1
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Krittayaphong R, Pumprueg S, Kaewkumdee P, Yindeengam A, Lip GYH. Three-year outcomes of patients with non-valvular atrial fibrillation: the COOL-AF registry. J Geriatr Cardiol 2023; 20:163-173. [PMID: 37091259 PMCID: PMC10114190 DOI: 10.26599/1671-5411.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Clinical outcomes of patients with non-valvular atrial fibrillation (AF) in Asian populations may be different from non-Asians. In this study, we aimed to determine the incidence of ischemic stroke/systemic embolism (SSE), major bleeding, and death, and the predictors for clinical outcomes in a contemporary Asian cohort of newly diagnosed AF patients. METHODS This is a prospective multicenter nationwide registry of patients with AF from 27 hospitals in Thailand. Baseline data and follow-up data were collected every 6 months until 3 years. Data collections included demographic, medical history, laboratory, and medication details. Clinical outcomes were SSE, major bleeding, and all-cause mortality. Incidence rates for each clinical outcome were calculated and presented as rate per 100 person-years. Univariate and multivariate analysis was performed to determine the independent predictors for clinical outcomes. RESULTS There was a total of 3405 patients: mean age was 67.8 ± 11.3 years, 1981 (58.2%) were male. During 30.8 ± 9.7 months follow-up, there was a total of 132 SSE (3.9%), 191 major bleeding (5.6%), and 357 all-cause deaths (10.5%). The incidence rates of SSE, major bleeding, and death were 1.56 (1.30-1.84), 2.26 (1.96-2.61), and 4.17 (3.33-4.25), per 100 person-years respectively. Independent predictors for clinical outcomes were age, type of AF, and the presence of comorbid conditions. CONCLUSION The incidence rate of SSE, major bleeding, and death remains high reflecting the unmet needs in AF management.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Satchana Pumprueg
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pontawee Kaewkumdee
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ahthit Yindeengam
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory YH Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; and Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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2
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Cheng X, Sun B, Liu S, Li D, Yang X, Zhang Y. Identification of thrombomodulin as a dynamic monitoring biomarker for deep venous thrombosis evolution. Exp Ther Med 2020; 21:142. [PMID: 33456509 PMCID: PMC7791923 DOI: 10.3892/etm.2020.9574] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/26/2020] [Indexed: 01/14/2023] Open
Abstract
It has been demonstrated that thrombomodulin (TM) serves an important role in the formation of deep venous thrombosis (DVT) and is regarded to be a marker that can be used to measure vascular endothelial cell damage. However, how TM levels change during DVT evolution has not yet been well understood. The current study aimed to investigate the dynamic changes of TM during the evolution of DVT and explore the possible mechanisms behind these. A total of 48 patients newly diagnosed with DVT and 23 matched healthy controls were enrolled in the present study, and their plasma TM levels were examined and compared. In addition, a DVT model was established using Sprague-Dawley rats via the ‘stenosis’ method. The thrombi size, histopathologic changes and expression of TM and NF-κB in plasma and venous endothelium were measured at 9 different time points (1, 4, 6, 12 and 24 h, and at 3, 7, 14 and 21 days). Finally, the effect of inhibiting the activation of NF-κB on TM was investigated using pyrrolidine dithiocarbamate (PDTC), which is a potent inhibitor of the NF-κB pathway. The results of the current study indicated that the mean level of plasma TM in patients with DVT was significantly increased compared with healthy controls. In addition, thrombi size (clot length and weight), TM and NF-κB expression in the animal model plasma exhibited three distinct periods (1-12, 24 h-day 7 and 14-21) of markedly different results between periods. Immunofluorescence results confirmed the co-localization of TM and NF-κB in endothelial cells. In addition, it was indicated that the expression of TM in the endothelium of DVT models was upregulated compared with the control, while NF-κB was significantly downregulated. Following the administration of PDTC, the level of NF-κB and TM in the plasma were decreased significantly dose-dependently. The results of the current study suggested that TM was involved in the evolution of DVT and may be used as a dynamic biomarker to measure disease activity. Furthermore, the expression of TM during the evolution of DVT was indicated to be associated with the NF-κB signaling pathway.
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Affiliation(s)
- Xi Cheng
- Medical College, Nantong University, Nantong, Jiangsu 226001, P.R. China.,Laboratory Animal Center, Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Baolan Sun
- Medical College, Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Shiyi Liu
- Medical College, Nantong University, Nantong, Jiangsu 226001, P.R. China.,Laboratory Animal Center, Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Dandan Li
- Medical College, Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Xiaoqing Yang
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Yuquan Zhang
- Department of Gynecology and Obstetrics, Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
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3
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Okada H, Yoshida S, Hara A, Ogura S, Tomita H. Vascular endothelial injury exacerbates coronavirus disease 2019: The role of endothelial glycocalyx protection. Microcirculation 2020; 28:e12654. [PMID: 32791568 PMCID: PMC7435519 DOI: 10.1111/micc.12654] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 06/29/2020] [Accepted: 08/06/2020] [Indexed: 01/08/2023]
Abstract
The potential for a rapid increase in severity is among the most frightening aspects of severe acute respiratory syndrome coronavirus 2 infection. Evidence increasingly suggests that the symptoms of coronavirus disease‐2019 (COVID‐19)‐related acute respiratory distress syndrome (ARDS) differ from those of classic ARDS. Recently, the severity of COVID‐19 has been attributed to a systemic, thrombotic, and inflammatory disease that damages not only the lungs but also multiple organs, including the heart, brain, toes, and liver. This systemic form of COVID‐19 may be due to inflammation and vascular endothelial cell injury. The vascular endothelial glycocalyx comprises glycoproteins and plays an important role in systemic capillary homeostasis maintenance. The glycocalyx covers the entire vascular endothelium, and its thickness varies among organs. The endothelial glycocalyx is very thin in the pulmonary capillaries, where it is affected by gaseous exchange with the alveoli and the low intravascular pressure in the pulmonary circulation. Despite the clearly important roles of the glycocalyx in vascular endothelial injury, thrombosis, vasculitis, and inflammation, the link between this structure and vascular endothelial cell dysfunction in COVID‐19 remains unclear. In this prospective review, we summarize the importance of the glycocalyx and its potential as a therapeutic target in cases of systemic COVID‐19.
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Affiliation(s)
- Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Akira Hara
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumor Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
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4
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Suzuki K, Okada H, Takemura G, Takada C, Tomita H, Yano H, Muraki I, Zaikokuji R, Kuroda A, Fukuda H, Nishio A, Takashima S, Suzuki A, Miyazaki N, Fukuta T, Yamada N, Watanabe T, Doi T, Yoshida T, Kumada K, Ushikoshi H, Yoshida S, Ogura S. Recombinant thrombomodulin protects against LPS-induced acute respiratory distress syndrome via preservation of pulmonary endothelial glycocalyx. Br J Pharmacol 2020; 177:4021-4033. [PMID: 32497259 PMCID: PMC7429482 DOI: 10.1111/bph.15153] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 04/15/2020] [Accepted: 05/28/2020] [Indexed: 01/05/2023] Open
Abstract
Background and Purpose Disruption of the endothelial glycocalyx is causally related to microvascular endothelial dysfunction, a characteristic of sepsis‐induced acute respiratory distress syndrome (ARDS). Recombinant human thrombomodulin (rhTM) attenuates vascular endothelial injuries, but the underlying mechanism remains elusive. Here, we investigated the structural basis and molecular mechanisms of rhTM effects on vascular endothelial injury in a model of sepsis. Experimental Approach LPS (20 mg·kg−1) was intraperitoneally injected into 10‐week‐old male C57BL6 mice, and saline or rhTM was intraperitoneally injected 3 and 24 h after LPS injection. Using serum and/or lung tissue, histological, ultrastructural, and microarray analyses were performed. Key Results Survival rate of rhTM‐treated mice was significantly higher than that of control mice 48 h after LPS injection. Serum concentrations of IL‐6 and high‐mobility group box 1 were lower in the rhTM‐treated group than in the control. Injury to the endothelial glycocalyx in pulmonary capillaries was attenuated by rhTM treatment. Gene set enrichment analysis revealed up‐regulation of gene sets corresponding to cell proliferation/differentiation and anti‐inflammation, such as the TGF‐β pathway, and negative regulation of IL‐6, upon rhTM treatment. Gene expression of heparan sulfate 6‐O‐sulfotransferase 1 and endothelial cell‐specific molecule 1 (components of the endothelial glycocalyx) was significantly preserved by rhTM treatment, and their protein expression levels were maintained in endothelial cells. Conclusion and Implications Our findings show that rhTM treatment affected inflammation, cell proliferation/differentiation, and glycocalyx synthesis in serum and lung tissue, subsequently attenuating ARDS caused by endothelial injury.
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Affiliation(s)
- Kodai Suzuki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hideshi Okada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Genzou Takemura
- Department of Internal Medicine, Asahi University School of Dentistry, Mizuho, Japan
| | - Chihiro Takada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroyuki Tomita
- Department of Tumour Pathology, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hirohisa Yano
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Isamu Muraki
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ryogen Zaikokuji
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ayumi Kuroda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hirotsugu Fukuda
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Ayane Nishio
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shigeo Takashima
- Division of Genomics Research, Life Science Research Center, Gifu University, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, Gifu, Japan
| | - Nagisa Miyazaki
- Department of Internal Medicine, Asahi University School of Dentistry, Mizuho, Japan
| | - Tetsuya Fukuta
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Noriaki Yamada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takatomo Watanabe
- Division of Clinical Laboratory, Gifu University Hospital, Gifu, Japan
| | - Tomoaki Doi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Takahiro Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Keisuke Kumada
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hiroaki Ushikoshi
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shozo Yoshida
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shinji Ogura
- Department of Emergency and Disaster Medicine, Gifu University Graduate School of Medicine, Gifu, Japan
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5
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Cheng Y, Liu J, Su Y, Zhao H, Zhao Y, Wen M, Lu S, Zhang W, Wu J. Clinical Impact of Coagulation and Fibrinolysis Markers for Predicting Postoperative Venous Thromboembolism in Total Joint Arthroplasty Patients. Clin Appl Thromb Hemost 2020; 25:1076029619877458. [PMID: 31608652 PMCID: PMC6900621 DOI: 10.1177/1076029619877458] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
One common complication after joint arthroplasty is venous thromboembolism (VTE).
Therefore, it is essential to measure the changes in coagulation and fibrinolysis in order
to predict VTE among patients who underwent joint arthroplasty. This study aimed to
identify potential useful biomarkers for prognosing to VTE. This was a prospective cohort
study enrolling 83 patients who underwent joint arthroplasty. The levels of
d-dimer, thrombin–antithrombin complex (TAT), plasmin–α2-antiplasmin complex
(PIC), soluble thrombomodulin, and tissue plasminogen activator inhibitor complex were
measured on day 0 (before surgery) and days 1, 3, and 6 after surgery. Ultrasound
examination was used to diagnose VTE on preoperative day 0 and postoperative day 6. A
total of 35 patients developed VTE after surgery. Patients with VTE exhibited
significantly higher levels of d-dimer and TAT on postoperative days 3 and 6 (all
P < .05). The area under curves (AUC) of receiver operating
characteristic (ROC) were 0.65 and 0.68 and 0.68 and 0.74 for d-dimer and TAT
levels on postoperative days 3 and 6, respectively. The level of TAT/PIC ratio on
postoperative day 6 was significantly increased among patients with VTE compared to
non-VTE patients (P < .0001). In addition, the AUC of ROC, cutoff
level, sensitivity, specificity, positive-predictive value, and negative-predictive value
of TAT/PIC ratio were 0.78, 4.03 ng/TU, 97.14%, 33.33%, 51.52%, and 94.12%, respectively.
The high sensitivity and negative predictive value of TAT/PIC ratio make it a potential
prognostic index for diagnosing VTE during the early phase of postoperative joint
arthroplasty.
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Affiliation(s)
- Yuying Cheng
- Department of laboratory medicine, Peking University Fourth School of
Clinical Medicine, Beijing, China
| | - Jian Liu
- Adult reconstruction department, Beijing Jishuitan Hospital, Beijing,
China
| | - Yu Su
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Huiru Zhao
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Yujing Zhao
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Meng Wen
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Shan Lu
- Department of laboratory medicine, Beijing Jishuitan Hospital, Beijing,
China
| | - Wenjie Zhang
- Department of laboratory medicine, Peking University Fourth School of
Clinical Medicine, Beijing, China
| | - Jun Wu
- Department of laboratory medicine, Peking University Fourth School of
Clinical Medicine, Beijing, China
- Jun Wu, Peking University Fourth School of Clinical
Medicine, Beijing 100035, China.
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6
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Borgel D, Bianchini E, Lasne D, Pascreau T, Saller F. Inflammation in deep vein thrombosis: a therapeutic target? Hematology 2019; 24:742-750. [DOI: 10.1080/16078454.2019.1687144] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Delphine Borgel
- Laboratoire d’Hématologie, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- INSERM UMR-S1176, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Elsa Bianchini
- INSERM UMR-S1176, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Dominique Lasne
- Laboratoire d’Hématologie, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- INSERM UMR-S1176, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - Tiffany Pascreau
- Laboratoire d’Hématologie, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- INSERM UMR-S1176, Université Paris Saclay, Le Kremlin-Bicêtre, France
| | - François Saller
- INSERM UMR-S1176, Université Paris Saclay, Le Kremlin-Bicêtre, France
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7
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Pascreau T, de la Morena-Barrio ME, Lasne D, Serrano M, Bianchini E, Kossorotoff M, Boddaert N, Bruneel A, Seta N, Vicente V, de Lonlay P, Corral J, Borgel D. Elevated thrombin generation in patients with congenital disorder of glycosylation and combined coagulation factor deficiencies. J Thromb Haemost 2019; 17:1798-1807. [PMID: 31271700 DOI: 10.1111/jth.14559] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 06/25/2019] [Accepted: 07/01/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Congenital disorders of glycosylation are rare inherited diseases affecting many different proteins. The lack of glycosylation notably affects the hemostatic system and leads to deficiencies of both procoagulant and anticoagulant factors. OBJECTIVE To assess the hemostatic balance in patients with multiple coagulation disorders by using a thrombin generation assay. METHOD We performed conventional coagulation assays and a thrombin generation assay on samples from patients with congenital disorder of glycosylation. The thrombin generation assay was performed before and after activation of the protein C system by the addition of soluble thrombomodulin. RESULTS A total of 35 patients were included: 71% and 57% had low antithrombin and factor XI levels, respectively. Protein C and protein S levels were abnormally low in 29% and 26% of the patients, respectively, whereas only 11% displayed low factor IX levels. Under baseline conditions, the thrombin generation assay revealed a significantly higher endogenous thrombin potential and thrombin peak in patients, relative to controls. After spiking with thrombomodulin, we observed impaired involvement of the protein C system. Hence, 54% of patients displayed a hypercoagulant phenotype in vitro. All the patients with a history of stroke-like episodes or thrombosis displayed this hypercoagulant phenotype. CONCLUSION A thrombin generation assay revealed a hypercoagulant in vitro phenotype under baseline condition; this was accentuated by impaired involvement of the protein C system. This procoagulant phenotype may thus reflect the risk of severe vascular complications. Further research will have to determine whether the thrombin generation assay is predictive of vascular events.
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Affiliation(s)
- Tiffany Pascreau
- Laboratoire d'Hématologie, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- INSERM UMR-S1176, Le Kremlin-Bicêtre, France
| | - Maria E de la Morena-Barrio
- Servicio de Hematología y Oncología Médica, Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, CIBERER, Murcia, Spain
| | - Dominique Lasne
- Laboratoire d'Hématologie, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- INSERM UMR-S1176, Le Kremlin-Bicêtre, France
| | - Mercedes Serrano
- Department of Pediatric Neurology, Institute of Pediatric Research-Hospital Sant Joan de Déu, U-703 Center for Biomedical Research on Rare Diseases, Barcelona, Spain
- Department of Genetic Medicine, Institute of Pediatric Research-Hospital Sant Joan de Déu, U-703 Center for Biomedical Research on Rare Diseases, Barcelona, Spain
| | | | - Manoelle Kossorotoff
- Paediatric Neurology Department, French Center for Paediatric Stroke, AP-HP, Hôpital Necker-Enfants-Malades, Paris, France
| | - Nathalie Boddaert
- Pediatric Radiology Department, AP-HP, Hôpital Necker-Enfants-Malades, Paris, France
- Institut Imagine, INSERM U1000 and UMR 1163, Paris, France
| | - Arnaud Bruneel
- Biochimie Métabolique, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Nathalie Seta
- Biochimie Métabolique, AP-HP, Hôpital Bichat-Claude Bernard, Paris, France
| | - Vicente Vicente
- Servicio de Hematología y Oncología Médica, Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, CIBERER, Murcia, Spain
| | - Pascale de Lonlay
- Reference Center of Metabolism, Imagine Institute, AP-HP, Hôpital Necker-Enfants Maladies, University Paris-Descartes, Paris, France
| | - Javier Corral
- Servicio de Hematología y Oncología Médica, Centro Regional de Hemodonación, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, CIBERER, Murcia, Spain
| | - Delphine Borgel
- Laboratoire d'Hématologie, AP-HP, Hôpital Necker-Enfants malades, Paris, France
- INSERM UMR-S1176, Le Kremlin-Bicêtre, France
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8
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Núñez-Navarro NE, Santana FM, Parra LP, Zacconi FC. Surfing the Blood Coagulation Cascade: Insight into the Vital Factor Xa. Curr Med Chem 2019; 26:3175-3200. [PMID: 29376487 DOI: 10.2174/0929867325666180125165340] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 12/28/2017] [Accepted: 01/11/2018] [Indexed: 01/19/2023]
Abstract
Factor Xa (FXa) plays a key role in haemostasis, it is a central part of the blood coagulation cascade which catalyzes the production of thrombin and leads to clot formation and wound closure. Therefore, FXa is an attractive target for the development of new anticoagulant agents. In this review, we will first describe the molecular features of this fundamental protein in order to understand its mechanism of action, an essential background for the design of novel inhibitors by means of synthetic organic chemistry or using peptides obtained from recombinant methodologies. Then, we will review the current state of the synthesis of novel direct FXa inhibitors along with their mechanisms of action. Finally, approved reversal agents that aid in maintaining blood haemostasis by using these commercial drugs will also be discussed.
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Affiliation(s)
- Nicolás E Núñez-Navarro
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Department of Chemical and Bioprocesses Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Fabián M Santana
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Loreto P Parra
- Department of Chemical and Bioprocesses Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Flavia C Zacconi
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Research Center for Nanotechnology and Advanced Materials "CIEN-UC", Pontificia Universidad Catolica de Chile, Santiago, Chile
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9
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Thrombomodulin Regulation of Mitogen-Activated Protein Kinases. Int J Mol Sci 2019; 20:ijms20081851. [PMID: 30991642 PMCID: PMC6514922 DOI: 10.3390/ijms20081851] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 04/08/2019] [Accepted: 04/13/2019] [Indexed: 12/12/2022] Open
Abstract
The multifaceted role of mitogen-activated protein kinases (MAPKs) in modulating signal transduction pathways in inflammatory conditions such as infection, cardiovascular disease, and cancer has been well established. Recently, coagulation factors have also emerged as key players in regulating intracellular signaling pathways during inflammation. Among coagulation factors, thrombomodulin, as a high affinity receptor for thrombin on vascular endothelial cells, has been discovered to be a potent anti-inflammatory and anti-tumorigenic signaling molecule. The protective signaling function of thrombomodulin is separate from its well-recognized role in the clotting cascade, which is to function as an anti-coagulant receptor in order to switch the specificity of thrombin from a procoagulant to an anti-coagulant protease. The underlying protective signaling mechanism of thrombomodulin remains largely unknown, though a few published reports link the receptor to the regulation of MAPKs under different (patho)physiological conditions. The goal of this review is to summarize what is known about the regulatory relationship between thrombomodulin and MAPKs.
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10
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Székely O, Miyazawa K, Lip GYH. Current and emerging pharmacotherapy for ischemic stroke prevention in patients with atrial fibrillation. Expert Opin Pharmacother 2018; 19:1999-2009. [PMID: 30359142 DOI: 10.1080/14656566.2018.1537368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction: Atrial fibrillation (AF) is associated with high morbidity and mortality rates due to thromboembolic complications, and anticoagulation is central to the management of this common arrhythmia to prevent acute thromboembolic events. The traditional anticoagulants: heparin, fondaparinux, and vitamin K antagonists (VKA, e.g. warfarin, acenocoumarol or phenprocoumin) have long served as pharmacotherapy for ischemic stroke prophylaxis. Areas covered: In this review article, the authors provide an overview on current and emerging pharmacotherapy for ischemic stroke prevention. Furthermore, they review the data from novel therapeutic targets in the coagulation cascade, and investigational anticoagulant drugs currently assessed in preclinical and clinical studies. Expert opinion: The introduction of nonvitamin K antagonist oral anticoagulants (NOACs) was an important milestone, as these drugs show relative efficacy, safety, and convenience compared to the VKAs. Nevertheless, their clinical use still has some limitations with, for example, patients with severe renal impairment and those with mechanical heart valves, high bleeding risks, lack of standard laboratory monitoring and (some) reversal agents. To overcome some of these limitations, various attempts are now underway to discover new strategies and targets via the hemostatic pathway in order to develop new coagulation inhibiting drugs.
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Affiliation(s)
- Orsolya Székely
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK
| | - Kazuo Miyazawa
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK
| | - Gregory Yoke Hong Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Liverpool Centre for Cardiovascular Science , University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,c Aalborg Thrombosis Research Unit , Aalborg University , Aalborg , Denmark
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11
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Dimitropoulos G, Rahim SMZ, Moss AS, Lip GYH. New anticoagulants for venous thromboembolism and atrial fibrillation: what the future holds. Expert Opin Investig Drugs 2017; 27:71-86. [DOI: 10.1080/13543784.2018.1416090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Gerasimos Dimitropoulos
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - S. M. Zubair Rahim
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - Alexandra Sophie Moss
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Cardiology Department, City Hospital, Birmingham, UK
| | - Gregory Y. H. Lip
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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12
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Kim JH, Lim KM, Gwak HS. New Anticoagulants for the Prevention and Treatment of Venous Thromboembolism. Biomol Ther (Seoul) 2017; 25:461-470. [PMID: 28365976 PMCID: PMC5590789 DOI: 10.4062/biomolther.2016.271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 01/21/2017] [Accepted: 01/26/2017] [Indexed: 12/14/2022] Open
Abstract
Anticoagulant drugs, like vitamin K antagonists and heparin, have been the mainstay for the treatment and prevention of venous thromboembolic disease for many years. Although effective if appropriately used, traditional anticoagulants have several limitations such as unpredictable pharmacologic and pharmacokinetic responses and various adverse effects including serious bleeding complications. New oral anticoagulants have recently emerged as an alternative because of their rapid onset/offset of action, predictable linear dose-response relationships and fewer drug interactions. However, they are still associated with problems such as bleeding, lack of reversal agents and standard laboratory monitoring. In an attempt to overcome these drawbacks, key steps of the hemostatic pathway are investigated as targets for anticoagulation. Here we reviewed the traditional and new anticoagulants with respect to their targets in the coagulation cascade, along with their therapeutic advantages and disadvantages. In addition, investigational anticoagulant drugs currently in the development stages were introduced.
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Affiliation(s)
- Joo Hee Kim
- College of Pharmacy & Institute of Pharmaceutical Science and Technology, Ajou University, Suwon 16499, Republic of Korea.,College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea
| | - Kyung-Min Lim
- College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy, Ewha Womans University, Seoul 03760, Republic of Korea
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13
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Abstract
Extremity injury is a significant burden to those injured in explosive incidents and local ischaemia can result in poor functionality in salvaged limbs. This study examined whether blast injury to a limb resulted in a change in endothelial phenotype leading to changes to the surrounding tissue. The hind limbs of terminally anaesthetized rabbits were subjected to one of four blast exposures (high, medium, low, or no blast). Blood samples were analyzed for circulating endothelial cells pre-injury and at 1, 6, and 11 h postinjury as well as analysis for endothelial activation pre-injury and at 1, 6, and 12 h postinjury. Post-mortem tissue (12 h post-injury) was analysed for both protein and mRNA expression and also for histopathology. The high blast group had significantly elevated levels of circulating endothelial cells 6 h postinjury. This group also had significantly elevated tissue mRNA expression of IL-6, E-selectin, TNF-α, HIF-1, thrombomodulin, and PDGF. There was a significant correlation between blast dose and the degree of tissue pathology (hemorrhage, neutrophil infiltrate, and oedema) with the worst scores in the high blast group. This study has demonstrated that blast injury can activate the endothelium and in some cases cause damage that in turn leads to pathological changes in the surrounding tissue. For the casualty injured by an explosion the damaging effects of hemorrhage and shock could be exacerbated by blast injury and vice versa so that even low levels of blast become damaging, all of which could affect tissue functionality and long-term outcomes.
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Recombinant human soluble thrombomodulin ameliorates cerebral ischemic injury through a high-mobility group box 1 inhibitory mechanism without hemorrhagic complications in mice. J Neurol Sci 2016; 362:278-82. [PMID: 26944163 DOI: 10.1016/j.jns.2016.01.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 01/09/2016] [Accepted: 01/21/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND It has been reported that recombinant human soluble thrombomodulin (rhsTM) has a high-mobility group box (HMGB)1 inhibitory effect. Some investigators reported that HMGB1 is associated with ischemic stroke. However, there have been no previous studies to determine whether rhsTM can ameliorate cerebral ischemic injury through its HMGB1 inhibitory mechanism in ischemic stroke. We investigated the effects of rhsTM on cerebral ischemic injury in a 4-h middle cerebral artery occlusion (MCAO) murine model. METHODS rhsTM (1 or 5mg/kg, i.v.) was administered immediately after 4-h MCAO. Infarct volume, motor coordination, plasma HMGB1 level, and hemorrhage volume were evaluated 24h after 4-h MCAO. RESULTS The infarct volume (P<0.05) was reduced by rhsTM in mice subjected to 4-h MCAO in a dose-dependent manner. Moreover, rhsTM (5mg/kg) significantly improved motor coordination determined by the rotarod test (P<0.05), and significantly decreased plasma HMGB1 level compared with vehicle-treated controls (P<0.001). In addition, there was no difference in hemorrhage volume between vehicle-treated controls and the rhsTM treatment group. CONCLUSIONS This represents the first report that rhsTM ameliorates cerebral ischemic injury through an HMGB1 inhibitory mechanism without hemorrhagic complications in mice. Taken together, these observations indicate a palliative effect of rhsTM and suggest new therapeutic possibilities for treatment of ischemic stroke via inhibition of HMGB1.
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15
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Greineder CF, Brenza JB, Carnemolla R, Zaitsev S, Hood ED, Pan DC, Ding BS, Esmon CT, Chacko AM, Muzykantov VR. Dual targeting of therapeutics to endothelial cells: collaborative enhancement of delivery and effect. FASEB J 2015; 29:3483-92. [PMID: 25953848 DOI: 10.1096/fj.15-271213] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 04/21/2015] [Indexed: 12/16/2022]
Abstract
Anchoring pharmacologic agents to the vascular lumen has the potential to modulate critical processes at the blood-tissue interface, avoiding many of the off-target effects of systemically circulating agents. We report a novel strategy for endothelial dual targeting of therapeutics, which both enhances drug delivery and enables targeted agents to partner enzymatically to generate enhanced biologic effect. Based on the recent discovery that paired antibodies directed to adjacent epitopes of platelet endothelial cell adhesion molecule (PECAM)-1 stimulate each other's binding, we fused single-chain fragments (scFv) of paired anti-mouse PECAM-1 antibodies to recombinant murine thrombomodulin (TM) and endothelial protein C receptor (EPCR), endothelial membrane proteins that partner in activation of protein C (PC). scFv/TM and scFv/EPCR bound to mouse endothelial PECAM-1 with high affinity (EC50 1.5 and 3.8 nM, respectively), and codelivery induced a 5-fold increase in PC activation not seen when TM and EPCR are anchored to distinct cell adhesion molecules. In a mouse model of acute lung injury, dual targeting reduces both the expression of lung inflammatory markers and trans-endothelial protein leak by as much as 40%, as compared to either agent alone. These findings provide proof of principle for endothelial dual targeting, an approach with numerous potential biomedical applications.
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Affiliation(s)
- Colin F Greineder
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Jacob B Brenza
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Ronald Carnemolla
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Sergei Zaitsev
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Elizabeth D Hood
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Daniel C Pan
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Bi-Sen Ding
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Charles T Esmon
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Ann Marie Chacko
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
| | - Vladimir R Muzykantov
- *Department of Pharmacology, Center for Targeted Therapeutics and Translational Nanomedicine, Institute for Translational Medicine and Therapeutics, and Departments of Radiology and Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetic Medicine, Howard Hughes Medical Institute, Weill Cornell Medical College, New York, New York, USA; and Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Howard Hughes Medical Institute, Oklahoma City, Oklahoma, USA
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16
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Nakamura K, Hatano E, Miyagawa-Hayashino A, Okuno M, Koyama Y, Narita M, Seo S, Taura K, Uemoto S. Soluble thrombomodulin attenuates sinusoidal obstruction syndrome in rat through suppression of high mobility group box 1. Liver Int 2014; 34:1473-87. [PMID: 24498917 DOI: 10.1111/liv.12420] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 11/21/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND Sinusoidal obstruction syndrome (SOS) is a drug-induced liver injury caused by anticancer treatment such as oxaliplatin-based chemotherapy in patients with hepatic colorectal metastases. SOS is also associated with postoperative morbidity after hepatectomy. AIMS The aim of this study was to investigate the effects of recombinant human soluble thrombomodulin (rTM) in a monocrotaline (MCT)-induced SOS model in rats. METHODS Rats were administered rTM by intravenous injection (3 mg/kg) and subcutaneous injection (3 mg/kg) concurrently with MCT administration. Other rats received the same volume of normal saline (NS) and MCT. Liver tissue and blood were collected 48 h after MCT administration to evaluate SOS. Survival after 30% partial hepatectomy was also investigated in both groups. Electron microscopy and immunohistochemistry were used to examine sinusoidal endothelial cells (SECs). Serum concentrations of high mobility group box 1 (HMGB1) and neutrophil accumulation were also measured. RESULTS In the NS group, liver histology showed SOS phenotypes. In the rTM group, these changes were suppressed, total SOS scores were significantly lower, and serum transaminase levels were significantly reduced compared with the NS group. Survival after 30% hepatectomy was significantly higher in the rTM group (57% vs. 22%, P = 0.0070). Electron microscopy and immunohistochemistry showed a protective effect of rTM on SECs. rTM also attenuated the serum HMGB1 level (9.2 vs. 19.6 ng/ml, P = 0.0086), active neutrophil recruitment and myeloperoxidase activity. CONCLUSION rTM preserved SECs and attenuated MCT-induced SOS in rats through suppression of circulatory HMGB1 and neutrophil accumulation, resulting in improved survival after hepatectomy.
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Affiliation(s)
- Kojiro Nakamura
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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17
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Pathak R, Shao L, Chafekar SM, Feng W, Ponnappan U, Fink LM, Zhou D, Hauer-Jensen M. IKKβ regulates endothelial thrombomodulin in a Klf2-dependent manner. J Thromb Haemost 2014; 12:1533-1544. [PMID: 25039491 PMCID: PMC4163124 DOI: 10.1111/jth.12664] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND Endothelial thrombomodulin (TM) is critically involved in anticoagulation, anti-inflammation, cytoprotection and normal fetal development. Tumor necrosis factor alpha (TNFα) suppresses TM expression. OBJECTIVE TNFα has been shown to down-regulate TM partly via activation of nuclear factor kappa B (NF-κB). However, because the TM promoter lacks an NF-κB binding site, the direct involvement of NF-κB has been controversial. We investigated the role of the upstream regulatory serine kinase, inhibitory kappa-B kinase-β (IKKβ), in TM expression and function with or without TNFα treatment. METHODS Inhibition of IKKβ was achieved by specific chemical inhibitors, siRNA or shRNA. TM expression was assessed by qRT-PCR, Western blot, flow cytometry, luciferase reporter assay and chromatin immune-precipitation (ChIP) assay. TM function was estimated by generation of activated protein C (APC). NF-κB activation was determined by immunocytochemistry. RESULTS AND CONCLUSIONS IKKβ inhibition increased TM expression and function, and attenuated TNFα-mediated TM down-regulation. In contrast, inhibition of downstream canonical NF-κB protein family members p50 and p65 (RelA) failed to up-regulate TM expression and did not affect IKKβ inhibition-mediated TM over-expression. However, knockdown of cRel and RelB, family members of the canonical and non-canonical NF-κB pathway, respectively, resulted in TM over-expression. IKKβ inhibition caused over-expression, increased promoter activity and enhanced binding of Krüppel-like factor 2 (Klf2) to the TM promoter, which positively regulates TM expression. Finally, knockdown of Klf2 completely attenuated IKKβ inhibition-mediated TM up-regulation. We conclude that IKKβ regulates TM in a Klf2-dependent manner.
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Affiliation(s)
- R Pathak
- Division of Radiation Health, Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR
| | - L Shao
- Division of Radiation Health, Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR
| | - S M Chafekar
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - W Feng
- Division of Radiation Health, Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR
| | - U Ponnappan
- Department of Microbiology and Immunology, University of Arkansas for Medical Sciences, Little Rock, AR
| | - L M Fink
- Desert Research Institute, Las Vegas, NV
| | - D Zhou
- Division of Radiation Health, Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR
| | - M Hauer-Jensen
- Division of Radiation Health, Department of Pharmaceutical Sciences, University of Arkansas for Medical Sciences, Little Rock, AR
- Surgical Service, Central Arkansas Veterans Healthcare System, Little Rock, AR, USA
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18
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Wade WE, Spruill WJ. Fondaparinux sodium in the prophylaxis and treatment of deep vein thrombosis and pulmonary embolism. Expert Rev Pharmacoecon Outcomes Res 2014; 7:227-37. [DOI: 10.1586/14737167.7.3.227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Wang L, Jiang R, Sun XL. Recombinant thrombomodulin of different domains for pharmaceutical, biomedical, and cell transplantation applications. Med Res Rev 2013; 34:479-502. [PMID: 23804235 DOI: 10.1002/med.21294] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Thrombomodulin (TM) is a membrane glycoprotein mainly expressed by vascular endothelial cells and is involved in many physiological and pathological processes, such as coagulation, inflammation, cancer development, and embryogenesis. Human TM consists of 557 amino acids divided into five distinct domains: N-terminal lectin-like domain (designated as TMD1); six epidermal growth factor (EGF)-like domain (TMD2); Ser/Thr-rich domain (TMD3); transmembrane domain (TMD4); and cytoplasmic tail domain (TMD5). The different domains are responsible for different biological functions of TM. In the past decades, various domains of TM have been cloned and expressed for TM structural and functional study. Further, recombinant TMs of different domains show promising antithrombotic and anti-inflammatory activity in both rodents and primates and a recombinant soluble TM has been approved for therapeutic application. This review highlights recombinant TMs of diverse structures and their biological functions, as well as the complex interactions of TM with factors involved in the related biological processes. Particularly, recent advances in exploring recombinant TM of different domains for pharmaceutical, biomedical, and cell transplantation applications are summarized.
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Affiliation(s)
- Lin Wang
- Department of Chemistry, Chemical and Biomedical Engineering, Cleveland State University, Cleveland, Ohio 44115
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20
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Borgel D, Lerolle N. Quel avenir pour les médicaments de l’hémostase dans le traitement du sepsis sévère après le Xigris® ? MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0665-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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21
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Iba T, Aihara K, Watanabe S, Yanagawa Y, Takemoto M, Yamada A, Yang D. Recombinant thrombomodulin improves the visceral microcirculation by attenuating the leukocyte-endothelial interaction in a rat LPS model. Thromb Res 2012; 131:295-9. [PMID: 23273403 DOI: 10.1016/j.thromres.2012.11.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 10/24/2012] [Accepted: 11/19/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Abnormalities in vascular endothelial function play an important role in the development of septic organ dysfunction. The aim of this study was to examine the effect of recombinant thrombomodulin (rTM) on leukocyte-endothelial interaction and subsequent malcirculation in endotoxemia. MATERIALS AND METHODS Wistar rats were administered with either low, medium or high dose of rTM (n=7 each) 2hours after lipopolysaccharide (LPS) infusion. Mesenteric microcirculation after the treatment was observed under the intravital microscopy. In another series (n=5 each), plasma levels of high-mobility group box 1 (HMGB1) levels were measured at 5hours after LPS infusion. RESULTS Microscopic findings revealed suppression in leukocyte adhesion, thrombus formation and endothelial damage with the treatment by rTM. However, high-dose rTM tended to increase the bleeding events. Thus, blood flow was better maintained with medium-dose rTM (P<0.05). The increase in HMGB1 level was significantly suppressed by medium and high-dose rTM (P<0.05, respectively). CONCLUSIONS rTM demonstrated a protective effect on microcirculation through the inhibition of leukocyte-endothelial interaction and suppression of HMGB1.
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Affiliation(s)
- Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan.
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Weitz JI, Eikelboom JW, Samama MM. New antithrombotic drugs: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e120S-e151S. [PMID: 22315258 DOI: 10.1378/chest.11-2294] [Citation(s) in RCA: 161] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This article focuses on new antithrombotic drugs that are in or are entering phase 3 clinical testing. Development of these new agents was prompted by the limitations of existing antiplatelet, anticoagulant, or fibrinolytic drugs. Addressing these unmet needs, this article (1) outlines the rationale for development of new antithrombotic agents; (2) describes the new antiplatelet, anticoagulant, and fibrinolytic drugs; and (3) provides clinical perspectives on the opportunities and challenges faced by these novel agents.
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Affiliation(s)
- Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute and Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, ON, Canada.
| | - John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute and Department of Medicine, McMaster University, Hamilton, ON, Canada
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Thrombomodulin: a bifunctional modulator of inflammation and coagulation in sepsis. Crit Care Res Pract 2012; 2012:614545. [PMID: 22482044 PMCID: PMC3299293 DOI: 10.1155/2012/614545] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 12/01/2011] [Accepted: 12/01/2011] [Indexed: 01/08/2023] Open
Abstract
Deregulated interplay between inflammation and coagulation plays a pivotal role in the pathogenesis of sepsis. Therapeutic approaches that simultaneously target both inflammation and coagulation hold great promise for the treatment of sepsis. Thrombomodulin is an endogenous anticoagulant protein that, in cooperation with protein C and thrombin-activatable fibrinolysis inhibitor, serves to maintain the endothelial microenvironment in an anti-inflammatory and anticoagulant state. A recombinant soluble form of thrombomodulin has been approved to treat patients suffering from disseminated intravascular coagulation (DIC) and has thus far shown greater therapeutic potential than heparin. A phase II clinical trial is currently underway in the USA to study the efficacy of thrombomodulin for the treatment of sepsis with DIC complications. This paper focuses on the critical roles that thrombomodulin plays at the intersection of inflammation and coagulation and proposes the possible existence of interactions with integrins via protein C. Finally, we provide a rationale for the clinical application of thrombomodulin for alleviating sepsis.
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Kazmi RS, Lwaleed BA. New anticoagulants: how to deal with treatment failure and bleeding complications. Br J Clin Pharmacol 2012; 72:593-603. [PMID: 21752066 DOI: 10.1111/j.1365-2125.2011.04060.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Conventional anticoagulants have proven efficacy in the management of thromboembolism. Their adverse effects and a narrow therapeutic window, necessitating regular need for monitoring, however, have long been an incentive for the development of safer anticoagulants without compromising efficacy. Over the last decade or so several new parenteral and oral anticoagulants have been launched with efficacy comparable with conventional agents. From fondaparinux to its long acting derivative idraparinux, and the factor Xa inhibitor rivaroxaban to the direct thrombin inhibitor dabigatran, the advent of new anticoagulants is radically changing anticoagulation. For conventional anticoagulants, despite their shortcomings, effective methods of reversing their anticoagulant effects exist. Moreover, strategies to deal with the occurrence of fresh thrombotic events in the face of therapeutic anticoagulation with the conventional agents have also been addressed. Nevertheless, for the new anticoagulants, the optimal management of these complications remains unknown. This review explores these issues in the light of current evidence.
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Affiliation(s)
- Rashid S Kazmi
- Southampton University Hospital, Tremona Road, Southampton SO16 6YD, UK.
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25
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Lee YK, Chung CY, Koo KH, Lee KM, Ji HM, Park MS. Conflict of interest in the assessment of thromboprophylaxis after total joint arthroplasty: a systematic review. J Bone Joint Surg Am 2012; 94:27-33. [PMID: 22218379 DOI: 10.2106/jbjs.j.01033] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The choice of modalities for thromboprophylaxis after total joint arthroplasty is controversial. To address this issue, an evidence-based review of previous studies was performed. The characteristics of the studies selected for review can affect the final conclusion of an evidence-based review. One such characteristic, financial conflict of interest related to medical research, is a widespread concern. The purpose of the present study was to determine what proportion of studies on thromboprophylaxis after total joint arthroplasty were sponsored by industry and whether the assessments of thromboprophylaxis after total joint arthroplasty were associated with industry support. METHODS We searched PubMed for prospective, original, English-language studies, published from 2004 to 2010, on thromboprophylaxis after total joint arthroplasty. The funding sources of the articles were reviewed, and qualitative conclusions regarding the modality of interest for thromboprophylaxis after total joint arthroplasty were classified as being favorable, neutral, or unfavorable. RESULTS Seventy-one eligible articles were identified; fifty-two were funded by industry, and fourteen were not. The other five studies did not include information about the funding source. A significant association was observed between the funding source and qualitative conclusions (p = 0.033). Only two (3.8%) of the fifty-two industry-sponsored studies had unfavorable conclusions, whereas three (21.4%) of the fourteen non-industry-sponsored studies indicated that, depending on the clinical scenario, the modality examined was neither effective nor safe. CONCLUSIONS Most studies on thromboprophylaxis after total joint arthroplasty are sponsored by industry. Moreover, the qualitative conclusions in those studies are favorable to the use of the sponsored prophylactic agent.
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Affiliation(s)
- Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-Gu, Sungnam-si, Gyeonggi-do 463-707, South Korea
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Conway EM. Thrombomodulin and its role in inflammation. Semin Immunopathol 2012; 34:107-25. [PMID: 21805323 DOI: 10.1007/s00281-011-0282-8] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 07/20/2011] [Indexed: 12/30/2022]
Abstract
The goal is to provide an extensive review of the physiologic role of thrombomodulin (TM) in maintaining vascular homeostasis, with a focus on its anti-inflammatory properties. Data were collected from published research. TM is a transmembrane glycoprotein expressed on the surface of all vascular endothelial cells. Expression of TM is tightly regulated to maintain homeostasis and to ensure a rapid and localized hemostatic and inflammatory response to injury. By virtue of its strategic location, its multidomain structure and complex interactions with thrombin, protein C (PC), thrombin activatable fibrinolysis inhibitor (TAFI), complement components, the Lewis Y antigen, and the cytokine HMGB1, TM exhibits a range of physiologically important anti-inflammatory, anti-coagulant, and anti-fibrinolytic properties. TM is an essential cofactor that impacts on multiple biologic processes. Alterations in expression of TM and its partner proteins may be manifest by inflammatory and thrombotic disorders. Administration of soluble forms of TM holds promise as effective therapies for inflammatory diseases, and infections and malignancies that are complicated by disseminated intravascular coagulation.
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Affiliation(s)
- Edward M Conway
- Division of Hematology-Oncology, Department of Medicine, Centre for Blood Research (CBR), University of British Columbia, Vancouver, BC, Canada.
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Toschi V, Lettino M. Inhibitors of propagation of coagulation: factors V and X. Br J Clin Pharmacol 2011; 72:563-80. [PMID: 21545479 PMCID: PMC3195734 DOI: 10.1111/j.1365-2125.2011.04001.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 04/05/2011] [Indexed: 12/17/2022] Open
Abstract
Cardiovascular diseases are still the most important cause of morbidity and mortality in western countries and antithrombotic treatment is nowadays widely used. Drugs able to reduce coagulation activation are the treatment of choice for a number of arterial and/or venous thromboembolic conditions. Some of the drugs currently used for this purpose, such as heparins (UFH or LMWH) and VKA, have limitations consisting of a narrow therapeutic window and an unpredictable response with the need of laboratory monitoring in order to assess their efficacy and safety. These drawbacks have stimulated an active research aimed to develop new drugs able to act on single factors involved in the coagulation network, with predictable response. Intense experimental and clinical work on new drugs has focused on synthetic agents, which could preferably be administered orally and at fixed doses. The most advanced clinical development with new anticoagulants has been achieved for those inhibiting FXa and some of them, like fondaparinux, are already currently used in clinical practice. Other agents, such as rivaroxaban, apixaban, otamixaban and edoxaban are under development and have already been studied or are currently under investigation in large scale phase III clinical trials for prevention and treatment of venous thromboembolism, atrial fibrillation and acute coronary syndromes. Some of them have proved to be more effective than conventional therapy. Data on some agents inhibiting FVa are still preliminary and some of these drugs have so far been considered only in patients with disseminated intravascular coagulation secondary to sepsis.
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Affiliation(s)
- Vincenzo Toschi
- Department of Hematology and Blood Transfusion, Thrombosis Center, San Carlo Borromeo Hospital, Milan, Italy.
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Abstract
INTRODUCTION Thromboembolic disease encompasses a spectrum of conditions extending from deep vein thrombosis to stroke and myocardial infarction. The current anticoagulation therapy is cumbersome and characterized by several important drawbacks. AREAS COVERED Existing treatments and latest breakthroughs on emerging anticoagulants are presented. Oral and parenteral novel anticoagulants are being developed and tested for efficacy and safety and results are being published regularly. The introduction of novel anticoagulants marks a new era in the management of anticoagulated patients. It is important for the healthcare provider to understand the benefits and risks of the armamentarium of anticoagulants that will be available in the very near future. The critical conclusions drawn will help the reader look past what is the most highlighted feature of the new anticoagulantion era: the non-necessity for monitoring. EXPERT OPINION Currently, novel anticoagulants seem to lack the indefinable 'charm' of weakness. However, important questions remain unanswered and will require in-depth evaluations.
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Affiliation(s)
- Gentian Denas
- University of Padua School of Medicine, Clinical Cardiology, Thrombosis Center, Department of Cardiothoracic and Vascular Sciences, Via Giustiniani 2, 35128 Padua, Italy
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Ahmed TAN, Karalis I, Jukema JW. Emerging drugs for coronary artery disease. From past achievements and current needs to clinical promises. Expert Opin Emerg Drugs 2011; 16:203-33. [DOI: 10.1517/14728214.2011.549606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Perzborn E, Roehrig S, Straub A, Kubitza D, Misselwitz F. The discovery and development of rivaroxaban, an oral, direct factor Xa inhibitor. Nat Rev Drug Discov 2010; 10:61-75. [PMID: 21164526 DOI: 10.1038/nrd3185] [Citation(s) in RCA: 222] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bal S, Ojha P, Hill MD. Stroke prevention treatment of patients with atrial fibrillation: old and new. Curr Neurol Neurosci Rep 2010; 11:15-27. [PMID: 21086074 DOI: 10.1007/s11910-010-0161-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Atrial fibrillation is the most common cause of cardioembolic ischemic stroke and has a rising prevalence worldwide. Stroke prevention in this condition is poised to take a substantial leap forward with the evolution of new anticoagulant medications, with superior properties compared to vitamin K antagonists. New, safer and more effective chronic therapy is on the horizon. However, many issues surrounding the management of stroke prevention after an acute stroke and during the course of chronic anticoagulant therapy remain to be resolved.
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Affiliation(s)
- Simerpreet Bal
- Departments of Clinical Neurosciences, Calgary Stroke Program, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Gómez-Outes A, Suárez-Gea ML, Lecumberri R, Rocha E, Pozo-Hernández C, Vargas-Castrillón E. New parenteral anticoagulants in development. Ther Adv Cardiovasc Dis 2010; 5:33-59. [PMID: 21045018 DOI: 10.1177/1753944710387808] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The therapeutic armamentarium of parenteral anticoagulants available to clinicians is mainly composed by unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), fondaparinux, recombinant hirudins (i.e. bivalirudin, desirudin, lepirudin) and argatroban. These drugs are effective and safe for prevention and/or treatment of thromboembolic diseases but they have some drawbacks. Among other inconveniences, UFH requires regular anticoagulant monitoring as a result of variability in the anticoagulant response and there is a risk of serious heparin-induced thrombocytopaenia (HIT). LMWH, fondaparinux and recombinant hirudins are mainly cleared through the kidneys and their use in patients with severe renal insufficiency may be problematic. LMWH is only partially neutralized by protamine while fondaparinux and recombinant hirudins have no specific antidote. Novel anticoagulants in development for parenteral administration include new indirect activated factor Xa (FXa) inhibitors (idrabiotaparinux, ultra-low-molecular-weight heparins [semuloparin, RO-14], new LMWH [M118]), direct FXa inhibitors (otamixaban), direct FIIa inhibitors (flovagatran sodium, pegmusirudin, NU172, HD1-22), direct FXIa inhibitors (BMS-262084, antisense oligonucleotides targeting FXIa, clavatadine), direct FIXa inhibitors (RB-006), FVIIIa inhibitors (TB-402), FVIIa/tissue factor inhibitors (tifacogin, NAPc2, PCI-27483, BMS-593214), FVa inhibitors (drotrecogin alpha activated, ART-123) and dual thrombin/FXa inhibitors (EP217609, tanogitran). These new compounds have the potential to complement established parenteral anticoagulants. In the present review, we discuss the pharmacology of new parenteral anticoagulants, the results of clinical studies, the newly planned or ongoing clinical trials with these compounds, and their potential advantages and drawbacks over existing therapies.
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Affiliation(s)
- Antonio Gómez-Outes
- Division of Pharmacology and Clinical Evaluation, Medicines for Human Use, Spanish Agency for Medicines and Health Care Products (AEMPS), Parque Empresarial Las Mercedes, Edificio 8, C/Campezo 1, Madrid, 28022, Spain.
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Cui W, Angsana J, Wen J, Chaikof EL. Liposomal Formulations of Thrombomodulin Increase Engraftment after Intraportal Islet Transplantation. Cell Transplant 2010; 19:1359-67. [DOI: 10.3727/096368910x513964] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Early destruction of donor islet grafts due to an instant blood-mediated inflammatory reaction (IBMIR) remains a major obstacle in islet transplantation. Thrombomodulin plays an important role in limiting coagulation and inflammatory events through a variety of effects. In this study, we investigated the ability of thrombomodulin (TM), when reconstituted as a liposomal formulation, to enhance early syngeneic islet engraftment by minimizing or abrogating the IBMIR. Administration of TM significantly improved early engraftment of syngeneic islets after intraportal transplantation in diabetic mice. In the absence of treatment, conversion to euglycemia was observed among 46.6% (7/15) of recipients. In contrast, administration of TM led to euglycemia in 93.3% (14/15) of recipients ( p = 0.0142). Recipients that received TM exhibited a lower incidence of primary nonfunction and better glucose control over a 30-day period after transplantation. Fibrin deposition ( p < 0.05), neutrophil infiltration ( p < 0.05), expression of TNF-α and IL-β mRNA ( p < 0.05), as well as NF-κB activity ( p < 0.05) were significantly reduced in the liver of islet recipients having been treated with liposomal TM. These data demonstrate that TM significantly improves early syngeneic islet engraftment through effects that target both coagulation and inflammatory pathways.
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Affiliation(s)
- Wanxing Cui
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Julianty Angsana
- Department of Biomedical Engineering, Emory University/Georgia Institute of Technology, Atlanta, GA, USA
| | - Jing Wen
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Elliot L. Chaikof
- Department of Surgery, Emory University, Atlanta, GA, USA
- Department of Biomedical Engineering, Emory University/Georgia Institute of Technology, Atlanta, GA, USA
- School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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Cui W, Wilson JT, Wen J, Angsana J, Qu Z, Haller CA, Chaikof EL. Thrombomodulin improves early outcomes after intraportal islet transplantation. Am J Transplant 2009; 9:1308-16. [PMID: 19459803 PMCID: PMC2759690 DOI: 10.1111/j.1600-6143.2009.02652.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Primary islet nonfunction due to an instant blood mediated inflammatory reaction (IBMIR) leads to an increase in donor islet mass required to achieve euglycemia. In the presence of thrombin, thrombomodulin generates activated protein C (APC), which limits procoagulant and proinflammatory responses. In this study, we postulated that liposomal formulations of thrombomodulin (lipo-TM), due to its propensity for preferential uptake in the liver, would enhance intraportal engraftment of allogeneic islets by inhibiting the IBMIR. Diabetic C57BL/6J mice underwent intraportal transplantation with B10.BR murine islets. In the absence of treatment, conversion to euglycemia was observed among 29% of mice receiving 250 allo-islets. In contrast, a single infusion of lipo-TM led to euglycemia in 83% of recipients (p = 0.0019). Fibrin deposition (p < 0.0001), neutrophil infiltration (p < 0.0001), as well as expression TNF-alpha and IL-beta (p < 0.03) were significantly reduced. Significantly, thrombotic responses mediated by human islets in contact with human blood were also reduced by this approach. Lipo-TM improves the engraftment of allogeneic islets through a reduction in local thrombotic and inflammatory processes. As an enzyme-based pharmacotherapeutic, this strategy offers the potential for local generation of APC at the site of islet infusion, during the initial period of elevated thrombin production.
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Affiliation(s)
- W. Cui
- Department of Surgery, Emory University, Atlanta, GA
| | - J. T. Wilson
- Department of Biomedical Engineering, Emory University/Georgia Institute of Technology, Atlanta, GA
| | - J. Wen
- Department of Surgery, Emory University, Atlanta, GA
| | - J. Angsana
- Department of Biomedical Engineering, Emory University/Georgia Institute of Technology, Atlanta, GA
| | - Z. Qu
- Department of Biomedical Engineering, Emory University/Georgia Institute of Technology, Atlanta, GA
| | - C. A. Haller
- Department of Surgery, Emory University, Atlanta, GA
| | - E. L. Chaikof
- Department of Surgery, Emory University, Atlanta, GA,Department of Biomedical Engineering, Emory University/Georgia Institute of Technology, Atlanta, GA,School of Chemical and Biomolecular Engineering, Georgia Institute of Technology, Atlanta, GA,Corresponding author: Elliot L. Chaikof,
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Weitz JI, Hirsh J, Samama MM. New antithrombotic drugs: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:234S-256S. [PMID: 18574267 DOI: 10.1378/chest.08-0673] [Citation(s) in RCA: 190] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
This chapter focuses on new antithrombotic drugs that are in phase II or III clinical testing. Development of these new agents was prompted by limitations of existing antiplatelet, anticoagulant, or fibrinolytic drugs. Addressing these unmet needs, this chapter (1) outlines the rationale for development of new antithrombotic agents, (2) describes the new antiplatelet, anticoagulant, and fibrinolytic drugs, and (3) provides clinical perspectives on the opportunities and challenges faced by these novel agents.
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Affiliation(s)
- Jeffrey I Weitz
- From the Henderson Research Center, McMaster University, Hamilton, ON, Canada.
| | - Jack Hirsh
- From the Henderson Research Center, McMaster University, Hamilton, ON, Canada
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36
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Development in anticoagulant therapy. Crit Rev Oncol Hematol 2008; 66:145-54. [DOI: 10.1016/j.critrevonc.2007.09.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 07/30/2007] [Accepted: 09/28/2007] [Indexed: 12/21/2022] Open
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Abstract
In contrast to older anticoagulant agents vitamin K antagonists and heparins, the new ones are directed towards a single target in general. The main characteristics of the new agents are: their site of action in the coagulation cascade and their mechanism of action which is indirect, antithrombin dependent, most often such as Fondaparinux and Idraparinux or direct such as Dabigatran, Rivaroxaban; the specificity of the new molecules, since they must not interact with other enzymes: trypsin, kallikrein, t-PA, etc...; their mode of administration parenteral and/or oral; their pharmacokinetics and their clearance frequently by the kidney (Hirudin, fondaparinux) or through hepatic metabolism (argatroban); tolerance including for all compounds the bleeding risk or an unexpected hepatic intolerance for Ximelagatran; the availability of a specific antidote and the cost of the drug; one compound is registered in France Arixtra Fondaparinux in major orthopedic surgery and in the treatment of venous thromboembolism and in prophylactic treatment in medical patients. However, the main indications of interest for these new drugs is atrial fibrillation. There is a real need in this indication and the number of patients to treat is growing with the longer life expectancy.
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Affiliation(s)
- M-M Samama
- Service d'hématologie Biologique, Hôtel-Dieu, place du Parvis Notre-Dame, F 75181 Paris Cedex 04.
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Weitz JI, Linkins LA. Beyond heparin and warfarin: the new generation of anticoagulants. Expert Opin Investig Drugs 2007; 16:271-82. [PMID: 17302522 DOI: 10.1517/13543784.16.3.271] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Heparin and warfarin are widely used for the prevention and treatment of venous and arterial thromboembolism. Although effective, both agents have important limitations; for example, both drugs must be monitored, which is inconvenient for patients and for physicians. Heparin requires parenteral administration and can cause heparin-induced thrombocytopenia, an immune-mediated process that can lead to life-threatening thrombosis. Warfarin also has its limitations. Due to its slow onset of action, warfarin must be overlapped with heparin (or another rapidly acting anticoagulant) when treating patients with established thrombosis or who are at high risk for thrombosis. Warfarin dosing is variable because its activity is influenced by dietary intake of vitamin K, genetic polymorphisms in enzymes that are involved in its metabolism and numerous drug-drug interactions that promote or reduce its activity. New anticoagulants have been developed to overcome these problems. Building on a better understanding of coagulation pathways, advances in structure-based drug design and information derived from natural anticoagulants isolated from hematophagous organisms, most of the new anticoagulants target specific coagulation enzymes. Focussing on drugs that have at least completed Phase II evaluation, this article briefly reviews the coagulation pathways and its natural regulators; outlines the limitations of existing anticoagulants and identifies the opportunities for new ones; highlights the properties of selected new anticoagulants; describes the clinical trial results with these agents; and provides a perspective on their potential strengths and weaknesses.
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Affiliation(s)
- Jeffrey I Weitz
- McMaster University and Henderson Research Centre, 711 Concession Street, Hamilton, Ontario, L8V 1C3, Canada.
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Abstract
PURPOSE OF REVIEW In this paper, recent advances in new anticoagulants with the potential to be used for prevention or treatment of venous thrombosis are reviewed. RECENT FINDINGS Numerous novel anticoagulants targeting specific stages of the coagulant pathway are in various stages of development. Fondaparinux, an indirect activated factor VII inhibitor, has been shown to be effective for initial treatment and prevention of venous thromboembolism, but still requires parenteral administration. Ximelagatran, an oral direct thrombin inhibitor, has also been shown to effective for treatment and prevention of venous thrombosis. Both agents are associated with bleeding, however, and ximelagatran is associated with hepatic toxicity with long-term use. Direct activated factor X inhibitors, orally available forms of heparin, and other direct thrombin inhibitors remain in early stages of development. Further data on the clinical utility of these agents are likely to emerge in the next few years, and uptake of their use will be affected by the cost considerations. SUMMARY Numerous alternative anticoagulants are in varying stages of development. Clinical data have yet to show that these agents have a clearly superior risk-benefit ratio compared with currently used antithrombotics. Many drugs remain in initial stages of development. The ideal anticoagulant agent is being sought but has yet to be discovered.
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Affiliation(s)
- Simon J McRae
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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McRae SJ, Ginsberg JS. New anticoagulants for the prevention and treatment of venous thromboembolism. Vasc Health Risk Manag 2007; 1:41-53. [PMID: 17319097 PMCID: PMC1993925 DOI: 10.2147/vhrm.1.1.41.58936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Anticoagulant therapy is effective at preventing the development of venous thromboembolism in high-risk patients, and reduces morbidity and mortality in individuals with established thromboembolic disease. Vitamin K antagonists and heparins are currently the most commonly used anticoagulant drugs, but they have practical limitations. Therefore, new antithrombotic agents with predictable dose-responses (thereby decreasing the need for monitoring without compromising efficacy or safety), ideally available in an oral formulation and with a rapidly reversible anticoagulant effect, are needed. New drugs fulfilling some of the above criteria have been developed and have proven to be effective agents for the treatment and prevention of venous thromboembolism.
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Affiliation(s)
- Simon J McRae
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Tanaka KA, Levy JH. Regulation of Thrombin Activity—Pharmacologic and Structural Aspects. Hematol Oncol Clin North Am 2007; 21:33-50. [PMID: 17258117 DOI: 10.1016/j.hoc.2006.11.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Thrombin is an essential serine protease for survival. Since the discovery of heparin in the early twentieth century, significant advances have been made in the understanding of thrombin structure and function in coagulation system. Endogenous anticoagulant proteins in blood tightly regulate thrombin generation, but additional anticoagulant agents may be necessary to suppress excessive thrombin formation or defective anticoagulant proteins. Despite the availability of an array of anticoagulant agents based on chemical and biological engineering technologies, anticoagulation therapy remains a challenge for clinicians in terms of balancing bleeding and thrombosis. The aim of this article is to review endogenous serine protease inhibitors and novel antithrombotic agents in relation to pharmacologic regulation of thrombin.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, Division of Cardiothoracic Anesthesia, Emory Healthcare, 1364 Clifton Road N.E., Atlanta, GA 30322, USA.
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Saito H, Maruyama I, Shimazaki S, Yamamoto Y, Aikawa N, Ohno R, Hirayama A, Matsuda T, Asakura H, Nakashima M, Aoki N. Efficacy and safety of recombinant human soluble thrombomodulin (ART-123) in disseminated intravascular coagulation: results of a phase III, randomized, double-blind clinical trial. J Thromb Haemost 2007; 5:31-41. [PMID: 17059423 DOI: 10.1111/j.1538-7836.2006.02267.x] [Citation(s) in RCA: 411] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Soluble thrombomodulin is a promising therapeutic natural anticoagulant that is comparable to antithrombin, tissue factor pathway inhibitor and activated protein C. OBJECTIVES We conducted a multicenter, double-blind, randomized, parallel-group trial to compare the efficacy and safety of recombinant human soluble thrombomodulin (ART-123) to those of low-dose heparin for the treatment of disseminated intravascular coagulation (DIC) associated with hematologic malignancy or infection. METHODS DIC patients (n = 234) were assigned to receive ART-123 (0.06 mg kg(-1) for 30 min, once daily) or heparin sodium (8 U kg(-1) h(-1) for 24 h) for 6 days, using a double-dummy method. The primary efficacy endpoint was DIC resolution rate. The secondary endpoints included clinical course of bleeding symptoms and mortality rate at 28 days. RESULTS DIC was resolved in 66.1% of the ART-123 group, as compared with 49.9% of the heparin group [difference 16.2%; 95% confidence interval (CI) 3.3-29.1]. Patients in the ART-123 group also showed more marked improvement in clinical course of bleeding symptoms (P = 0.0271). The incidence of bleeding-related adverse events up to 7 days after the start of infusion was lower in the ART-123 group than in the heparin group (43.1% vs. 56.5%, P = 0.0487). CONCLUSIONS When compared with heparin therapy, ART-123 therapy more significantly improves DIC and alleviates bleeding symptoms in DIC patients.
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Affiliation(s)
- H Saito
- Jr Tokai General Hospital, Nagoya, Japan.
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Sugiyama S, Hirota H, Kimura R, Kokubo Y, Kawasaki T, Suehisa E, Okayama A, Tomoike H, Hayashi T, Nishigami K, Kawase I, Miyata T. Haplotype of thrombomodulin gene associated with plasma thrombomodulin level and deep vein thrombosis in the Japanese population. Thromb Res 2007; 119:35-43. [PMID: 16507317 DOI: 10.1016/j.thromres.2005.12.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2005] [Revised: 12/19/2005] [Accepted: 12/20/2005] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Thrombomodulin (TM) is an essential cofactor in protein C activation by thrombin. Here, we evaluated the contribution of genetic variations in the TM gene to soluble TM (sTM) level and deep vein thrombosis (DVT) in Japanese. PATIENTS AND METHODS We sequenced the TM putative promoter, exon, and 3'-untranslated region in DVT patients (n=118). Among 17 genetic variations we identified, two missense mutations (R385K, D468Y) and three common single nucleotide polymorphisms (-202G>A, 2487A>T, 2729A>C) were genotyped in a general population of 2247 subjects (1032 men and 1215 women) whose sTM levels were measured. We then compared the frequency of these mutations in DVT patients with that in the age, body mass index-adjusted population-based controls. RESULTS We identified one neutral mutation (H381) and three missense mutations (R385K; n=2, A455V; n=53 heterozygous, n=14 homozygous, D468Y; n=2) of TM in the DVT patients. Age-adjusted mean values of sTM were lower in C-allele carriers of 2729A>C than in noncarriers in the Japanese general population (women: 16.7+/-0.3 U/ml vs. 17.9+/-0.2 U/ml, p<0.01, men: 19.4+/-0.3 U/ml vs. 20.4+/-0.3 U/ml, p=0.03). Additionally, the CC genotype of this mutation was more common in the male DVT patients than in the male individuals of the general population (odds ratio=2.76, 95% confidence interval=1.14-6.67; p=0.02). This mutation was in linkage disequilibrium (r-square>0.9) with A455V mutation. CONCLUSIONS TM mutations, especially those with a haplotype consisting of 2729A>C and A455V missense mutation, affect sTM levels, and may be associated with DVT in Japanese.
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Affiliation(s)
- Shoko Sugiyama
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita City, Osaka 565-0871, Japan
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NG HENGJOO, CROWTHER MARK. New anticoagulants and the management of their bleeding complications. ACTA ACUST UNITED AC 2006. [DOI: 10.1111/j.1778-428x.2006.00026.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Abstract
Currently available anticoagulants include heparin, low-molecular weight heparin, fondaparinux and warfarin. Despite advances with low-molecular weight heparin and fondaparinux, the currently available agents have limitations that have provided the impetus for the development of new drugs for prevention and treatment of both venous and arterial thromboembolism. Novel anticoagulants targeting specific steps in coagulation are in various stages of development. This paper reviews the pharmacology of these new agents and describes the results of clinical trials with new anticoagulants in more advanced stages of clinical testing.
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Tanaka KA, Szlam F, Levy JH. The effect of aprotinin on activated protein C-mediated downregulation of endogenous thrombin generation. Br J Haematol 2006; 134:77-82. [PMID: 16803571 DOI: 10.1111/j.1365-2141.2006.06099.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Thrombin plays a central role in coagulation and haemostasis. Binding of thrombin to thrombomodulin generates activated protein C (APC), which exerts a negative feedback on thrombin formation. Aprotinin, a natural proteinase inhibitor is used extensively during cardiac surgery because this procedure is often associated with profound activation of coagulation and inflammatory pathways. Some in vitro evidences suggest that aprotinin inhibits APC, but the clinical relevance is unclear. The recombinant human soluble thrombomodulin (rhsTM)-modified thrombin generation (TG) assay was used to investigate the effects of aprotinin on APC in plasma samples obtained from healthy volunteers, aprotinin-treated cardiac surgical patients and in protein C (PC)-depleted plasma. Based on the results of in vitro TG assay, addition of rhsTM (0.75-3.0 microg/ml) to volunteer or patient platelet-poor plasma significantly reduced (70.8 +/- 21.9 and 95.3% +/- 4.6%, respectively) thrombin formation when compared with PC-depleted plasma (8.3% +/- 5.2%). Aprotinin (100-200 KIU) caused a small, statistically insignificant decrease in the peak thrombin formation in normal and PC-deficient plasma (12.0 +/- 6.1%). In cardiac surgical patients, levels of functional PC, factor II, antithrombin and platelet significantly decreased after cardiopulmonary bypass (CPB). Soluble thrombomodulin concentrations were increased after CPB (3.5 +/- 2.2 to 5.0 +/- 2.2 ng/ml), but they were still within the normal range for human plasma. Our results showed that, even though endogenous PC level is decreased after CPB, it retains its activity in the presence of thrombomodulin, and aprotinin has limited inhibitory effect on APC generation.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA.
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Ng HJ, Crowther MA. New Anti-thrombotic Agents: Emphasis on Hemorrhagic Complications and Their Management. Semin Hematol 2006; 43:S77-83. [PMID: 16427390 DOI: 10.1053/j.seminhematol.2005.11.023] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Our advanced knowledge of coagulation has led to the synthesis of novel procoagulant substances, such as recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark). Similarly, in-depth understanding of the interaction between anticoagulant proteins and their natural inhibitors has led to the synthesis of various novel anticoagulants. Novel anticoagulants are characterized by highly specific coagulation-inhibiting activities and, frequently, a complete lack of effective antidotes. This lack of antidotes is particularly important in the case of novel inhibitors with extended half-lives; for example, idraparinux may produce effective anticoagulation for as long as one week after subcutaneous administration. As novel anticoagulants complete licensing evaluations and are used in clinical practice, the likelihood of anticoagulant-associated hemorrhage will increase. This will require physicians to have an understanding of the mechanism of action of these anticoagulants, and to have an advanced degree of knowledge of the potential specific and nonspecific inhibitors of these anticoagulant agents. This paper will briefly review the biochemistry of coagulation, focusing on the complexes inhibited by currently available and novel anticoagulants. Specific and nonspecific prohemostatic agents will be reviewed and discussed. The ability of nonspecific procoagulant agents (particularly rFVIIa) to reverse the effects of novel anticoagulants will also be reviewed.
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Affiliation(s)
- Heng Joo Ng
- Department of Haematology, Singapore General Hospital, Singapore
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