The 70% ethanol extract (KS-ext) from Kochiae Fructus (dried fruits of Kochia scoparia L.) was screened for its activity on nociceptive and inflammatory responses in experimental animals. Although KS-ext at an oral administration of 500 mg/kg had an antinociceptive effect on writhing responses induced by acetic acid, it was ineffective on nociceptive response in the hot plate test. Oleanolic acid oligoglycoside, momordin Ic isolated from Kochiae Fructus significantly decreased the frequency of licking behavior within a unit of time at the late phase without affecting that of the early phase in the formalin test. Also, KS-ext inhibited the rise of vascular permeability induced by acetic acid, the increase of paw edema induced by carrageenin, histamine, serotonin or bradykinin and ear swelling induced by arachidonic acid. Momordin Ic also exhibited an inhibitory effect on carrageenin-induced edema. These results indicated that Kochiae Fructus has a peripheral antinociceptive effect mediated by antiinflammatory action, and that its active component can be partially attributed to momordin Ic.

Mechanized assay of plasma prekallikrein by activation with Pseudomonas aeruginosa elastase and amidolysis of chromogenic substrate

An automated assay of plasma prekallikrein is described. Prekallikrein was converted to kallikrein with Pseudomonas aeruginosa elastase, and the hydrolytic activity of kallikrein to H-D-Pro-Phe-Arg-paranitroanilide subsequently measured. The conversion was complete within 8 minutes and the amidolytic activity remained stable at least another 10 min at 37 degrees C. This method worked in plasma deficient in Hageman factor (blood coagulation factor XII). Using anti-prekallikrein antibody and plasma deficient in prekallikrein, the amidolytic activity generated in normal plasma was identified as due to kallikrein. With plasma samples, the coefficients of variation (CV) for multiple measurements within run (n = 10) and between run (n = 10) were as low as 5.0% and 6.6%, respectively, and the minimum measurable concentration of prekallikrein in plasma was 10% of the normal level.

Mechanism-based isocoumarin inhibitors for trypsin and blood coagulation serine proteases: new anticoagulants

Trypsin, porcine pancreatic kallikrein, and several blood coagulation enzymes, including bovine thrombin, bovine factor Xa, human factor Xa, human plasma factor XIa, human plasma factor XIIa, and human plasma kallikrein, were inactivated by a number of substituted isocoumarins containing basic functional groups (aminoalkoxy, guanidino, and isothiureidoalkoxy). 3-Alkoxy-4-chloro-7-guanidinoisocoumarins were found to be the most potent inhibitors for the coagulation enzymes tested with kobsd/[I] values in the range of 10(3)-10(5) M-1 s-1. 4-Chloro-3-isothiureidoalkoxyisocoumarins show high inhibitory potency toward porcine pancreatic kallikrein, human plasma kallikrein, human factor XIa, human factor XIIa, and trypsin with kobsd/[I] values of the order of 10(4)-10(5) M-1 s-1. The inhibition of these serine proteases by the substituted isocoumarins are time dependent, and the inactivation of trypsin by 3-alkoxy-4-chloro-7-guanidinoisocoumarins and 7-amino-4-chloro-3-(3-isothiureidopropoxy)isocoumarin occured concurrently with the loss of the isocoumarin absorbance. The complex formed from inactivation of trypsin by these two types of inhibitors was very stable and regained less than 4% activity in 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid buffer (pH 7.5) after 1 day at 25 degrees C and regained 8-45% activity upon addition of buffered 0.29 M hydroxylamine. Trypsin inactivated by other inhibitors regained full activity upon standing or addition of hydroxylamine. Thrombin inactivated by 3-alkoxy-4-chloro-7-guanidinoisocoumarins was also quite stable and only regained 9-15% activity under similar conditions. These results are consistent with a proposed mechanism, where serine proteases inactivated by aminoalkoxyisocoumarins or isothiureidoalkoxyisocoumarins form acyl enzymes that will deacylate upon standing or addition of hydroxylamine. However, the acyl enzymes formed from 3-alkoxy-4-chloro-7-guanidinoisocoumarins or 7-amino-4-chloro-3-(3-isothiureidopropoxy)-isocoumarin will decompose further, probably through a quinone imine methide, to give an irreversibly inactivated enzyme by reaction with an active-site nucleophile such as His-57. The quinone imine methide intermediate may also react with a solvent nucleophile to give an acyl enzyme that can be reactivated by hydroxylamine. The inhibitors 4-chloro-7-guanidino-3-methoxyisocoumarin and 4-chloro-3-ethoxy-7-guanidinoisocoumarin have been tested as anticoagulants in human plasma and were effective at prolonging the prothrombin time. However, they are unstable in plasma (t1/2 = 4-8 min), and their in vivo utility may be limited.

Prokallikrein and kallikrein inhibitors in human urine

Kallikrein activity (KA) and kallikrein inhibitors (KI) were evaluated in urine from normal subjects and essential hypertensives. Kallikrein inhibitors were almost completely removed by dialysis against water, confirming previous reports of their low molecular size. The negative relationship found between KA and KI in urine samples from 12 normal subjects suggests that KI might play a role in the modulation of KA excreted by the kidney. Heating (85 degrees C for 20 min) partially reduced (-52%) KI, indicating thermostable substances other than peptides as KI. When cations were evaluated as possible KI, by adding different salts to dialysed salt-free urine, only sodium was able to inhibit KA by 20% at a concentration not far from the physiological range. Trypsin added to dialysed urine produced a striking increase in KA without significant changes in Km and pH optimum. These findings, together with the observation that acid dialysis did not increase KA, strongly support the hypothesis that trypsin-activatable kallikrein might be a pro-enzyme. A lower urinary excretion of active kallikrein was found in 48 essential hypertensives when compared with 31 normotensive controls. However, trypsin-activatable kallikrein excretion was similar in the two groups, suggesting that low KA in hypertensives might not reflect a defective conversion of the pro-enzyme into the active form.

Isolation of bovine platelet cationic proteins which inhibit the surface-mediated activation of factor XII and prekallikrein

A possible role of bovine platelets in the surface-mediated activation of Factor XII and prekallikrein was studied, using the contact system reconstituted with the purified proteins from bovine plasma. The washed platelets before and after aggregation by ADP, thrombin or collagen did not show any ability to trigger or accelerate the activation of Factor XII and prekallikrein. On the contrary, these aggregates showed a potent inhibitory activity on the activation of those zymogens triggered by kaolin, amylose sulfate and sulfatide. The inhibitory substances from the supernatant of the thrombin-induced aggregates were separated into two major fractions, a low affinity fraction and a high affinity fraction, on a heparin-Sepharose column. The high affinity protein was identified as platelet factor 4, based on the amino acid composition. From the low affinity fraction, a beta-thromboglobulin (beta-TG)-like substance and three kinds of unknown proteins, named LA1, LA2, and LA3, were isolated by gel-filtration on a column of Sephadex G-100 or Sephadex G-75 followed by chromatography on a column of Mono S. The molecular weights of LA1, LA2, and LA3 were estimated to be 35,000, 26,000, and 11,000, respectively, on SDS-PAGE. LA2 was identified as a carbohydrate-less LA1, as judged from the amino acid composition and carbohydrate content. The inhibitory activities of these five cationic proteins on the activation of Factor XII and prekallikrein mediated with amylose sulfate, sulfatide and kaolin were different from each other. In the case of kaolin-mediated activation, LA3 was the most potent inhibitor, while platelet factor 4 and beta-TG-like substance did not show any significant inhibitory activity. Moreover, the inhibitory activities of all the cationic proteins were not correlated with their anti-heparin activities. Since these proteins were rapidly liberated from platelets by the action of the stimulants, the present results demonstrate a negative role of platelets in the surface-mediated activation of Factor XII and prekallikrein.

Prekallikrein inhibition associated with the lupus anticoagulant: a mechanism of thrombosis

The lupus anticoagulant was identified in three patients. Laboratory studies gave evidence of inhibitory activity directed against phospholipid and prekallikrein. Inhibition of prekallikrein has not been reported previously. When exposed to kaolin, all three patients' plasmas failed to develop the level of fibrinolytic activity achieved by similarly treated normal plasma. The data suggest that compromised fibrinolytic capacity may be a contributing factor in the development of thrombosis in patients with the lupus anticoagulant.