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A concomitant bone fracture delays cognitive recovery from traumatic brain injury. J Trauma Acute Care Surg 2019; 85:275-284. [PMID: 29787539 DOI: 10.1097/ta.0000000000001957] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Brain injury progression after severe traumatic brain injury (TBI) is associated with worsening cerebral inflammation but it is unknown how a concomitant bone fracture (BF) affects this progression. Enoxaparin (ENX) decreases penumbral leukocyte mobilization after TBI and improves neurologic recovery. We hypothesized that a concomitant BF worsens learning/memory recovery weeks after TBI and that ENX improves this recovery. METHODS CD1 male mice underwent controlled cortical impact or sham craniotomy with or without tibial fracture, receiving either daily ENX (0.8 mg/kg) or saline for 14 days after injury. Randomization defined four groups (Sham, TBI only, TBI + Fx, TBI + Fx + ENX, n = 5/each). Body weight loss and neurologic recovery (Garcia Neurologic Test, max score = 18) were assessed each day. Mouse learning (swimming time [s] and total distance [m] to reach the submerged platform Days 14 to 17 after TBI) and memory (swimming time [s] in platform quadrant after platform removed [probe]) was assessed by the Morris water maze. Ly-6G (cerebral neutrophil sequestration) and glial fibrillary acidic protein were evaluated by immunohistochemistry in brain tissue post mortem. Analysis of variance with Tukey's post hoc test determined significance (p < 0.05). RESULTS A concurrent BF worsened Garcia Neurologic Test scores post-TBI Days 2 to 4 (p < 0.01) as compared with TBI only, and ENX reversed this worsening on Day 4 (p < 0.01). Learning was significantly slower (greater swimming time and distance) in TBI + Fx versus TBI only on Day 17 (p < 0.01). This was despite similar swimming velocities in both groups, indicating intact extremity motor function. Memory was similar in isolated TBI and Sham which was significantly better than in TBI + Fx animals (p < 0.05). Glial fibrillary acidic protein-positive cells in penumbral cortex were most prevalent in TBI + Fx animals, significantly greater than in Sham (p < 0.05). CONCLUSION A long BF accompanying TBI worsens early neurologic recovery and subsequent learning/memory. Enoxaparin may partially counter this and improve neurologic recovery.
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Suto Y, Nagata K, Ahmed SM, Jacovides CL, Browne KD, Cognetti J, Johnson VE, Leone R, Kaplan LJ, Smith DH, Pascual JL. Cerebral Edema and Neurological Recovery after Traumatic Brain Injury Are Worsened if Accompanied by a Concomitant Long Bone Fracture. J Neurotrauma 2018; 36:609-618. [PMID: 30084745 DOI: 10.1089/neu.2018.5812] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Progression of severe traumatic brain injury (TBI) is associated with worsening cerebral inflammation, but it is unknown how a concomitant bone fracture (FX) affects this progression. Enoxaparin (ENX), a low molecular weight heparin often used for venous thromboembolic prophylaxis, decreases penumbral leukocyte (LEU) mobilization in isolated TBI and improves neurological recovery. We investigated if TBI accompanied by an FX worsens LEU-mediated cerebral inflammation and if ENX alters this process. CD1 male mice underwent controlled cortical impact (CCI) or sham craniotomy with or without an open tibial FX, and received either ENX (1 mg/kg, three times/day) or saline for 2 days following injury. Randomization defined four groups (Sham, CCI, CCI+FX, CCI+FX+ENX, n = 10/group). Two days after CCI, neurological recovery was assessed with the Garcia Neurological Test (GNT); intravital microscopy (LEU rolling and adhesion, microvascular leakage) and blood hemoglobin levels were also evaluated. Penumbral cerebral neutrophil sequestration (Ly-6G immunohistochemistry [IHC]) were evaluated post-mortem. In vivo LEU rolling was greater in CCI+FX (45.2 ± 4.8 LEUs/100 μm/min) than in CCI alone (26.5 ± 3.1, p = 0.007), and was suppressed by ENX (23.2 ± 5.5, p = 0.003 vs. CCI + FX). Neurovascular permeability was higher in CCI+FX (71.1 ± 2.9%) than CCI alone (42.5 ± 2.3, p < 0.001). GNT scores were lower in CCI+FX (15.2 ± 0.2) than in CCI alone (16.3 ± 0.3, p < 0.001). Hemoglobin was lowest in the CCI+FX+ENX group, lower than in Sham or CCI. IHC demonstrated greatest polymorphonuclear neutrophil (PMN) invasion in CCI+FX in uninjured cerebral territories. A concomitant long bone FX worsens TBI-induced cerebral LEU mobilization, microvascular leakage, and cerebral edema, and impairs neurological recovery at 48 h. ENX suppresses this progression but may increase bleeding.
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Affiliation(s)
- Yujin Suto
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Katsuhiro Nagata
- 3 Department of Emergency and Critical Care Medicine, Tokyo Medical University Hachioji Medical Center , Tokyo, Japan
| | - Syed M Ahmed
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Christina L Jacovides
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Kevin D Browne
- 2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - John Cognetti
- 2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Victoria E Johnson
- 2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Ryan Leone
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Lewis J Kaplan
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Douglas H Smith
- 2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Jose L Pascual
- 1 Division of Traumatology, Surgical Clinical Care and Emergency Surgery, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania.,2 Department of Neurosurgery, Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
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Gargiulo G, Moschovitis A, Windecker S, Valgimigli M. Developing drugs for use before, during and soon after percutaneous coronary intervention. Expert Opin Pharmacother 2016; 17:803-18. [DOI: 10.1517/14656566.2016.1145666] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Thind GS, Parida R, Gupta N. Pharmacotherapy in the cardiac catheterization laboratory: evolution and recent developments. Ther Clin Risk Manag 2014; 10:885-900. [PMID: 25364258 PMCID: PMC4211856 DOI: 10.2147/tcrm.s71927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Many recent innovations have been made in developing new antiplatelet and anticoagulant drugs in the last few years, with a total of nine new antithrombotic drugs approved by the Food and Drug Administration after the year 2000. This has revolutionized the medical therapy given to manage acute coronary syndrome and support cardiac catheterization. The concept of dual antiplatelet therapy has been emphasized, and clopidogrel has emerged as the most-popular second antiplatelet drug after aspirin. Newer P2Y12 inhibitors like prasugrel and ticagrelor have been extensively studied and compared to clopidogrel. The role of glycoprotein (Gp) IIb/IIIa inhibitors is being redefined. Other alternatives to unfractionated heparin have become available, of which enoxaparin and bivalirudin have been studied the most. Apart from these, many more drugs with novel therapeutic targets are being studied and are currently under development. In this review, current evidence on these drugs is presented and analyzed in a way that would facilitate decision making for the clinician. For this analysis, various high-impact clinical trials, pharmacological studies, meta-analyses, and reviews were accessed through the MEDLINE database. Adopting a unique interdisciplinary approach, an attempt has been made to integrate pharmacological and clinical evidence to better understand and appreciate the pros and cons of each of these classes of drugs.
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Affiliation(s)
| | - Raunak Parida
- SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
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Bhatty S, Ali A, Shetty R, Sumption KF, Topaz O, Jovin IS. Contemporary anticoagulation therapy in patients undergoing percutaneous intervention. Expert Rev Cardiovasc Ther 2014; 12:451-61. [PMID: 24506409 DOI: 10.1586/14779072.2014.885839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The proper use of anticoagulants is crucial for ensuring optimal patient outcomes post percutaneous interventions in the cardiac catheterization laboratory. Anticoagulant agents such as unfractionated heparin, a thrombin inhibitor; low-molecular weight heparins, predominantly Factor Xa inhibitors; fondaparinux, a Factor Xa inhibitor and bivalirudin, a direct thrombin inhibitor have been developed to target various steps in the coagulation cascade to prevent formation of thrombin. Optimal anticoagulation achieves the correct balance between thrombosis and bleeding and is related to optimal outcomes with minimal complications. This review will discuss the mechanisms and appropriate use of current and emerging anticoagulant therapies used during percutaneous interventions.
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Affiliation(s)
- Shaun Bhatty
- Department of Internal Medicine, Cardiovascular Division, Virginia Commonwealth University Health System/Medical College of Virginia, Richmond, VA, USA
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Gesslbauer B, Theuer M, Schweiger D, Adage T, Kungl AJ. New targets for glycosaminoglycans and glycosaminoglycans as novel targets. Expert Rev Proteomics 2013; 10:77-95. [PMID: 23414361 DOI: 10.1586/epr.12.75] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Biological functions of a variety of proteins are mediated via their interaction with glycosaminoglycans (GAGs). The structural diversity within the wide GAG landscape provides individual interaction sites for a multitude of proteins involved in several pathophysiological processes. This 'GAG angle' of such proteins as well as their specific GAG ligands give rise to novel therapeutic concepts for drug development. Current glycomic technologies to elucidate the glycan structure-function relationships, methods to investigate the selectivity and specificity of glycan-protein interactions and existing therapeutic approaches to interfere with GAG-protein interactions are discussed.
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Affiliation(s)
- Bernd Gesslbauer
- ProtAffin Biotechnologie AG, Reininghausstrasse 13a, 8020 Graz, Austria
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Součková L, Opatřilová R, Suk P, Čundrle I, Pavlík M, Zvoníček V, Hlinomaz O, Šrámek V. Impaired bioavailability and antiplatelet effect of high-dose clopidogrel in patients after cardiopulmonary resuscitation (CPR). Eur J Clin Pharmacol 2012; 69:309-17. [PMID: 22890586 DOI: 10.1007/s00228-012-1360-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 07/13/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Bioavailability of clopidogrel in the form of crushed tablets administered via nasogastric tube (NGT) has not been established in patients after cardiopulmonary resuscitation. Therefore, we performed a study comparing pharmacokinetic and pharmacodynamic response to high loading dose of clopidogrel in critically ill patients after cardiopulmonary resuscitation (CPR) with patients scheduled for elective coronary angiography with stent implantation. METHODS In the NGT group (nine patients, after cardiopulmonary resuscitation, mechanically ventilated, therapeutic hypothermia), clopidogrel was administered in the form of crushed tablets via NGT. Ten patients undergoing elective coronary artery stenting took clopidogrel per os (po) in the form of intact tablets. Pharmacokinetics of clopidogrel was measured with high-performance liquid chromatography (HPLC) before and at 0.5, 1, 6, 12, 24 h after administration of a loading dose of 600 mg. In five patients in each group, antiplatelet effect was measured with thrombelastography (TEG; Platelet Mapping) before and 24 h after administration. RESULTS The carboxylic acid metabolite of clopidogrel was detected in all patients in the po group. In eight patients, the maximum concentration was measured in the range of 0.5-1 h after the initial dose. In four patients in the of NGT group, the carboxylic acid metabolite of clopidogrel was undetectable and in the remaining patients was significantly delayed (peak values at 12 h). All patients in the po group reached clinically relevant (>50 %) inhibition of thrombocyte adenosine diphosphate (ADP) receptor after 24 h compared with only two in the NGT group (p = 0.012). There was a close correlation between peak of inactive clopidogrel metabolite plasmatic concentration and inhibition of the ADP receptor (r = 0.79; p < 0.001). CONCLUSION The bioavailability of clopidogrel in critically ill patients after cardiopulmonary resuscitation is significantly impaired compared with stable patients. Therefore, other drugs, preferentially administered intravenously, should be considered.
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Affiliation(s)
- L Součková
- Department of Anaesthesiology and Intensive Care, University Hospital St. Anne's Brno, Brno, Czech Republic
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The effects of heparins on the liver: application of mechanistic serum biomarkers in a randomized study in healthy volunteers. Clin Pharmacol Ther 2012; 92:214-20. [PMID: 22739141 PMCID: PMC4320779 DOI: 10.1038/clpt.2012.40] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Heparins have been reported to cause elevations in serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) but have not been associated with clinically significant liver injury. The mechanisms underlying these benign laboratory abnormalities are unknown. Forty-eight healthy men were randomized to receive subcutaneous injections of unfractionated heparin (UFH; 150 U/kg), enoxaparin sodium (1 mg/kg), dalteparin sodium (120 IU/kg), or adomiparin sodium (125 IU/kg; a novel heparin) every 12 h for 4.5 days. Asymptomatic elevations in serum ALT or AST were observed in >90% of the subjects. Elevations were also observed in the levels of serum sorbitol dehydrogenase (SDH), glutamate dehydrogenase (GLDH), miR-122, high-mobility group box-1 protein (including the acetylated form), full-length keratin 18, and DNA. Keratin 18 fragments, which are apoptosis biomarkers, were not detected. Biomarker profiles did not differ significantly across heparin treatments. We conclude that heparins as a class cause self-limited and mild hepatocyte necrosis with secondary activation of an innate immune response.
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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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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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Dixon SR, Grines CL. The Year in Interventional Cardiology. J Am Coll Cardiol 2011. [DOI: 10.1016/j.jacc.2011.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Giugliano RP, Braunwald E. The year in non-ST-segment elevation acute coronary syndrome. J Am Coll Cardiol 2011; 56:2126-38. [PMID: 21144974 DOI: 10.1016/j.jacc.2010.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Revised: 08/30/2010] [Accepted: 09/02/2010] [Indexed: 12/30/2022]
Affiliation(s)
- Robert P Giugliano
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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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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