Antithrombotic Therapy

Glycosaminoglycans and activated contact system in cancer patient plasmas

Oncogenic mutations create cancer cells. Cancer cells require thrombin for growth, angiogenesis, and metastasis. All cancer patients display a hypercoagulable state, which includes platelet activation, blood coagulation, complement activation, vasodilatation, and inflammation. This often results in thrombosis, the second leading cause of death in cancer patients. It is established that chemically oversulfated glycosaminoglycans (GAGs) induce thrombin generation through contact system activation in human plasma. Thrombin is responsible for thrombosis. In this chapter, we show that plasmas from lung cancer patients contain activated contact systems apparent by the absence of high molecular weight kininogen and processed C1inh, by abnormal kallikrein and thrombin activities, and by increased glucosamine, galactosamine, and GAG levels. Activated contact systems were also evident in plasmas from breast, colon, and pancreatic cancer patients. These data suggest that GAGs or other molecules produced by tumors induce abnormal thrombin generation through contact system activation. Therefore, the contact system and glycans represent new targets for cancer diagnosis, prevention, and treatment.

Oversulfated Heparin By-Products Induce Thrombin Generation in Human Plasmas Through Contact System Activation

Thrombin generation is thought to be mediated predominantly by the tissue factor or ‘‘extrinsic’’ coagulation pathway. An alternate pathway to thrombin generation (the ‘‘intrinsic’’ pathway or contact system) has been observed when blood or plasma comes in contact with artificial surfaces. Here we present evidence for a new route to thrombin formation that begins with the activation of the contact system protein prekallikrein by oversulfated heparin (OS-HB). Kallikrein, instead of activated factor X, cleaves prothrombin to form thrombin. Thrombin then cleaves fibrinogen to form fibrin clots. Moreover, we show that OS-HB by-products induce kallikrein- and thrombin-like activities in normal human plasma and in human plasma devoid of coagulation factor X or downstream contact system components factor IX or factor XI. Oversulfated heparin by-product-induced thrombin generation may have had a role in the adverse reactions associated with the recent clinical use of contaminated heparin.

Glycosaminoglycan (GAG) biosynthesis and GAG-binding proteins

Two major types of glycosaminoglycan (GAG) polysaccharides, heparan sulfate and chondroitin sulfate, are polymerized and modified by enzymes that are encoded by more than 40 genes in animal cells. Because of the expression repertoire of the GAG assembly and modification enzymes, each heparan sulfate and chondroitin sulfate chain has a sulfation pattern, chain length, and fine structure that is potentially unique to each animal cell. GAGs interact with hundreds of proteins. Such interactions protect growth factors, chemokines, and cytokines against proteolysis. GAGs catalyze protease (such as thrombin) inhibition by serpins. GAGs regulate multiple signaling pathways including, but not limited to, fibroblast growth factor (FGF)/FGFR, hepatocyte growth factor (HGF)/c-Met, glial cell line-derived neurotrophic factor (GDNF)/c-Ret/GFRalpha1, vascular endothelial growth factor (VEGF)/VEGFR, platelet derived growth factor (PDGF)/PDGFR, BAFF/TACI, Indian hedgehog, Wnt, and BMP signaling pathways,where genetic studies have revealed an absolute requirement for GAGs in these pathways. Most importantly, protein/GAG aggregates induce thrombin generation and immune system upregulation by activating the contact system. Abnormal protein/GAG aggregates are associated with a variety of devastating human diseases including, but not limited to, Alzheimer's, diabetes, prion or transmissible spongiform encephalopathies, Lupus, heparin-induced thrombocytopenia/thrombosis, and different kinds of cancers. Therefore, GAGs are essential components of modern molecular biology and human physiology. Understanding GAG structure and function at molecular level with regard to development and health represents a unique opportunity in combating different kinds of human diseases.

Clinical pharmacology of antithrombotic drugs in coronary artery disease

Coronary heart disease is the leading cause of death in the Western world. Antithrombotic therapy is the cornerstone of its successful treatment. Clinical trials have demonstrated that antithrombotic therapy reduces the risk for recurrent myocardial infarction and cardiovascular death. Antiplatelet drugs and anticoagulants interfere with haemostasis and thus bleeding is a major risk factor of these drugs. The benefit of antithrombotic therapy must therefore be carefully balanced with the risk of bleeding and other potential adverse reactions of these drugs. However, to date there is no firm evidence that dosage adaptation of aspirin or clopidogrel according to platelet aggregation testing translates directly into any clinical benefit. Resistance to antithrombotic drugs is a serious problem because these patients are at a higher risk of myocardial infarction, stroke and cardiovascular death. It has most recently been demonstrated that resistance to clopidogrel is at least in part caused by polymorphism of CYP2C19. Clinical trials have also demonstrated that optimal benefit in different settings depends unequivocally on the meticulous choice of the various drugs. Thus, profound knowledge of the clinical pharmacological profiles of the different antithrombotic drugs is indispensable for successful treatment.