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Lwin TN, Mudannayake R, MacDonald S, Arrowsmith JE, Burt C, Besser M, Falter F. Assessing the impact of different heparin dosing regimens for cardiopulmonary bypass on anticoagulation: the HepDOSE pilot study. Can J Anaesth 2024; 71:234-243. [PMID: 37985627 DOI: 10.1007/s12630-023-02645-6] [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: 02/02/2023] [Revised: 07/11/2023] [Accepted: 07/23/2023] [Indexed: 11/22/2023] Open
Abstract
PURPOSE It has been suggested that a larger heparin dose during cardiopulmonary bypass (CPB) is associated with reduced perioperative coagulopathy and thromboembolic complications. We investigated the effect of different heparin doses during routine elective cardiac surgery. Our primary outcomes include blood loss and transfusion and secondary outcomes investigate the effects on coagulation biomarkers. METHODS In this prospective pilot trial, we allocated 60 patients undergoing cardiac surgery on CPB in a single tertiary cardiac centre into three groups to receive an initial dose of 300, 400, or 500 units (U) per kilogram of intravenous heparin prior to the commencement of CPB. Blood was sampled after induction of anesthesia, at 30 and 60 min of CPB, and three minutes after heparin reversal with protamine. Samples were analyzed for fibrinopeptide A (FPA), fibrinopeptide B (FPB), D-dimer, and thrombin-antithrombin (TAT) complexes. Postoperative blood loss and transfusion was measured for the first 24-hr period after surgery. RESULTS The total mean (95% CI) administered heparin dose in the 300 U·kg-1, 400 U·kg-1, and 500 U·kg-1 groups were 39,975 (36,528 to 43,421) U, 43,195 (36,940 to 49,449) U and 47,900 (44,807 to 50,992) U, respectively. There were no statistically significant differences in FPA, FPB or D-dimer levels at the measured time intervals. There was a trend towards lower TAT levels while on CPB with greater heparin dosing, which was statistically significant after the administration of protamine. The clinical significance appears to be negligible, as there is no difference in overall blood loss and amount of packed red blood cell transfusion or other blood product transfusion. CONCLUSION This pilot study indicates that, while larger heparin dosing for routine cardiac surgery results in subtle biochemical changes in coagulation, there is no demonstrable benefit in postoperative blood loss or transfusion requirements.
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Affiliation(s)
- Thar Nyan Lwin
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Rahul Mudannayake
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Stephen MacDonald
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joseph E Arrowsmith
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Christiana Burt
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Martin Besser
- Division of Clinical Haematology and Blood Transfusion, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Florian Falter
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK.
- Department of Anaesthetics and Critical Care, The Royal Papworth Hospital NHS Foundation Trust, Papworth Road, Cambridge Biomedical Campus, Cambridge, CB2 0AY, UK.
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Gibert A, Lanoiselée J, Gouin-Thibault I, Pontis A, Azarnoush K, Petrosyan A, Grand N, Molliex S, Morel J, Gergelé L, Hodin S, Bin V, Chaux R, Delavenne X, Ollier E. Factors Influencing Unfractionated Heparin Pharmacokinetics and Pharmacodynamics During a Cardiopulmonary Bypass. Clin Pharmacokinet 2024; 63:211-225. [PMID: 38169065 DOI: 10.1007/s40262-023-01334-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Unfractionated heparin (UFH) is commonly used during cardiac surgery with a cardiopulmonary bypass to prevent blood clotting. However, empirical administration of UFH leads to variable responses. Pharmacokinetic and pharmacodynamic modeling can be used to optimize UFH dosing and perform real-time individualization. In previous studies, many factors that could influence UFH pharmacokinetics/pharmacodynamics had not been taken into account such as hemodilution or the type of UFH. Few covariates were identified probably owing to a lack of statistical power. This study aims to address these limitations through a meta-analysis of individual data from two studies. METHODS An individual patient data meta-analysis was conducted using data from two single-center prospective observational studies, where different UFH types were used for anticoagulation. A pharmacodynamic/pharmacodynamic model of UFH was developed using a non-linear mixed-effects approach. Time-varying covariates such as hemodilution and fluid infusions during a cardiopulmonary bypass were considered. RESULTS Activities of UFH's anti-activated factor/anti-thrombin were best described by a two-compartment model. Unfractionated heparin clearance was influenced by body weight and the specific UFH type. Volume of distribution was influenced by body weight and pre-operative fibrinogen levels. Pharmacodynamic data followed a log-linear model, accounting for the effect of hemodilution and the pre-operative fibrinogen level. Equations were derived from the model to personalize UFH dosing based on the targeted activated clotting time level and patient covariates. CONCLUSIONS The population model effectively characterized UFH's pharmacokinetics/pharmacodynamics in cardiopulmonary bypass patients. This meta-analysis incorporated new covariates related to UFH's pharmacokinetics/pharmacodynamics, enabling personalized dosing regimens. The proposed model holds potential for individualization using a Bayesian estimation.
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Affiliation(s)
- Audrick Gibert
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France.
| | - Julien Lanoiselée
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Isabelle Gouin-Thibault
- Laboratory of Hematology, Pontchaillou, University Hospital of Rennes, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Adeline Pontis
- Laboratory of Hematology, Pontchaillou, University Hospital of Rennes, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Kasra Azarnoush
- Service de Chirurgie Cardiaque, CHU de Saint-Etienne, Saint-Etienne, France
| | - Andranik Petrosyan
- Service de Chirurgie Cardiaque, CHU de Saint-Etienne, Saint-Etienne, France
| | - Nathalie Grand
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Serge Molliex
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Jérome Morel
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Laurent Gergelé
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Sophie Hodin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
| | - Valérie Bin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
| | - Robin Chaux
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - Xavier Delavenne
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Laboratoire de Pharmacologie Toxicologie Gaz du sang, CHU de Saint-Etienne, Saint-Etienne, France
| | - Edouard Ollier
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, Saint-Etienne, France
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3
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Piwowarczyk P, Szczukocka M, Cios W, Okuńska P, Raszewski G, Borys M, Wiczling P, Czuczwar M. Population Pharmacokinetics and Probability of Target Attainment Analysis of Nadroparin in Different Stages of COVID-19. Clin Pharmacokinet 2023; 62:835-847. [PMID: 37097604 PMCID: PMC10126531 DOI: 10.1007/s40262-023-01244-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND AND OBJECTIVE The risk of thrombotic complications in critical patients with COVID-19 remains extremely high, and multicenter trials failed to prove a survival benefit of escalated doses of low-molecular-weight heparins (nadroparin calcium) in this group. The aim of this study was to develop a pharmacokinetic model of nadroparin according to different stages of COVID-19 severity. METHODS Blood samples were obtained from 43 patients with COVID-19 who received nadroparin and were treated with conventional oxygen therapy, mechanical ventilation, and extracorporeal membrane oxygenation. We recorded clinical, biochemical, and hemodynamic variables during 72 h of treatment. The analyzed data comprised 782 serum nadroparin concentrations and 219 anti-Xa levels. We conducted population nonlinear mixed-effects modeling (NONMEM) and performed Monte Carlo simulations of the probability of target attainment for reaching 0.2-0.5 IU/mL anti-Xa levels in study groups. RESULTS We successfully developed a one-compartment model to describe the population pharmacokinetics of nadroparin in different stages of COVID-19. The absorption rate constant of nadroparin was 3.8 and 3.2 times lower, concentration clearance was 2.22 and 2.93 times higher, and anti-Xa clearance was 0.87 and 1.1 times higher in mechanically ventilated patients and the extracorporeal membrane oxygenation group compared with patients treated with conventional oxygen, respectively. The newly developed model indicated that 5.900 IU of nadroparin given subcutaneously twice daily in the mechanically ventilated patients led to a similar probability of target attainment of 90% as 5.900 IU of subcutaneous nadroparin given once daily in the group supplemented with conventional oxygen. CONCLUSIONS Different nadroparin dosing is required for patients undergoing mechanical ventilation and extracorporeal membrane oxygenation to achieve the same targets as those for non-critically ill patients. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier no. NCT05621915.
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Affiliation(s)
- Paweł Piwowarczyk
- II Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Marta Szczukocka
- II Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Wojciech Cios
- Department of Infectious Diseases, Medical University of Lublin, Lublin, Poland
| | - Paulina Okuńska
- Department of Biopharmaceutics and Pharmacodynamics, Medical University of Gdańsk, Al. Gen. Hallera 107, 80-416 Gdańsk, Poland
| | - Grzegorz Raszewski
- Department of Physiopathology, Institute of Rural Health, Lublin, Poland
| | - Michał Borys
- II Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
| | - Paweł Wiczling
- Department of Biopharmaceutics and Pharmacodynamics, Medical University of Gdańsk, Al. Gen. Hallera 107, 80-416 Gdańsk, Poland
| | - Mirosław Czuczwar
- II Department of Anesthesiology and Intensive Care, Medical University of Lublin, Lublin, Poland
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Song Y, Kouta A, Cera LM, Xia K, Zhang F, Kraemer R, Fareed J, Linhardt RJ, Jeske W. Absolute pharmacokinetics of heparin in primates. Carbohydr Polym 2023; 311:120779. [PMID: 37028882 DOI: 10.1016/j.carbpol.2023.120779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Heparin is a commonly used anticoagulant drug, derived from the tissues of animals including pigs, cows, and sheep. Measuring heparin concentration in plasma is challenging due to its complex molecular structure. Existing methods rely on measuring heparin's anticoagulant activity, which provides pharmacodynamic (PD) data but not pharmacokinetic (PK) data, measuring concentration over time. To overcome this limitation, we used liquid chromatography-mass spectrometry (LC-MS) and the multiple reaction monitoring (MRM) method to directly measure heparin's concentration in non-human primates after administering porcine, bovine, and ovine heparin. A protocol was developed to enable an MRM method for application to small plasma volumes without purification. The PK data obtained from LC-MS are then compared with the data obtained using the Heparin Red assay and the PD data determined using biochemical clinical assays. Results showed that LC-MS and Heparin Red assay measurements closely correlated with unfractionated heparin's biological activities, supporting the use of mass spectra and dye-binding assays to determine heparin levels in plasma. This study builds a way for the measurement of heparin concentration in plasma, which could lead to an improved understanding of heparin's metabolism and dosing safety.
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Affiliation(s)
- Yuefan Song
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Ahmed Kouta
- Cardiovascular Institute, Loyola University Chicago, Maywood, IL 60153, USA
| | - Lee M Cera
- Comparative Medicine Facility, Loyola University Chicago, Maywood, IL 60153, USA
| | - Ke Xia
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Fuming Zhang
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY 12180, USA
| | - Roland Kraemer
- Inorganic Chemistry Institute, Heidelberg University, Im Neuenheimer Feld 270, 69120 Heidelberg, Germany
| | - Jawed Fareed
- Cardiovascular Institute, Loyola University Chicago, Maywood, IL 60153, USA
| | - Robert J Linhardt
- Center for Biotechnology and Interdisciplinary Studies, Rensselaer Polytechnic Institute, Troy, NY 12180, USA.
| | - Walter Jeske
- Cardiovascular Institute, Loyola University Chicago, Maywood, IL 60153, USA.
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Katz D, Leffert L, Getrajdman C, Sison M, Shin DW, Lin HM, Butwick A. The relationship between INTEM/HEPTEM coagulation time ratio and heparin plasma concentration in obstetric patients: an exploratory in vitro investigation. Can J Anaesth 2022; 69:597-604. [PMID: 35102496 DOI: 10.1007/s12630-022-02193-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Unfractionated heparin continues to be one of the main agents used for thromboprophylaxis in obstetrics, which can complicate the placement of neuraxial anesthetics. In this study, we explored the relationship between a point-of-care coagulation test (thromboelastometry) and plasma heparin concentrations in vitro. METHODS We obtained blood from consenting obstetric patients with uncomplicated pregnancies in their third trimester who were not in labour and had a specific hematocrit range. Blood was processed and analyzed. We added increasing amounts of unfractionated heparin to samples from 0 to 0.3 U·mL-1 in 0.05 U·mL-1 increments to simulate increasing doses of unfractionated heparin. We performed INTEM and HEPTEM testing in parallel with activated partial thromboplastin time (aPTT) testing. We created a model of the relationship between heparin concentration and the INTEM/HEPTEM coagulation time (IH CT) ratio using nonlinear regression. A similar model for aPTT was also created. RESULTS Seventy-seven patients were included in the study. Only one concentration of heparin was added to blood samples of each patient. At a concentration of 0.05 U·mL-1, the IH CT ratio was less than or equal to 1.1 in 9/11 (82%) samples. Activated partial thromboplastin time was not prolonged (> 35 sec) until a concentration of 0.1 U·mL-1 heparin was added. In all samples, the IH CT ratio was prolonged at a concentration ≥ 0.2 U·mL-1 as measured by thromboelastometry; however, at no concentration of heparin was aPTT prolonged in all samples. CONCLUSION The point-of-care IH CT ratio may be useful in identifying the presence of little to no heparin activity. Further research is needed to determine if this ratio can predict heparin activity in vivo.
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Affiliation(s)
- Daniel Katz
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Lisa Leffert
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Chloe Getrajdman
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA.
| | - Matthew Sison
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Da Wi Shin
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Hung-Mo Lin
- Department of Anesthesiology, Pain, & Perioperative Medicine, Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, New York, NY, 10029, USA
| | - Alex Butwick
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
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Chaux R, Lanoiselée J, Magand C, Zufferey P, Delavenne X, Ollier E. Robust K-PD model for activated clotting time prediction and UFH dose individualisation during cardiopulmonary bypass. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 214:106553. [PMID: 34883383 DOI: 10.1016/j.cmpb.2021.106553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/17/2021] [Accepted: 11/24/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND OBJECTIVE Activated clotting time (ACT) is a point-of-care test used to monitor the effect of unfractionated heparin (UFH) during cardiopulmonary bypass (CPB). This test sometimes returns aberrant values, which can lead to the administration of an inappropriate dosing regimen. The development of a population-robust K-PD model of UFH could allow the individualisation and automation of UFH therapy during CPB. METHODS We conducted a prospective observational study to collect ACT measurements from patients undergoing surgery using CPB. The ACT data were split into a development and validation cohort. The development cohort was used to estimate a standard and robust population K-PD model characterised by a residual error following a normal distribution and student's t-distribution. The ACT prediction performance using Bayesian estimates of individual K-PD parameters was evaluated by comparing predicted versus observed ACTs. Using estimates of the robust K-PD model, a Bayesian individualisation strategy to automate UFH administration was proposed and evaluated using Monte Carlo simulations. RESULTS A total of 295 patients were included in the study, and 1561 ACTs were collected. In patients without outlier values, Bayesian estimates (based on four ACT measurements) from both standard and robust K-PD models had similar performances, with a median prediction bias close to 0 s. In patients with outlier measurements, the use of the robust K-PD model greatly improved the prediction bias and root-mean-square error (RMSE), with a mean prediction bias of 3.25 s, IQR = [-19.9; 46.03] versus -86 s IQR = [-135.7; -63.8] for the standard model. Monte Carlo simulations showed that the robust Bayesian individualisation strategy allowed the ACT to be maintained above the target using only two to three ACT measurements. CONCLUSIONS The use of a robust K-PD model reduced prediction bias and RMSE in patients with outlier ACT measurements. The Bayesian individualisation strategy using robust estimates of individual parameters may help automate UFH dosing regimens. Proper clinical validation is warranted before its use in daily clinical practice.
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Affiliation(s)
- Robin Chaux
- U1059, Dysfonction Vasculaire et Hémostase, INSERM, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, CHU de Saint-Etienne, Saint-Etienne Cedex 2, Saint-Etienne F-42055, France
| | - Julien Lanoiselée
- U1059, Dysfonction Vasculaire et Hémostase, INSERM, Saint-Etienne, France; Département d'Anesthésie-Réanimation, Hôpital Nord, CHU de Saint-Etienne, Saint-Etienne F-42055, France
| | - Clément Magand
- Département d'Anesthésie-Réanimation, Hôpital Nord, CHU de Saint-Etienne, Saint-Etienne F-42055, France
| | - Paul Zufferey
- U1059, Dysfonction Vasculaire et Hémostase, INSERM, Saint-Etienne, France; Département d'Anesthésie-Réanimation, Hôpital Nord, CHU de Saint-Etienne, Saint-Etienne F-42055, France
| | - Xavier Delavenne
- U1059, Dysfonction Vasculaire et Hémostase, INSERM, Saint-Etienne, France
| | - Edouard Ollier
- U1059, Dysfonction Vasculaire et Hémostase, INSERM, Saint-Etienne, France; Unité de Recherche Clinique, Innovation, Pharmacologie, Hôpital Nord, CHU de Saint-Etienne, Saint-Etienne Cedex 2, Saint-Etienne F-42055, France.
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Salem AM, Niu T, Li C, Moffett BS, Ivaturi V, Gopalakrishnan M. Reassessing the Pediatric Dosing Recommendations for Unfractionated Heparin Using Real-World Data: a Pharmacokinetic-Pharmacodynamic Modeling Approach. J Clin Pharmacol 2021; 62:733-746. [PMID: 34816442 DOI: 10.1002/jcph.2007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/19/2021] [Indexed: 11/07/2022]
Abstract
Optimal pediatric dosing of unfractionated heparin (UFH) is challenging due to paucity of clinical outcome and pharmacokinetic-pharmacodynamic (PK/PD) studies in pediatrics. This study aimed to: (i) develop a PK/PD model for UFH, quantified by anti-factor Xa assay and the UFH effect measured by activated partial thromboplastin time (aPTT) (ii) evaluate pediatric UFH infusions in achieving anti-factor Xa (0.3 - 0.7 IU/mL) therapeutic target by simulations. Electronic health record data were retrospectively collected from 633 patients < 19 years old admitted to Texas Children's Hospital. The PK/PD model was developed using a 70% (training)-30% (test) data split approach. A one-compartment PK model with linear elimination adequately described the UFH PK. An allometrically scaled body weight on clearance (CL) and volume of distribution (Vd) with an age-dependent maturation function of extracellular water on Vd were the covariates identified. Comparable with literature, the typical values for CL and Vd were 3.28 L/(hr·50 kg) and 8.83 L/50 kg, respectively. A linear model adequately described the UFH-aPTT relationship with an estimated slope of 150. Simulations of the currently recommended starting infusions (28 IU/hr/kg for pediatrics < 1 year old or 20 IU/hr/kg for pediatrics > 1 year old) showed that anti-factor Xa therapeutic target was achieved only in 15.3%, 14.6%, 36.9% and 45.11% of subjects in the age groups of < 1 year, 1-6 years, 6-12 years, and 12-19 years, respectively. In conclusion, the UFH anti-factor Xa target is not achieved initially especially in young pediatrics, suggesting the need to optimize UFH dosing to achieve higher therapeutic success. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Tao Niu
- Modeling & Simulations, Vertex Pharmaceuticals, Boston, MA, USA
| | - Chao Li
- Fosun Pharma, Princeton, NJ, USA
| | - Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Vijay Ivaturi
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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8
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Li T, Meng Z, Zhu X, Gan H, Gu R, Wu Z, Liu T, Han P, Gao J, Han S, Dou G. In vitro and in vivo safety studies indicate that R15, a synthetic polyarginine peptide, could safely reverse the effects of unfractionated heparin. FEBS Open Bio 2021; 11:2468-2489. [PMID: 34184429 PMCID: PMC8409304 DOI: 10.1002/2211-5463.13240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 06/03/2021] [Accepted: 06/28/2021] [Indexed: 11/09/2022] Open
Abstract
Unfractionated heparin (UFH) is an anionic glycosaminoglycan that is widely used to prevent blood clotting. However, in certain cases, unwanted side effects can require it to be neutralized. Protamine sulfate (PS), a basic peptide rich in arginine, is the only approved antagonist for UFH neutralization. Many adverse reactions occur with the clinical application of PS, including systemic hypotension, pulmonary hypertension, and anaphylaxis. We previously described R15, a linear peptide composed of 15 arginine molecules, as a potential UFH antagonist. In this study, the in-depth safety of R15 was explored to reveal its merits and associated risks in comparison with PS. In vitro safety studies investigated the interactions of R15 with erythrocytes, fibrin, complement, and rat plasma. In vivo safety studies explored potential toxicity and immunogenicity of R15 and the UFH-R15 complex. Results showed that both PS and R15 can induce erythrocyte aggregation, thicken fibrin fibers, activate complement, and cause anticoagulation in a concentration-dependent manner. However, those influences weakened in whole blood or in live animals and were avoided when R15 was in a complex with UFH. We found dramatically enhanced complement activation when there was excess UFH in analyses involving UFH-PS complexes, and a slight increase in those involving UFH-R15 complexes. Within 2 h, R15 was degraded in rat plasma in vitro, whereas PS was not. Enhanced creatinine was found after a single intravenous injection of PS or R15 (900 U·kg-1 , body weight), suggesting possible abnormal renal function. The UFH-PS complex, but not the UFH-R15 complex, exhibited obvious immunogenicity. In conclusion, R15 is nonimmunogenic and potentially safe at a therapeutic dose to reverse the effects of UFH.
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Affiliation(s)
- Tong Li
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Zhiyun Meng
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Xiaoxia Zhu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Hui Gan
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Ruolan Gu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Zhuona Wu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Taoyun Liu
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Peng Han
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Jiarui Gao
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Su Han
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
| | - Guifang Dou
- Department of Pharmaceutical Sciences, Beijing Institute of Radiation Medicine, China
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9
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Solís Clavijo D, Cotano AO, Peña NA, Caballero Gálvez S, Arellano Núñez F, Carballo Caro JM, Muñoz-Cacho P, Tocón Alé C. Variability of three activated clotting time point-of-care systems in cardiac surgery: reinforcing available evidence. Perfusion 2021; 37:711-714. [PMID: 34109886 DOI: 10.1177/02676591211023687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cardiac surgery with extracorporeal circulation (ECC) requires the administration of anticoagulant drugs to maintain ACT ranges 400-600 seconds, which requires exhaustive coagulation monitoring for which various point-of-care devices are available. However, there is variability between them, so we aimed to compare the values in ACT measurement. METHODS Simultaneous ACT measurements were performed with the Hemochron Response®, Hemostasis Management System Plus® (HMS Plus®) and Hemochron Signature® systems. RESULTS A total of 255 simultaneous measurements were taken, the mean and standard deviation (SD) of each device were: Hemochron Signature® 361.1 seconds (SD: 156.9), HMS Plus® 412.8 seconds (SD: 180.9) and Hemochron Response® 422.8 seconds (SD: 187.9), being these differences statistically significant (Fridman's test p < 0.01). For comparisons the Bland-Altman method was used, resulting the Hemochron Response® has 61.7 seconds higher mean values than the Hemochron Signature®, the Hemochron Response® 10 seconds higher than the HMS Plus® and the HMS Plus® 51.7 seconds higher than the Hemochron Signature®. CONCLUSION The differences found in comparisons are considered to be clinically relevant, which is why it is considered important to make the variability of the different monitoring systems known and to take them into account for optimal control of this parameter and its clinical repercussions.
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Affiliation(s)
| | | | - Nuria Alonso Peña
- Cardiovascular Surgery Area, Marqués de Valdecilla University Hospital, Santander, Cantabria, Spain
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10
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Miles LF, Burt C, Arrowsmith J, McKie MA, Villar SS, Govender P, Shaylor R, Tan Z, De Silva R, Falter F. Optimal protamine dosing after cardiopulmonary bypass: The PRODOSE adaptive randomised controlled trial. PLoS Med 2021; 18:e1003658. [PMID: 34097705 PMCID: PMC8216535 DOI: 10.1371/journal.pmed.1003658] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 06/21/2021] [Accepted: 05/14/2021] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The dose of protamine required following cardiopulmonary bypass (CPB) is often determined by the dose of heparin required pre-CPB, expressed as a fixed ratio. Dosing based on mathematical models of heparin clearance is postulated to improve protamine dosing precision and coagulation. We hypothesised that protamine dosing based on a 2-compartment model would improve thromboelastography (TEG) parameters and reduce the dose of protamine administered, relative to a fixed ratio. METHODS AND FINDINGS We undertook a 2-stage, adaptive randomised controlled trial, allocating 228 participants to receive protamine dosed according to a mathematical model of heparin clearance or a fixed ratio of 1 mg of protamine for every 100 IU of heparin required to establish anticoagulation pre-CPB. A planned, blinded interim analysis was undertaken after the recruitment of 50% of the study cohort. Following this, the randomisation ratio was adapted from 1:1 to 1:1.33 to increase recruitment to the superior arm while maintaining study power. At the conclusion of trial recruitment, we had randomised 121 patients to the intervention arm and 107 patients to the control arm. The primary endpoint was kaolin TEG r-time measured 3 minutes after protamine administration at the end of CPB. Secondary endpoints included ratio of kaolin TEG r-time pre-CPB to the same metric following protamine administration, requirement for allogeneic red cell transfusion, intercostal catheter drainage at 4 hours postoperatively, and the requirement for reoperation due to bleeding. The trial was listed on a clinical trial registry (ClinicalTrials.gov Identifier: NCT03532594). Participants were recruited between April 2018 and August 2019. Those in the intervention/model group had a shorter mean kaolin r-time (6.58 [SD 2.50] vs. 8.08 [SD 3.98] minutes; p = 0.0016) post-CPB. The post-protamine thromboelastogram of the model group was closer to pre-CPB parameters (median pre-CPB to post-protamine kaolin r-time ratio 0.96 [IQR 0.78-1.14] vs. 0.75 [IQR 0.57-0.99]; p < 0.001). We found no evidence of a difference in median mediastinal/pleural drainage at 4 hours postoperatively (140 [IQR 75-245] vs. 135 [IQR 94-222] mL; p = 0.85) or requirement (as a binary outcome) for packed red blood cell transfusion at 24 hours postoperatively (19 [15.8%] vs. 14 [13.1%] p = 0.69). Those in the model group had a lower median protamine dose (180 [IQR 160-210] vs. 280 [IQR 250-300] mg; p < 0.001). Important limitations of this study include an unblinded design and lack of generalisability to certain populations deliberately excluded from the study (specifically children, patients with a total body weight >120 kg, and patients requiring therapeutic hypothermia to <28°C). CONCLUSIONS Using a mathematical model to guide protamine dosing in patients following CPB improved TEG r-time and reduced the dose administered relative to a fixed ratio. No differences were detected in postoperative mediastinal/pleural drainage or red blood cell transfusion requirement in our cohort of low-risk patients. TRIAL REGISTRATION ClinicalTrials.gov Unique identifier NCT03532594.
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Affiliation(s)
- Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Department of Anaesthesia, Austin Health, Melbourne, Australia
- * E-mail:
| | - Christiana Burt
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Joseph Arrowsmith
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Mikel A. McKie
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Sofia S. Villar
- MRC Biostatistics Unit, School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Pooveshnie Govender
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ruth Shaylor
- Department of Anaesthesia, Austin Health, Melbourne, Australia
| | - Zihui Tan
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Ravi De Silva
- Department of Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Florian Falter
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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11
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Individual variation in unfractionated heparin dosing after pediatric cardiac surgery. Sci Rep 2020; 10:19438. [PMID: 33173059 PMCID: PMC7655810 DOI: 10.1038/s41598-020-76547-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 10/29/2020] [Indexed: 11/24/2022] Open
Abstract
We aimed to identify attributing factors to the interindividual variabilities of the infusion rates in unfractionated heparin therapy. We included patients who required unfractionated heparin therapy to achieve the target APTT after cardiac surgery between May 2014 and February 2018. Fifty-nine patients were included, of whom 8 underwent Blalock-Taussig shunt; 27, Glenn procedure; 19, Fontan procedure; 3, mechanical valve replacement; and 2, Rastelli procedure. Previously reported variables that influenced the response to unfractionated heparin treatment were initially compared, which included age; weight; sex; type of surgery; platelet count; fibrinogen, antithrombin III, total protein, albumin, alanine transaminase, and creatinine levels; and use of fresh frozen plasma. The type of surgical procedure was found to be significantly associated with the differences in heparin infusion rate (P = 0.00073). Subsequently, the variance explained by these factors was estimated through a selection based on the minimum Akaike information criterion value; models constructed by various combinations of the surgery types were compared. The model including the Blalock-Taussig shunt, Glenn procedure, and mechanical valve replacement showed the highest summed variance explained (29.1%). More than 70% of the interindividual variability in initial heparin maintenance dosing was unexplained.
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12
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Derbalah A, Duffull S, Newall F, Moynihan K, Al-Sallami H. Revisiting the Pharmacology of Unfractionated Heparin. Clin Pharmacokinet 2020; 58:1015-1028. [PMID: 30850987 DOI: 10.1007/s40262-019-00751-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Unfractionated heparin (UFH) is a commonly used anticoagulant therapy for the acute treatment and prevention of thrombosis. Its short duration of action, reversibility of effect by protamine sulfate, and extensive clinical experience are some of the advantages that support its use. However, the choice of dose and dosing regimen of UFH remains challenging for several reasons. First, UFH has a narrow therapeutic window and wide variability in the dose-response relationship. Second, its pharmacodynamic (PD) properties are difficult to characterise owing to the complex multidimensional mechanisms of interaction with the haemostatic system. Third, the complex heterogeneous chemical composition of UFH precludes precise characterisation of its pharmacokinetic (PK) properties. This review provides a comprehensive mechanistic approach to the interaction of UFH with the haemostatic system. The effect of chemical structure on its PK and PD properties is quantitatively described, and a framework for characterisation of the dose-response relationship of UFH for the purpose of dose optimisation is proposed.
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Affiliation(s)
| | - Stephen Duffull
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Fiona Newall
- Department of Nursing, The University of Melbourne, Parkville, VIC, Australia.,Department of Paediatrics, The Royal Children's Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Paediatrics, Harvard Medical School, Boston, MA, USA
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13
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Boorman S, Douglas H, Driessen B, Gillespie MJ, Schaer TP. Fatal Ovarian Hemorrhage Associated With Anticoagulation Therapy in a Yucatan Mini-Pig Following Venous Stent Implantation. Front Vet Sci 2020; 7:18. [PMID: 32083102 PMCID: PMC7002391 DOI: 10.3389/fvets.2020.00018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 01/10/2020] [Indexed: 01/10/2023] Open
Abstract
Swine models are commonly utilized in endovascular research for development of intravascular interventions and medical device development. As part of a pilot study for a venous vascular stent device, a 5-year-old female Yucatan mini-pig underwent bilateral external iliac vein stent placement under general anesthesia. To reduce thrombotic complications by reduction of thrombus formation on wires, sheaths, and catheters, the pig was heparinized with a total of 300 IU/kg of heparin, establishing an activated clotting time (ACT) of 436 s. The ACT had returned to below 200 s by the end of the procedure. To prevent postoperative thrombosis, the pig received an anticoagulation therapy protocol consisting of enoxaparin, clopidogrel, and aspirin. There were no complications during the immediate postoperative period. However, the pig died 4 days after surgery. Necropsy established the cause of death as abdominal exsanguination due to severe, acute, intra-ovarian hemorrhage, most likely related to ovulation. Life-threatening ovarian hemorrhage is occasionally seen in women with congenital or acquired bleeding disorders; to our knowledge this is the first report of fatal ovarian hemorrhage in an animal enrolled in a pre-clinical research trial.
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Affiliation(s)
- Sophie Boorman
- Department of Clinical Sciences, College of Veterinary Medicine, JT Vaughan Large Animal Teaching Hospital, Auburn University, Auburn, AL, United States
| | - Hope Douglas
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Bernd Driessen
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew J Gillespie
- Department of Cardiology, The Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Thomas P Schaer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States
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14
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Gan Y, Yang Z, Mei W, Zhu C. Identifying optimal heparin management during cardiopulmonary bypass in Chinese people: a retrospective observational comparative study. J Thromb Thrombolysis 2019; 49:480-486. [PMID: 31701359 DOI: 10.1007/s11239-019-01987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Traditionally heparin is adapted according to total body weight (TBW) to providing anticoagulation during cardiopulmonary bypass (CPB), but it may be inaccurate in some patients. The medical records of 100 adult patients who received CPB in Tongji Hospital of Tongji Medical College Huazhong University of Science and Technology over a 10-month period in 2017 were included in the retrospective study. An unfractionated heparin (UFH) bolus of 300 IU/kg TBW was injected before initiation of CPB followed by additional doses (50 to 100 IU/kg) to maintain a target activated coagulation time (ACT) of at least 480 s. We used TBW, ideal body weight (IBW), lean body weight (LBW), or body mass index (BMI) to establish and evaluate a linear model of ACT and the amount of heparin respectively. The linear fit effect of the model based on BMI on the original data is better than the others. As the instruments to measure heparin concentration is unavailable in most medical institutions in China. The new linear model based on BMI is helpful to estimate a more individualized heparin dosage in the heparinized phase and to provide useful reference to the amount of remaining heparin in the neutralization phase.
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Affiliation(s)
- Yongbo Gan
- School of Mathematics and Statistics, Wuhan University, Wuhan, 430072, Hubei, China
| | - Zhijian Yang
- School of Mathematics and Statistics, Wuhan University, Wuhan, 430072, Hubei, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Chang Zhu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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15
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Anticoagulant and side-effects of protamine in cardiac surgery: a narrative review. Br J Anaesth 2018; 120:914-927. [DOI: 10.1016/j.bja.2018.01.023] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 01/10/2018] [Accepted: 01/29/2018] [Indexed: 01/10/2023] Open
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16
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Kalathottukaren MT, Abbina S, Yu K, Shenoi RA, Creagh AL, Haynes C, Kizhakkedathu JN. A Polymer Therapeutic Having Universal Heparin Reversal Activity: Molecular Design and Functional Mechanism. Biomacromolecules 2017; 18:3343-3358. [DOI: 10.1021/acs.biomac.7b00994] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Manu Thomas Kalathottukaren
- Centre
for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Srinivas Abbina
- Centre
for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Kai Yu
- Centre
for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Rajesh A. Shenoi
- Centre
for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Drug Discovery, Inter University Centre for Biomedical Research & Super Speciality Hospital, Kottayam, Kerala, India
| | - A. Louise Creagh
- Michael
Smith Laboratories, Department of Chemical and Biological Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Charles Haynes
- Centre
for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Michael
Smith Laboratories, Department of Chemical and Biological Engineering, University of British Columbia, Vancouver, BC, Canada
| | - Jayachandran N. Kizhakkedathu
- Centre
for Blood Research and Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, Canada
- Department
of Chemistry, University of British Columbia, Vancouver, BC, Canada
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