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Weiss-Tessbach M, Dizdarevic AM, Kupis A, Bischof T, Firbas C, Quehenberger P, Derhaschnig U, Frimmel M, Jilma B, Schoergenhofer C. Osmotic laxatives do not alter dabigatran plasma concentration in healthy volunteers - a randomized, controlled, cross-over trial. Front Pharmacol 2025; 16:1579014. [PMID: 40421205 PMCID: PMC12104081 DOI: 10.3389/fphar.2025.1579014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2025] [Accepted: 04/28/2025] [Indexed: 05/28/2025] Open
Abstract
Background Laxatives are among the most commonly used pharmacological agents worldwide. Available data indicate a significant potential for clinically relevant drug-drug interactions. We hypothesized that osmotic laxatives may reduce the oral bioavailability of the direct oral anticoagulant dabigatran and thereby its anticoagulant effects. Methods In the first part of this single-centre, randomized, double-blind, crossover trial, 24 healthy volunteers received 150 mg dabigatran with placebo (10 g glucose) or 20 g lactulose. In the second, open label part, eight of these 24 healthy volunteers were randomly assigned to receive dabigatran with either 27.6 g macrogol, 30 g flaxseeds, or to receive 20 g lactulose 4-h after dabigatran intake. We measured dabigatran plasma concentrations using an ecarin-based chromogenic assay and calculated the pharmacokinetic parameters. Statistical analysis was performed using a linear mixed-effects model on log-transformed AUC values. Results The main pharmacokinetic parameters AUC, Cmax, Tmax, or t1/2 did not differ significantly between most treatment periods. A reduction in AUC was observed with flaxseed compared to placebo. Dabigatran's pharmacokinetics remained unaffected by concomitant intake of lactulose or macrogol. There was a high inter- and intra-individual variability in the pharmacokinetics of dabigatran. Conclusion In this study osmotic laxatives such as lactulose, macrogol or flaxseeds did not affect the pharmacokinetics of dabigatran in healthy individuals. These findings support the safe concurrent use of dabigatran with osmotic laxatives.
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Affiliation(s)
| | - Al Medina Dizdarevic
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Vienna, Austria
| | - Alexander Kupis
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Vienna, Austria
| | - Thorsten Bischof
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Vienna, Austria
| | - Christa Firbas
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Vienna, Austria
| | - Ulla Derhaschnig
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Vienna, Austria
| | - Max Frimmel
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Vienna, Austria
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Park JW, Kim JM, Bang YY, Kim KA, Yu S, Park JY. UGT2B15 single nucleotide polymorphism reduces dabigatran acylglucuronide formation in humans. Front Pharmacol 2025; 15:1507915. [PMID: 39850575 PMCID: PMC11754044 DOI: 10.3389/fphar.2024.1507915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Accepted: 12/02/2024] [Indexed: 01/25/2025] Open
Abstract
Background Dabigatran etexilate (DABE), a prodrug of dabigatran (DAB), is a direct thrombin inhibitor used to prevent ischemic stroke and thromboembolism during atrial fibrillation. The effect of genetic polymorphisms on its metabolism, particularly UGT2B15, has not been extensively explored in humans. This study aimed to investigate the effects of UGT2B15, ABCB1, and CES1 polymorphisms on the pharmacokinetics of DAB and its acylglucuronide metabolites in healthy subjects. Methods A total of 124 healthy males were genotyped for UGT2B15, ABCB1, and CES1 polymorphisms. After a single 150 mg dose of DABE, plasma concentrations of total and free DAB, as well as dabigatran acylglucuronide (DABG) were measured using LC-MS/MS. Pharmacokinetic parameters were analyzed using non-compartmental methods, and statistical comparisons were conducted between the genotype groups. Results UGT2B15 c.253G>T significantly affected free DAB pharmacokinetics, with a lower Tmax and oral clearance in TT genotype (n = 28, p < 0.05). For DABG, Cmax was significantly higher in GG genotypes (n = 32, 42.3 ± 16.3 ng/mL) compared to that in GT (n = 64, 32.4 ± 20.5 ng/mL) and TT (29.7 ± 17.1 ng/mL) genotypes. Similarly, the AUCall of DABG was highest in GG genotypes (327 ± 148.3 ng h·mL-1), followed by GT (238.7 ± 166.5 ng h·mL-1) and TT (223.3 ± 165.4 ng h·mL-1) genotypes (p < 0.05). The metabolite-to-parent ratios (m/p ratios) for Cmax and AUCall were significantly higher in GG and GT genotypes than that in TT genotype. ABCB1 and CES1 polymorphisms had no significant impact on the pharmacokinetics of DAB or DABG. Conclusion UGT2B15 polymorphisms were associated with difference in DAB glucuronidation and pharmacokinetics in healthy male participants.
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Affiliation(s)
- Jin-Woo Park
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
- Department of Neurology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jong-Min Kim
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Young Yoon Bang
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Ah Kim
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sungwook Yu
- Department of Neurology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji-Young Park
- Department of Clinical Pharmacology and Toxicology, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Xia Y, Chen Q, Liu HN, Chi Y, Zhu Y, Shan LS, Dai B, Wu L, Shi X. Synthetic routes and clinical application of new drugs approved by EMA during 2023. Eur J Med Chem 2024; 277:116762. [PMID: 39151275 DOI: 10.1016/j.ejmech.2024.116762] [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: 07/06/2024] [Revised: 07/29/2024] [Accepted: 07/31/2024] [Indexed: 08/19/2024]
Abstract
In 2023, the European Medicines Agency (EMA) granted approval to 77 new molecular entities (NMEs), consisting of 45 new chemical entities (NCEs) and 32 new biological entities (NBEs). These pharmacological agents encompass a broad spectrum of therapeutic domains, including oncology, cardiology, dermatology, diagnostic medicine, endocrinology, gastroenterology and hepatology, metabolic disorders, and neurology. Among the 77 approved pharmaceuticals, three received accelerated review status, and 17 (22 %) were granted orphan drug designation for the treatment of rare diseases. This review provides an overview of the clinical applications and synthetic routes of 42 newly approved NCEs by the EMA in 2023. The objective is to offer a comprehensive understanding of the synthetic approaches used in the development of these drug molecules, thereby inspiring the creation of novel, efficient, and applicable synthetic methodologies.
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Affiliation(s)
- Yu Xia
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Qingqing Chen
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - He-Nan Liu
- Department of Ophthalmology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuan Chi
- Department of Radiology, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Ying Zhu
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Li-Shen Shan
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China
| | - Bing Dai
- Department of Pediatrics, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Lin Wu
- Department of Thoracic Surgery, Shengjing Hospital of China Medical University, Shenyang, China.
| | - Xiaobao Shi
- Department of Radiology, The Fourth Affiliated Hospital of China Medical University, Shenyang, China.
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4
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Hayashida M, Suzuki M, Nakata Y, Kakita H, Eizawa H. Cardiac Tamponade and Duodenal Hemorrhage Caused by Inappropriate Use of Dabigatran in a Patient With End-Stage Renal Failure: A Case Report. Cureus 2024; 16:e52521. [PMID: 38371033 PMCID: PMC10874288 DOI: 10.7759/cureus.52521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
A 72-year-old man with end-stage renal failure, receiving 220 mg of dabigatran for chronic atrial fibrillation, was admitted with generalized edema and shortness of breath. Cardiac tamponade caused by pericardial hemorrhage due to inappropriate dabigatran use was treated with pericardial drainage and idarucizumab. Although coagulability normalized, consecutive duodenal hemorrhages occurred, requiring arterial embolization for hemostasis. In cases of severely impaired renal function, the usual dose of idarucizumab may not be sufficient to reverse the effects of dabigatran. Therefore, we considered the need for repeated idarucizumab administration to prevent recurrent bleeding.
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Affiliation(s)
| | | | - Yosuke Nakata
- Nephrology, Kobe City Nishi-Kobe Medical Center, Kobe, JPN
| | - Hiroko Kakita
- Nephrology, Kobe City Nishi-Kobe Medical Center, Kobe, JPN
| | - Hiroshi Eizawa
- Cardiology, Kobe City Nishi-Kobe Medical Center, Kobe, JPN
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Wu S, Wang T, Li J, Zhang Z, Li C, Xiao S, He J, Wang X, Hu Z, Wang X, Zheng S, Liang X, Chen G, Li Y, Li X, Zhan Y, Zou Q, Jiang H, Zheng Q, Ban L, Liu H, Fang Y. First-in-human trial of SAR107375E, a novel small molecule anticoagulant with dual inhibition of factor Xa and factor IIa. Expert Opin Investig Drugs 2023; 32:1085-1094. [PMID: 37955047 DOI: 10.1080/13543784.2023.2283024] [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: 08/11/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND SAR107375E is a direct dual inhibitor of both Factor Xa and Factor IIa and has shown potent anticoagulation activity in vitro and animals. This study evaluated the safety, tolerability, pharmacokinetics, and pharmacodynamics of single ascending intravenous doses of SAR107375E in healthy Chinese adult subjects. METHODS In this randomized, double-blind, placebo-controlled trial, 60 healthy Chinese adult subjects were administered intravenously single ascending doses (0.5, 1.5, 3.0, 5.0, 7.5, 10.0, 15.0, or 20.0 mg) of SAR107375E (N = 44) or placebo (N = 16). Plasma and urine concentrations of SAR107375E were measured and used to calculate pharmacokinetic parameters. Coagulation functions were measured and compared with baseline values. Treatment-emergent adverse events were recorded to evaluate safety. RESULTS In plasma, from the 0.5 to 20.0 mg dose group, t1/2 is 1.51-4.00 h, Cmax is 59.05-1360 ug/L, and AUC0-t is 25.01-528.45 h*ug/L. And it shows dose proportionality in the 5.0-20.0 mg range. Activated partial thromboplastin time and Ecarin clotting time correlated linearly with drug plasma concentration. No serious adverse events were reported during the study. CONCLUSION SAR107375E exhibits good safety and tolerability, predictable pharmacokinetics and pharmacodynamics. CLINICAL TRIAL REGISTRATION www.chinadrugtrials.org.cn, identifier is CTR20211082.
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Affiliation(s)
- Shuanzhi Wu
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Tenghua Wang
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jieyun Li
- Beijing Lianxin Pharmaceutical Co., Ltd, Beijing, China
| | - Zhixin Zhang
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chen Li
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shuangshuang Xiao
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jin He
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xuan Wang
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhiqin Hu
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaole Wang
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Sichao Zheng
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xintong Liang
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | | | - Yongmei Li
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xianbo Li
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yaoxuan Zhan
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qinwen Zou
- Beijing Lianxin Pharmaceutical Co., Ltd, Beijing, China
| | | | - Qingshan Zheng
- Center for Drug Clinical Research, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Li Ban
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Haiyan Liu
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yi Fang
- Clinical Trial Institution, The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Clinical Trial Institution, Peking University People's Hospital, Beijing, China
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Javed A, Ajmal M, Wolfson A. Dabigatran in cardiovascular disease management: A comprehensive review. World J Cardiol 2021; 13:710-719. [PMID: 35070113 PMCID: PMC8716972 DOI: 10.4330/wjc.v13.i12.710] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 09/27/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
Dabigatran, a direct thrombin inhibitor, has robust data for the treatment of deep venous thrombosis and pulmonary embolism, stroke prevention in non-valvular atrial fibrillation, and the prophylaxis of venous thromboembolism (VTE) after knee and hip replacement. Recent studies have evaluated dabigatran to determine its safety and efficacy in such conditions as VTE in malignancy, coronary artery disease, mechanical and bioprosthetic valves, and antiphospholipid syndrome. This article provides a comprehensive review on the role of dabigatran in various cardiovascular diseases.
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Affiliation(s)
- Ayesha Javed
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85719, United States
| | - Muhammad Ajmal
- Department of Cardiology, University of Arizona, Tucson, AZ 85719, United States.
| | - Aaron Wolfson
- Department of Cardiology, University of Southern California, Los Angeles, CA 90007, United States
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7
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The Effects of Bariatric Surgery and Gastrectomy on the Absorption of Drugs, Vitamins, and Mineral Elements. Pharmaceutics 2021; 13:pharmaceutics13122111. [PMID: 34959391 PMCID: PMC8708306 DOI: 10.3390/pharmaceutics13122111] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 12/17/2022] Open
Abstract
Bariatric surgery, which is an effective treatment for obesity, and gastrectomy, which is the primary treatment method for gastric cancer, alter the anatomy and physiology of the digestive system. Weight loss and changes in the gastrointestinal tract may affect the pharmacokinetic parameters of oral medications. Both bariatric and cancer patients use drugs chronically or temporarily. It is important to know how surgery affects their pharmacokinetics to ensure an effective and safe therapy. The Cochrane, PubMed, and Scopus databases were searched independently by two authors. The search strategy included controlled vocabulary and keywords. Studies show that bariatric surgery and gastrectomy most often reduce the time to maximum plasma concentration (tmax) and decrease the maximum plasma concentration (Cmax) in comparison with the values of these parameters measured in healthy volunteers. Vitamin and mineral deficiencies are also observed. The effect depends on the type of surgery and the properties of the drug. It is recommended to use the drugs that have been tested on these groups of patients as it is possible to monitor them.
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Duan J, Yang L, Li H, Yamamura N, Harada A. Pharmacokinetics and Safety of Dabigatran Etexilate after Single and Multiple Oral Doses in Healthy Chinese Subjects. Eur J Drug Metab Pharmacokinet 2021; 45:601-609. [PMID: 32474728 PMCID: PMC7511473 DOI: 10.1007/s13318-020-00626-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Objective Dabigatran etexilate is a non-vitamin K antagonist oral anticoagulant (NOAC) that is used to prevent stroke and systemic embolism in adults with nonvalvular atrial fibrillation (NVAF) and one or more risk factors. Pharmacokinetic data on this anticoagulant in Chinese subjects are limited. This study aimed to provide further information on the pharmacokinetic profile of dabigatran in healthy Chinese subjects, together with its safety profile. Methods This was an open-label, single-centre, phase I study. Subjects were randomized into 110 and 150 mg dabigatran etexilate treatment groups. Each subject received 7 days of treatment: a single dose on day 1, no dose on days 2–3, and then multiple doses on days 4–10. Blood samples were collected to analyze the pharmacokinetic profile of dabigatran. All adverse events (AEs) were recorded. Routine clinical laboratory tests, a physical examination, vital signs, and 12-lead electrocardiogram (ECG) measurements were performed. Results A total of 28 subjects (14 males and 14 females) were randomized in this trial. The plasma concentration of total dabigatran reached its maximum measured concentration at a median time of 3–4 h from the dose of interest (either the initial single dose on day 1 or the final dose on day 10) under fed conditions, and declined with an elimination half-life of 10.7–10.9 h following the dose of interest. There was a modest difference in pharmacokinetic profile between male and female subjects. None of the subjects experienced a serious adverse event (SAE) or an AE of moderate or severe intensity. The investigator reported that 17 of the 28 subjects had mild treatment-emergent AEs that resolved without any concomitant treatment or intervention. No clinically significant changes in vital signs or ECG parameters were observed. Conclusions This study revealed the pharmacokinetic characteristics and good safety profile of dabigatran in healthy Chinese subjects. Electronic supplementary material The online version of this article (10.1007/s13318-020-00626-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jingli Duan
- Department of Pharmacy, Peking University Third Hospital, Peking, China. .,Department of Pharmacy, Peking University International Hospital, No. 1 Life Park Road, Life Science Park of Zhongguancun, Changping District, Peking, 102206, China.
| | - Li Yang
- Department of Pharmacy, Peking University Third Hospital, Peking, China
| | - Haiyan Li
- Department of Cardiovascular, Peking University Third Hospital, Peking, China
| | - Norio Yamamura
- Department of Clinical Pharmacokinetics/Pharmacodynamics, Nippon Boehringer Ingelheim Co., Ltd., Kobe, Japan
| | - Akiko Harada
- Department of Clinical Pharmacokinetics/Pharmacodynamics, Nippon Boehringer Ingelheim Co., Ltd., Kobe, Japan
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Sun X, Ze B, Zhang LJ, BaiMa YZ, Zuo W, Zhao B, GeSang LB. Hemorrhage Risk Profiles among Different Antithrombotic Regimens: Evidence from a Real-World Analysis of Postmarketing Surveillance Data. Cardiovasc Drugs Ther 2020; 36:103-112. [PMID: 33226545 DOI: 10.1007/s10557-020-07110-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Although the use of direct oral anticoagulants (DOACs) has been reported in patients with atrial fibrillation (AF), there is currently no consensus on the occurrence or characteristics of the hemorrhage risk in different antithrombotic regimens. METHODS Disproportionality and Bayesian analyses were performed in mining data of suspected hemorrhagic events after antithrombotic drug use from the FDA Adverse Event Reporting System (FAERS) from January 2004 to September 2019. The time to onset and fatality rate of hemorrhage following different antithrombotic regimens were also compared. RESULTS A total of 84,998 reports of hemorrhage-related adverse events with the use of antithrombotic drugs were identified. The patients included were mostly from the Americas (80.87%) and Europe (13.22%), with most data submitted by nonhealthcare professionals. Among the seven antithrombotic drug monotherapies, betrixaban had the highest association with hemorrhage based on the highest reporting odds ratio (ROR, 829.95; 95% CI = 113.61-6063.15), proportional reporting ratio (PRR, 24.68, χ2 = 804.24), and multi-item gamma Poisson shrinker (MGPS, 24.68, 95% one-sided CI = 4.67). The combination therapies of clopidogrel plus new oral anticoagulants had higher RORs, PRRs, and empirical Bayesian geometric means (EBGMs) than the antithrombotic drug monotherapies. Hemorrhage associated with rivaroxaban plus clopidogrel appeared to have an earlier onset (171 days vs 219 days, 95% two-sided CI =68.68-27.34, p < 0.0001) and a lower fatality rate (15.30% vs 17.74%, p<0.05) than that associated with rivaroxaban monotherapy. CONCLUSION This study provides a relevant overview of the hemorrhagic complications/fatalities associated with different antithrombotic regimens in their real-world use. Among the combination therapies, clopidogrel plus DOACs were found to have stronger associations with hemorrhage than traditional dual antithrombotic therapies. Rivaroxaban showed a stronger association with hemorrhage than other antithrombotic drug monotherapies, and apixaban monotherapy appeared to have weaker associations with hemorrhage than others.
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Affiliation(s)
- Xue Sun
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Bi Ze
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Ling-Jun Zhang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
| | - Yang-Zhong BaiMa
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China
| | - Wei Zuo
- Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Bin Zhao
- People's Hospital of the Tibet Autonomous Region, Lhasa, 850000, China. .,Department of Pharmacy, Peking Union Medical College Hospital, No.1 Shuaifuyuan, Dongcheng District, Beijing, 100730, China.
| | - Luo-Bo GeSang
- Internal Medicine Branch of Cadiovascular Diseases/Plateau Medicine, People's Hospital of Tibet Autonomous Region, Lhasa, 850000, China
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Dubner S, Saraiva JFK, Fragoso JCN, Barón-Esquivias G, Teutsch C, Gurusamy VK, Marler S, Huisman MV, Lip GYH, Zeballos C. Effectiveness and safety of dabigatran in Latin American patients with atrial fibrillation: Two years follow up results from GLORIA-AF registry. IJC HEART & VASCULATURE 2020; 31:100666. [PMID: 33195793 PMCID: PMC7644920 DOI: 10.1016/j.ijcha.2020.100666] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/18/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
Background Real-world data from different regions are needed to support the external validity of controlled trials and assess the impact of new oral anticoagulants (NOAC) in clinical practice. Methods “GLORIA-AF” is a large, ongoing, multicenter, global, prospective registry program in patients with newly diagnosed non-valvular atrial fibrillation (NVAF) at risk of stroke. Newly diagnosed patients with NVAF (within 4.5 months) and a CHA2DS2-VASc score ≥ 1 were consecutively enrolled. The study objective was to estimate the incidence rate of stroke and major bleeding after a two year follow up of patients on dabigatran that participated in the “GLORIA-AF” study (Phase II) in Latin America. Results Latin America included 378 eligible patients that received dabigatran in eight countries (Argentina, Brazil, Chile, Colombia, Ecuador, Mexico, Perú, and Venezuela): 56.3% were male; mean age was 70.3 ± 10.8 years; 43.4% had paroxysmal AF; 36.0% persistent AF and 20.6% permanent AF. Mean CHA2DS2-VASc score was 3.2 ± 1.4; mean HAS-BLED score was 1.2 ± 0.8. Incidence rates for clinical events after 2-years of follow-up per 100 patient-years were as follows: stroke 0.33 (95% CI: 0.04–1.17), major bleeding 0.49 (95% CI: 0.10–1.42) and all-cause death 4.06 (95% CI: 2.63–6.00). Persistence with dabigatran at 6, 12 and 24 months was 91%, 86%, and 80%, respectively. Conclusion These regional data shows the sustained safety and effectiveness of dabigatran over two years of follow-up, consistent with already available evidence. An increase in accessibility and incorporation of NOAC to anticoagulant treatment strategies could potentially have a positive impact on AF stroke prevention in Latin America.
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Affiliation(s)
- Sergio Dubner
- Clinica y Maternidad Suizo Argentino Buenos Aires, Argentina
| | | | | | - Gonzalo Barón-Esquivias
- Cardiology and Cardiac Surgery Department. Hospital Universitario Virgen del Rocío. Universidad de Sevilla Institution, Seville, Spain
| | - Christine Teutsch
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| | | | | | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, and Liverpool Heart and Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Paar V, Jirak P, Gruber S, Prodinger C, Cadamuro J, Wernly B, Motloch LJ, Haschke-Becher E, Hoppe UC, Lichtenauer M. Influence of dabigatran on pro-inflammatory cytokines, growth factors and chemokines - Slowing the vicious circle of coagulation and inflammation. Life Sci 2020; 262:118474. [PMID: 32961229 DOI: 10.1016/j.lfs.2020.118474] [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] [Received: 07/09/2020] [Revised: 09/08/2020] [Accepted: 09/16/2020] [Indexed: 12/14/2022]
Abstract
AIMS Blood coagulation is one of the most important host-defending mechanisms in vivo by maintaining the blood pressure after injury. However, besides maintaining homeostasis, blood coagulation and the contributing factors are directly linked to pathological conditions, such as thromboembolism and inflammation, leading to cardiovascular diseases, among others. As anti-inflammatory drugs may reduce cardiovascular events, we hypothesized in this study that the direct thrombin inhibitor dabigatran may reduce cytokine, growth factor and chemokine expression in vitro. MAIN METHODS Initially, human whole blood was incubated in tubes for serum, EDTA plasma, and heparinized plasma. Furthermore, human PBMCs were isolated and incubated under different culture conditions, including the treatment with human serum or thrombin, respectively. The effect of the oral anticoagulant dabigatran on pro-inflammatory cytokines, growth factors and chemokines was investigated by ELISA. KEY FINDINGS Conditioned serum resulted in a significant alteration of the secretome's protein levels after 24 h. However, solely ANG showed a dose-dependent increment by the addition of serum (79.8 ± 9.2 ng/mL) in comparison to baseline (0.2 ± 0.2 ng/mL), as it was in trend for thrombin treatment. Furthermore, the pre-treatment of PBMCs with different doses of dabigatran significantly lowered supernatant protein levels measured. Moreover, dabigatran was shown to decrease most notably the growth factor and chemokine levels in the PBMC's secretome that were treated with 200 ng/mL thrombin in a dose-dependent manner. SIGNIFICANCE In conclusion, novel oral anticoagulants, such as dabigatran, could help to reduce not only procoagulatory effects in inflammatory conditions but could also reduce proinflammatory stimuli via reduced expression of cytokines and chemokines.
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Affiliation(s)
- Vera Paar
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria.
| | - Peter Jirak
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Susanne Gruber
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Christine Prodinger
- Department of Dermatology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Janne Cadamuro
- Department of Laboratory Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Bernhard Wernly
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Lukas J Motloch
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | - Uta C Hoppe
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Michael Lichtenauer
- Department of Internal Medicine II, Division of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria.
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Zubiaur P, Saiz-Rodríguez M, Ochoa D, Navares-Gómez M, Mejía G, Román M, Koller D, Soria-Chacartegui P, Almenara S, Abad-Santos F. Effect of Sex, Use of Pantoprazole and Polymorphisms in SLC22A1, ABCB1, CES1, CYP3A5 and CYP2D6 on the Pharmacokinetics and Safety of Dabigatran. Adv Ther 2020; 37:3537-3550. [PMID: 32564268 DOI: 10.1007/s12325-020-01414-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Dabigatran is a direct oral anticoagulant (DOAC) used for the treatment of several thrombotic conditions. To date, very few pharmacogenetic studies on dabigatran were published. We aimed to investigate the influence of 59 polymorphisms in 15 genes (including CES1, UGT and CYP that encode enzymes and ABCB1 and SLC that encode transporters), concomitant treatment with pantoprazole and demographic characteristics (including sex or race) on dabigatran pharmacokinetics and safety. METHODS This was a candidate gene pharmacogenetic study. The study population comprised 107 volunteers enrolled in two dabigatran bioequivalence clinical trials; they were genotyped with a ThermoFisher QuantStudio 12K Flex OpenArray instrument. SPSS software v.21 was used for statistical analysis. RESULTS Women showed a higher exposure to dabigatran compared to men. The concomitant treatment with pantoprazole was associated with a decreased exposure to the drug. CYP2D6 poor metabolizers (PMs) were related to lower clearance (Cl/F) (p = 0.049) and a tendency was observed towards higher area under the curve (AUC), maximum concentration (Cmax) and to lower volume of distribution (Vd/F) (p < 0.10). SLC22A1 haplotype was related to pharmacokinetic variability (p < 0.05). The remaining genes (including CYP, UGT1A1 and ABCB1) had no effect on dabigatran pharmacokinetics (p > 0.10). Women showed more adverse drug reactions (ADR) compared to men (0.40 ± 0.68 vs 0.15 ± 0.41 ADR per person, p = 0.03) and SLC22A1 mutant haplotype was related to a lower risk of nausea (p = 0.02). CONCLUSION Sex, concomitant use of pantoprazole and SLC22A1, CYP2D6 and CYP3A5 polymorphism had an effect on dabigatran pharmacokinetics and safety. Previously published pharmacogenetic predictors, namely CES1 or ABCB1 polymorphisms, had no effect on pharmacokinetics and safety. This study is of interest as it increases the scarce pharmacogenetic information on dabigatran.
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13
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Guglielmo N, Orso D, Mestroni R, Montanari G. A Case of Liver Failure Due to Dabigatran Treated with Venovenous Hemodiafiltration and Idarucizumab. Curr Drug Saf 2020; 15:227-230. [PMID: 32576132 DOI: 10.2174/1574886315666200623162926] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/07/2020] [Accepted: 05/18/2020] [Indexed: 11/22/2022]
Abstract
Dabigatran etexilate, a direct thrombin inhibitor, was recently introduced in clinical use to prevent thromboembolic events in patients with risk factors (such as non-valvular atrial fibrillation or deep vein thrombosis). Dabigatran is not recommended in patients with creatinine clearance below 30 mL/min. More than 85% of the drug is eliminated by the renal route while the remaining part via the enteral route. Acute renal failure can result in an unexpected increase in serum levels of Dabigatran. In elderly, renal dysfunction, co-morbidity, and concomitant intake of different drugs could make the dosage of Dabigatran challenging. We present a case of an elderly man who suffered a severe accidental dabigatran intoxication with acute liver toxicity recovered after dialytic treatment and Idarucizumab.
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Affiliation(s)
- Nicola Guglielmo
- Department of Emergency Medicine, A.A.S. 2 "Bassa Friulana-Isontina", Ospedale di Latisana, Latisana (UD), Italy
| | - Daniele Orso
- Department of Medicine, University of Udine, Udine, Italy
| | - Rosalba Mestroni
- Department of Medicine, A.A.S. 2 "Bassa Friulana - Isontina", Ospedale di Palmanova, Palmanova (UD), Italy
| | - Giulia Montanari
- Department of Emergency Medicine, A.A.S. 2 "Bassa Friulana-Isontina", Ospedale di Latisana, Latisana (UD), Italy
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14
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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: 1] [Impact Index Per Article: 0.2] [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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15
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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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16
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Shi CC, Chen TR, Zhang QH, Wei LH, Huang C, Zhu YD, Liu HB, Bai YK, Wang FJ, Guo WZ, Zhang LR, Ge GB. Inhibition of human thrombin by the constituents of licorice: inhibition kinetics and mechanistic insights through in vitro and in silico studies. RSC Adv 2020; 10:3626-3635. [PMID: 35492646 PMCID: PMC9048847 DOI: 10.1039/c9ra09203j] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/13/2020] [Indexed: 12/30/2022] Open
Abstract
Thrombin inhibition therapy is a practical strategy to reduce thrombotic and cardiovascular risks via blocking the formation of blood clots. This study aimed to identify naturally occurring thrombin inhibitors from licorice (one of the most popular edible herbs), as well as to investigate their inhibitory mechanisms. Among all tested licorice constituents, licochalcone A was found as the most efficacious agent against human thrombin (IC50 = 7.96 μM). Inhibition kinetic analyses demonstrated that licochalcone A was a mixed inhibitor against thrombin-mediated Z-Gly-Gly-Arg-AMC acetate hydrolysis, with a Ki value of 12.23 μM. Furthermore, mass spectrometry-based chemoproteomic assays and molecular docking simulations revealed that licochalcone A could bind to human thrombin at both exosite I and the catalytic site. In summary, our findings demonstrated that the chalcones isolated from licorice were a new class of direct thrombin inhibitors, also suggesting that licochalcone A was a promising lead compound for developing novel anti-thrombotic agents. Licochalcone A, a bioactive compound from licorice, displayed strong inhibition of thrombin.![]()
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Sivaraja M, Pozzi N, Rienzo M, Lin K, Shiau TP, Clemens DM, Igoudin L, Zalicki P, Chang SS, Estiarte MA, Short KM, Williams DC, Datta A, Di Cera E, Kita DB. Reversible covalent direct thrombin inhibitors. PLoS One 2018; 13:e0201377. [PMID: 30071045 PMCID: PMC6072017 DOI: 10.1371/journal.pone.0201377] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/13/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In recent years, the traditional treatments for thrombotic diseases, heparin and warfarin, are increasingly being replaced by novel oral anticoagulants offering convenient dosing regimens, more predictable anticoagulant responses, and less frequent monitoring. However, these drugs can be contraindicated for some patients and, in particular, their bleeding liability remains high. METHODS We have developed a new class of direct thrombin inhibitors (VE-DTIs) and have utilized kinetics, biochemical, and X-ray structural studies to characterize the mechanism of action and in vitro pharmacology of an exemplary compound from this class, Compound 1. RESULTS We demonstrate that Compound 1, an exemplary VE-DTI, acts through reversible covalent inhibition. Compound 1 inhibits thrombin by transiently acylating the active site S195 with high potency and significant selectivity over other trypsin-like serine proteases. The compound inhibits the binding of a peptide substrate with both clot-bound and free thrombin with nanomolar potency. Compound 1 is a low micromolar inhibitor of thrombin activity against endogenous substrates such as fibrinogen and a nanomolar inhibitor of the activation of protein C and thrombin-activatable fibrinolysis inhibitor. In the thrombin generation assay, Compound 1 inhibits thrombin generation with low micromolar potency but does not increase the lag time for thrombin formation. In addition, Compound 1 showed weak inhibition of clotting in PT and aPTT assays consistent with its distinctive profile in the thrombin generation assay. CONCLUSION Compound 1, while maintaining strong potency comparable to the current DTIs, has a distinct mechanism of action which produces a differentiating pharmacological profile. Acting through reversible covalent inhibition, these direct thrombin inhibitors could lead to new anticoagulants with better combined efficacy and bleeding profiles.
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Affiliation(s)
- Mohanram Sivaraja
- Verseon Corporation, Fremont, California, United States of America
- * E-mail:
| | - Nicola Pozzi
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Matthew Rienzo
- Verseon Corporation, Fremont, California, United States of America
| | - Kenneth Lin
- Verseon Corporation, Fremont, California, United States of America
| | - Timothy P. Shiau
- Verseon Corporation, Fremont, California, United States of America
| | | | - Lev Igoudin
- Verseon Corporation, Fremont, California, United States of America
| | - Piotr Zalicki
- Verseon Corporation, Fremont, California, United States of America
| | | | | | - Kevin M. Short
- Verseon Corporation, Fremont, California, United States of America
| | | | - Anirban Datta
- Verseon Corporation, Fremont, California, United States of America
| | - Enrico Di Cera
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - David B. Kita
- Verseon Corporation, Fremont, California, United States of America
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18
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Sucker C, Hager A, Koscielny J, Feltgen N. [Oral anticoagulation : Current overview and perioperative management in ophthalmic surgery]. Ophthalmologe 2018; 116:144-151. [PMID: 29766263 DOI: 10.1007/s00347-018-0724-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Antithrombotic treatment with oral anticoagulants and antiplatelet agents can increase the risk for perioperative bleeding. In contrast to other surgical fields, the optimal perioperative management in ophthalmic surgery has not yet been exactly defined and, thus, is not standardized. In this contribution, we provide an overview of currently available oral anticoagulants and discuss potential strategies for the management of these agents in different ophthalmic surgical procedures.
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Affiliation(s)
- C Sucker
- Gerinnungszentrum Berlin Dr. Sucker, Tauentzienstraße 7b/c, 10789, Berlin, Deutschland.
| | - A Hager
- Gerinnungsambulanz, Charité, Berlin, Deutschland
| | - J Koscielny
- Augenarztpraxis am Elsterplatz, Kissinger Straße 1, 14199, Berlin, Deutschland
| | - N Feltgen
- Augenklinik, Universitätsmedizin Göttingen, Göttingen, Deutschland
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