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Frol S, Oblak JP, Šabovič M, Kermer P. Andexanet Alfa to Reverse the Effect of Factor Xa Inhibitors in Intracranial Hemorrhage. CNS Drugs 2023; 37:477-487. [PMID: 37133623 DOI: 10.1007/s40263-023-01006-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/04/2023]
Abstract
Andexanet alfa (AA) is a recombinant factor Xa competing for binding with factor Xa inhibitors, thereby reversing their anticoagulation effects. Since 2019, it has been approved for individuals under apixaban or rivaroxaban therapy suffering from life-threatening or uncontrolled bleeding. Apart from the pivotal trial, real-world data on the use of AA in daily clinics are scarce. We reviewed the current literature on patients with intracranial hemorrhage (ICH) and summarized the available evidence regarding several outcome parameters. On the basis of this evidence, we provide a standard operating procedure (SOP) for routine AA application. We searched PubMed and additional databases through 18 January 2023 for case reports, case series, studies, reviews, and guidelines. Data on hemostatic efficacy, in-hospital mortality, and thrombotic events were pooled and compared with the pivotal trial data. While hemostatic efficacy in world-wide clinical routine seems to be comparable to the pivotal trial, thrombotic events and in-hospital mortality appear to be substantially higher. Various confounding factors responsible for this finding such as exclusion and inclusion criteria resulting in a highly selected patient cohort within the controlled clinical trial have to be considered. The SOP provided should support physicians in patient selection for AA treatment as well as facilitate routine use and dosing. This review underlines the urgent need for more data from randomized trials to appreciate the benefit and safety profile of AA. Meanwhile, this SOP should help to improve frequency and quality of AA use in patients suffering from ICH while on apixaban or rivaroxaban treatment.
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Affiliation(s)
- Senta Frol
- Department of Vascular Neurology, University Medical Center Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia.
- Faculty of Medicine, University of Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia.
| | - Janja Pretnar Oblak
- Department of Vascular Neurology, University Medical Center Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Mišo Šabovič
- Department of Vascular Disorders, University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Zaloška 2, 1000, Ljubljana, Slovenia
| | - Pawel Kermer
- Department of Neurology, Nordwest-Krankenhaus Sanderbusch, Friesland Kliniken GmbH, Sande, Germany
- University Medical Center, Göttingen, Germany
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Liu YB, Zhang L, Zhou XC, Zhou Y, Liu Y, Zheng C, Xu X, Geng PP, Hao CH, Zhao ZY, Wu CT, Jin JD. The Antithrombotic Effect of Recombinant Neorudin on Thrombi. Drug Des Devel Ther 2022; 16:1667-1678. [PMID: 35677424 PMCID: PMC9169676 DOI: 10.2147/dddt.s353088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Methods Results Conclusion
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Affiliation(s)
- Yu-Bin Liu
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
| | - Lin Zhang
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
| | - Xing-Chen Zhou
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
| | - Ying Zhou
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
| | - Yun Liu
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
| | - Can Zheng
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
| | - Xiao Xu
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
| | - Pan-Pan Geng
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
| | - Chun-Hua Hao
- Center for Pharmacodynamic Research, Tianjin Institute of Pharmaceutical Research, Tianjin, 300462, People’s Republic of China
| | - Zhuan-You Zhao
- Center for Pharmacodynamic Research, Tianjin Institute of Pharmaceutical Research, Tianjin, 300462, People’s Republic of China
| | - Chu-Tse Wu
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
- Correspondence: Chu-Tse Wu; Ji-De Jin, Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, No. 27 Taiping Road, Beijing, People’s Republic of China, Tel +86 1086-68158312; +86 1086-66931425, Email ;
| | - Ji-De Jin
- Department of Experimental Hematology and Biochemistry, Beijing Institute of Radiation Medicine, Beijing, 100850, People’s Republic of China
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Management of Left Ventricular Thrombi with Direct Oral Anticoagulants: Retrospective Comparative Study with Vitamin K Antagonists. Clin Drug Investig 2020; 40:343-353. [DOI: 10.1007/s40261-020-00898-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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4
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Affiliation(s)
- Andrea Cervi
- Department of Medicine Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Mark Crowther
- Department of Pathology and Molecular Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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5
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Qiu X, Zhou J, Wang W, Zhao Z, Tang L, Sun S. Effect of a new inhibitor of factor Xa zifaxaban, on thrombosis in the inferior vena cava in rabbits. J Thromb Thrombolysis 2018; 47:80-86. [PMID: 30298304 DOI: 10.1007/s11239-018-1743-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
In recent years, oral factor Xa inhibitors have become a research focus as anticoagulant drugs. Zifaxaban is the first oral FXa inhibitor to enter clinical trials in China. The aim of this study was to determine the inhibitory effect of zifaxaban on thrombosisthrough a model ofinferior vena cava (IVC) thrombosis in rabbits. IVC thrombosis model was established by electrical injury and stenosis, and zifaxaban was administered (p.o.) for 5 consecutive days, then coagulation indicators and bleeding were observed. The results showed that zifaxaban had obvious inhibitory effects on FXa, and had a significant inhibitory effect on IVC thrombosis induced by electrical damage and stenosis. The effect of zifaxaban was similar to that of rivaroxaban, but the bleeding side-effects of zifaxaban were less severe than those of rivaroxaban. Zifaxaban could prolong the prothrombin time and activated partial thromboplastin time of plasma similar to that of other oral FXa inhibitors. Zifaxaban had a significant inhibitory effect on FXa, but it had no obvious effect on other coagulation factors, major anticoagulant factors or fibrinolytic indices. Our results suggest that zifaxaban had specific inhibitory effects on FXa and inhibited IVC thrombosis in rabbits with its hemorrhagic effect was less than that of rivaroxaban. Zifaxaban is ecpected to be developed as a new drug for the prevention of deep venous thrombosis, providing more medication options for patients with such disease, more research is required to support it in the future.
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Affiliation(s)
- Xiaomiao Qiu
- Tianjin Medical University School, Tianjin, 300070, People's Republic of China
| | - Junjun Zhou
- Department of Pharmacology, Dalian Medical University, Dalian, 116044, Liaoning, People's Republic of China
| | - Weiting Wang
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co.Ltd, 308, Huiren Street, Binhai New Area, Tianjin, 300301, People's Republic of China
| | - Zhuanyou Zhao
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co.Ltd, 308, Huiren Street, Binhai New Area, Tianjin, 300301, People's Republic of China
| | - Lida Tang
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co.Ltd, 308, Huiren Street, Binhai New Area, Tianjin, 300301, People's Republic of China
| | - Shuangyong Sun
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co.Ltd, 308, Huiren Street, Binhai New Area, Tianjin, 300301, People's Republic of China.
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Qiu X, Wang W, Zhao Z, Sun S, Tang L. Pre-clinical pharmacodynamic study of a novel oral factor Xa inhibitor zifaxaban. Eur J Pharmacol 2018; 836:50-56. [PMID: 30125563 DOI: 10.1016/j.ejphar.2018.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 08/13/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022]
Abstract
Zifaxaban is an orally active, direct Factor Xa (FXa) inhibitor that is in development for the prevention and treatment of arterial and venous thrombosis. This study was conducted to investigate the biochemical and pharmacological activity of zifaxaban. In vitro activity was evaluated by enzyme, platelet aggregation, and clotting assays. In vivo effects were examined in venous thrombosis, arteriovenous-shunt thrombosis, carotid thrombosis, and bleeding models in rats. Zifaxaban competitively inhibits human FXa (IC50 = 11.1 nM) with > 10,000-fold greater selectivity than other serine proteases. It did not impair platelet aggregation induced by collagen, adenosine diphosphate (ADP) or arachidonic acid. It significantly prolonged clotting time, prothrombin time (PT), and activated partial thromboplastin time (APTT) in the plasma of humans, rabbits, and rats, with a relatively weak effect on thrombin time (TT). In venous thrombosis models in rats, zifaxaban strongly suppressed thrombus formation with ED50 values of 3.09 mg/kg, and its best efficacy time occurred at 2 h after administration. In arteriovenous-shunt thrombosis and carotid thrombosis models in rats, it inhibited thrombus formation in a dose-dependent manner. And in the rat tail bleeding assay, it showed a trend of less bleeding than rivaroxaban at doses that achieved the same antithrombotic effect. In conclusion, zifaxaban is a selective and direct FXa inhibitor and a promising oral anticoagulant for the prophylaxis and treatment of thromboembolic diseases.
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Affiliation(s)
- Xiaomiao Qiu
- Tianjin Medical University, Tianjin 300070, China
| | - Weiting Wang
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co. Ltd, Tianjin 300193, China
| | - Zhuanyou Zhao
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co. Ltd, Tianjin 300193, China
| | - Shuangyong Sun
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co. Ltd, Tianjin 300193, China.
| | - Lida Tang
- Tianjin Institute of Pharmaceutical Research New Drug Evaluation Co. Ltd, Tianjin 300193, China.
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Andexanet alfa in the treatment of acute major bleeding related to apixaban and rivaroxaban: a profile of its use in the USA. DRUGS & THERAPY PERSPECTIVES 2018; 34:507-512. [PMID: 30459509 PMCID: PMC6223707 DOI: 10.1007/s40267-018-0561-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Andexanet alfa (Andexxa®), a first-in-class recombinant modified factor Xa protein, is currently the only specific agent available to reverse life-threatening or uncontrolled bleeding with the factor Xa inhibitors apixaban and rivaroxaban. Andexanet alfa acts as a decoy and competes with endogenous factor Xa to bind factor Xa inhibitors, thereby reversing the anticoagulant effects of factor Xa inhibitors, and restoring the activity of endogenous factor Xa. In adults with major bleeding associated with the use of apixaban or rivaroxaban, intravenous administration of andexanet alfa effectively and rapidly reduces anti-factor Xa levels, with reduced levels being maintained during continued treatment. The tolerability profile of andexanet alfa in patients is generally similar to that reported of other approved anticoagulation reversal agents. With the known increased risk of thromboembolic events following andexanet alfa treatment, anticoagulant therapy should be resumed as soon as medically appropriate.
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8
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Kaatz S, Bhansali H, Gibbs J, Lavender R, Mahan CE, Paje DG. Reversing factor Xa inhibitors - clinical utility of andexanet alfa. J Blood Med 2017; 8:141-149. [PMID: 28979172 PMCID: PMC5602457 DOI: 10.2147/jbm.s121550] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Approximately half of patients started on an oral anticoagulant in the USA now receive one of the newer direct oral anticoagulants (DOACs). Although there is an approved reversal agent for the direct thrombin inhibitor dabigatran, a specific reversal agent for the anti-factor Xa (FXa) DOACs has yet to be licensed. Unlike the strategy to reverse the only oral direct thrombin inhibitor with idarucizumab, which is a humanized monoclonal antibody fragment, a different approach is necessary to design a single agent that can reverse multiple anti-FXa medications. Andexanet alfa is a FXa decoy designed to reverse all anticoagulants that act through this part of the coagulation cascade including anti-FXa DOACs, such as apixaban, edoxaban and rivaroxaban, and indirect FXa inhibitors such as low-molecular-weight heparins. This narrative reviews the development of andexanet alfa and explores its basic science, pharmacokinetics/pharmacodynamics, animal models, and human studies.
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Affiliation(s)
| | | | - Joseph Gibbs
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Robert Lavender
- Division of General Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Charles E Mahan
- University of New Mexico, Presbyterian Healthcare Services, Albuquerque, NM
| | - David G Paje
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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