1
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Roberts LN, Arya R, Hunt BJ. Advances and current research in primary thromboprophylaxis to prevent hospital-associated venous thromboembolism. Br J Haematol 2024; 204:1635-1648. [PMID: 38577829 DOI: 10.1111/bjh.19424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
Hospital-associated venous thromboembolism (VTE) is defined as any case of VTE occurring during hospital admission and for up to 90 days post discharge. It accounts for over 50% of all cases of VTE internationally; indeed, there are an estimated 10 million cases of hospital-associated VTE annually. Over the last decade, there has been increasing interest in improving VTE risk assessment and thromboprophylaxis. This review summarises all the recent and ongoing major research studies and future challenges in the different areas, including medical, surgical and obstetric patients, as well as special areas such as lower limb immobilisation. We include sections on both pharmacological and mechanical thromboprophylaxis.
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Affiliation(s)
- Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Roopen Arya
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, London, UK
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2
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Schlake A, Scheiermann P, Weber CF. [What is new…for factor XI inhibitors: DOAC 2.0?]. Anaesthesiologie 2024; 73:272-274. [PMID: 38568254 PMCID: PMC11021273 DOI: 10.1007/s00101-024-01396-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/17/2024]
Affiliation(s)
- A Schlake
- Abteilung für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Klinik Wandsbek, Alphonsstraße 14, 22043, Hamburg, Deutschland
| | - P Scheiermann
- Klinik für Anaesthesiologie, LMU Klinikum München, München, Deutschland
| | - C F Weber
- Abteilung für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Klinik Wandsbek, Alphonsstraße 14, 22043, Hamburg, Deutschland.
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland.
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3
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Presume J, Ferreira J, Ribeiras R. Factor XI Inhibitors: A New Horizon in Anticoagulation Therapy. Cardiol Ther 2024; 13:1-16. [PMID: 38306010 PMCID: PMC10899133 DOI: 10.1007/s40119-024-00352-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024] Open
Abstract
Anticoagulation therapy has undergone significant evolution, marked by the emergence of direct oral anticoagulants with distinct advantages. Despite these advancements, challenges persist in managing residual thrombotic and bleeding risks, particularly among vulnerable populations. The pursuit of alternative drugs has honed in on factor XI/XIa inhibitors. This comprehensive review delves into several key aspects regarding this new target: (i) the role of factor XI in the coagulation cascade; (ii) the genetic evidence and pathophysiologic rationale supporting factor XI inhibition as a therapeutic target; (iii) an exploration of the various types of factor XI/XIa inhibitors currently under investigation; (iv) potential applications of these medications, spanning thromboprophylaxis after orthopedic surgery, stroke prevention in atrial fibrillation, secondary prevention after acute coronary syndrome, non-cardioembolic stroke, thromboprophylaxis after foreign material implantation, end-stage renal disease, and patients with cancer; and (v) an overview of ongoing studies, recent findings, and the future trajectory of research into these drugs.
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Affiliation(s)
- João Presume
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
- Comprehensive Health Research Centre, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Jorge Ferreira
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal
| | - Regina Ribeiras
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo Dos Santos, Carnaxide, 2790-134, Lisbon, Portugal.
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4
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Andreotti F, Massetti M, Montalescot G. Thrombosis, Bleeding, and the Promise of Factor XI(a) Inhibition. J Am Coll Cardiol 2024; 83:679-681. [PMID: 38325993 DOI: 10.1016/j.jacc.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 02/09/2024]
Affiliation(s)
- Felicita Andreotti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University Medical School, Rome, Italy.
| | - Massimo Massetti
- Department of Cardiovascular Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University Medical School, Rome, Italy
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (AP-HP), Paris, France
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5
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Verstraete A, Engelen MM, Van Edom C, Vanassche T, Verhamme P. Reshaping Anticoagulation: Factor XI Inhibition in Thrombosis Management. Hamostaseologie 2024; 44:49-58. [PMID: 38122819 DOI: 10.1055/a-2202-8620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Affiliation(s)
- Andreas Verstraete
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Matthias M Engelen
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Charlotte Van Edom
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
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6
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Prakash S, Mares AC, Porres-Aguilar M, Mukherjee D, Barnes GD. Factor XI/XIa inhibitors for the prevention and treatment of venous and arterial thromboembolism: A narrative review. Vasc Med 2024; 29:85-92. [PMID: 37947131 DOI: 10.1177/1358863x231206778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
During the past decade, direct oral anticoagulants (DOACs) have advanced and simplified the prevention and treatment of venous thromboembolism (VTE). However, there remains a high incidence of bleeds, which calls for agents that have a reduced risk of bleeding. Factor XI (FXI) deficiency is associated with lower rates of venous thrombosis and stroke compared to the general population with a lower risk of bleeding. In conjunction with this, phase 2 studies have demonstrated safety and the potential for reduced thrombotic events with FXI inhibitors as compared to currently available medications. The aim of this review is to summarize key data on the clinical pharmacology of FXI, the latest developments in clinical trials of FXI inhibitors, and to describe the efficacy and safety profiles of FXI inhibitors for the prevention of venous and arterial thromboembolism.
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Affiliation(s)
- Swathi Prakash
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Adriana C Mares
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
- Yale University School of Medicine, New Haven, CT, USA
| | - Mateo Porres-Aguilar
- Department of Internal Medicine, Divisions of Hospital and Adult Thrombosis Medicine, Texas Tech University Health Sciences Center and Paul L Foster School of Medicine, El Paso, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center and Paul L Foster School of Medicine, El Paso, TX, USA
| | - Geoffrey D Barnes
- Department of Internal Medicine, Division of Cardiovascular Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
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7
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Páramo JA, Marcos-Jubilar M. [Factor XI inhibitors: A new era in antithrombotic therapy]. Med Clin (Barc) 2024; 162:73-76. [PMID: 37863734 DOI: 10.1016/j.medcli.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 10/22/2023]
Affiliation(s)
- José A Páramo
- Servicio de Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España.
| | - María Marcos-Jubilar
- Servicio de Hematología y Hemoterapia, Clínica Universidad de Navarra, Pamplona, España
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8
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Santagata D, Donadini MP, Ageno W. Factor XI inhibitors for the prevention of cardiovascular disease: A new therapeutic approach on the horizon? Blood Rev 2023; 62:101119. [PMID: 37580207 DOI: 10.1016/j.blre.2023.101119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/16/2023]
Abstract
Anticoagulant drugs that are currently used to prevent and/or treat thrombosis have some limitations that hinder their ability to meet specific clinical requirements. While these drugs effectively reduce the rates of thrombotic events, they simultaneously increase the risk of bleeding. Moreover, their risk-to-benefit balance is problematic in some patients, such as those with severe chronic kidney disease or those at high bleeding risk. A novel anticoagulation method, FXI inhibition has emerged as a promising alternative. It demonstrates a strong rationale for the prevention and treatment of venous thromboembolism and the potential fulfillment of unmet clinical needs in the cardiovascular field. A number of FXI inhibitors are currently undergoing clinical investigation. The objective of this review is to provide an overview of early results of research on FXI inhibitors in the cardiovascular setting, offering valuable insights into their potential role in shaping the future of anticoagulation.
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Affiliation(s)
- D Santagata
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - M P Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Medicine and Surgery, University of Insubria, Varese, Italy.
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9
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Vedovati MC, Becattini C, Agnelli G. A new strategy for anticoagulation: The factor XI inhibitors. Eur J Intern Med 2023; 116:8-15. [PMID: 37544845 DOI: 10.1016/j.ejim.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Direct oral anticoagulants (DOACs) are currently the first-choice therapy for the prevention of cardioembolic events in patients with atrial fibrillation and for the treatment of venous thromboembolism (VTE) due to their more favorable efficacy to safety profile in comparison to vitamin K antagonists (VKA). DOACs did not show a clinical benefit when used for in stroke prevention in patients with mechanic or rheumatic valves or in those who underwent transcatheter aortic valve implantation (TAVI), in the treatment of VTE in patients with antiphospholipid antibody syndrome and in prevention of VTE in medically ill patients. There are some concerns for bleeding excess at the gastrointestinal site for some, but not all, DOACs. In recent years, in order to overcome the limitations of the available DOACs and to explore the advantages of anticoagulation in additional clinical settings, the development of factor XI and factor XII inhibitors as anticoagulant agents has been proposed. Emerging data show that factor XI has a minor role in the physiological process of hemostasis and an important role in the development of thrombosis. Bleeding has been viewed for several years as an unavoidable side effect of anticoagulant therapy. The aim of factor XI inhibitors is to challenge this dogma by favoring the uncoupling between hemostasis and thrombosis. This paper provides an update on the rationale for the use of factor XI inhibitors, their pharmacological properties and the preliminary clinical findings.
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Affiliation(s)
- Maria Cristina Vedovati
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Giorgio Menghini, 3, Perugia 06129, Italy.
| | - Cecilia Becattini
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Giorgio Menghini, 3, Perugia 06129, Italy
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazzale Giorgio Menghini, 3, Perugia 06129, Italy; Maugeri Scientific Clinical Institutes - IRCCS, Pavia, Italy
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10
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Poenou G, Heestermans M, Lafaie L, Accassat S, Moulin N, Rodière A, Petit B, Duvillard C, Mismetti P, Bertoletti L. Inhibition of Factor XI: A New Era in the Treatment of Venous Thromboembolism in Cancer Patients? Int J Mol Sci 2023; 24:14433. [PMID: 37833881 PMCID: PMC10572808 DOI: 10.3390/ijms241914433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/03/2023] [Accepted: 09/13/2023] [Indexed: 10/15/2023] Open
Abstract
Direct oral anticoagulants against activated factor X and thrombin were the last milestone in thrombosis treatment. Step by step, they replaced antivitamin K and heparins in most of their therapeutic indications. As effective as the previous anticoagulant, the decreased but persistent risk of bleeding while using direct oral anticoagulants has created space for new therapeutics aiming to provide the same efficacy with better safety. On this basis, drug targeting factor XI emerged as an option. In particular, cancer patients might be one of the populations that will most benefit from this technical advance. In this review, after a brief presentation of the different factor IX inhibitors, we explore the potential benefit of this new treatment for cancer patients.
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Affiliation(s)
- Géraldine Poenou
- Therapeutic and Vascular Medecine Department, Saint-Etienne Universitary Hospital Center, F-42270 Saint-Priest en Jarez, France (C.D.)
- INSERM, U 1059 SAINBIOSE, Jean Monnet University, Mines Saint-Étienne, F-42023 Saint Priest en Jarez, France
| | - Marco Heestermans
- INSERM, U 1059 SAINBIOSE, Jean Monnet University, Mines Saint-Étienne, F-42023 Saint Priest en Jarez, France
- French Blood Establishement Auvergne-Rhône-Alpes, Research Department, F-42023 Saint-Etienne, France
| | - Ludovic Lafaie
- INSERM, U 1059 SAINBIOSE, Jean Monnet University, Mines Saint-Étienne, F-42023 Saint Priest en Jarez, France
- Geriatry Department, Saint-Etienne Universitary Hospital Center, F-42000 Saint-Etienne, France
| | - Sandrine Accassat
- Therapeutic and Vascular Medecine Department, Saint-Etienne Universitary Hospital Center, F-42270 Saint-Priest en Jarez, France (C.D.)
- INSERM, CIC-1408, Saint-Etienne Universitary Hospital Center, F-42055 Saint Priest en Jarez, France
| | - Nathalie Moulin
- Therapeutic and Vascular Medecine Department, Saint-Etienne Universitary Hospital Center, F-42270 Saint-Priest en Jarez, France (C.D.)
| | - Alexandre Rodière
- Therapeutic and Vascular Medecine Department, Saint-Etienne Universitary Hospital Center, F-42270 Saint-Priest en Jarez, France (C.D.)
| | - Bastien Petit
- Therapeutic and Vascular Medecine Department, Saint-Etienne Universitary Hospital Center, F-42270 Saint-Priest en Jarez, France (C.D.)
| | - Cécile Duvillard
- Therapeutic and Vascular Medecine Department, Saint-Etienne Universitary Hospital Center, F-42270 Saint-Priest en Jarez, France (C.D.)
| | - Patrick Mismetti
- Therapeutic and Vascular Medecine Department, Saint-Etienne Universitary Hospital Center, F-42270 Saint-Priest en Jarez, France (C.D.)
- INSERM, U 1059 SAINBIOSE, Jean Monnet University, Mines Saint-Étienne, F-42023 Saint Priest en Jarez, France
- INSERM, CIC-1408, Saint-Etienne Universitary Hospital Center, F-42055 Saint Priest en Jarez, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
| | - Laurent Bertoletti
- Therapeutic and Vascular Medecine Department, Saint-Etienne Universitary Hospital Center, F-42270 Saint-Priest en Jarez, France (C.D.)
- INSERM, U 1059 SAINBIOSE, Jean Monnet University, Mines Saint-Étienne, F-42023 Saint Priest en Jarez, France
- INSERM, CIC-1408, Saint-Etienne Universitary Hospital Center, F-42055 Saint Priest en Jarez, France
- F-CRIN INNOVTE Network, F-42000 Saint-Etienne, France
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11
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Jones A, Al-Horani RA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors. Med Sci (Basel) 2023; 11:49. [PMID: 37606428 PMCID: PMC10443384 DOI: 10.3390/medsci11030049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7-14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration.
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Affiliation(s)
| | - Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA;
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12
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Yin Q, Zhang X, Liao S, Huang X, Wan CC, Wang Y. Potential anticoagulant of traditional chinese medicine and novel targets for anticoagulant drugs. Phytomedicine 2023; 116:154880. [PMID: 37267694 DOI: 10.1016/j.phymed.2023.154880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/04/2023] [Accepted: 05/12/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Anticoagulants are the main drugs used for the prevention and treatment of thrombosis. Currently, anticoagulant drugs are primarily multitarget heparin drugs, single-target FXa inhibitors and FIIa inhibitors. In addition, some traditional Chinese drugs also have anticoagulant effects, but they are not the main direction of treatment at present. But the anticoagulant drugs mentioned above, all have a common side effect is bleeding. Many other anticoagulation targets are under investigation. With further exploration of coagulation mechanism, how to further determine new anticoagulant targets and how to make traditional Chinese medicine play anticoagulant role have become a new field of exploration. PURPOSE The purpose of the study was to summarize the recent research progress on coagulation mechanisms, new anticoagulant targets and traditional Chinese medicine. METHODS A comprehensive literature search was conducted using four electronic databases, including PubMed, Embase, CNKI, Wanfang database and ClinicalTrials.gov, from the inception of the study to 28 Feb 2023. Key words used in the literature search were "anticoagulation", "anticoagulant targets", "new targets", "coagulation mechanisms", "potential anticoagulant", "herb medicine", "botanical medicine", "Chinese medicine", "traditional Chinese medicine", "blood coagulation factor", keywords are linked with AND/OR. Recent findings on coagulation mechanisms, potential anticoagulant targets and traditional Chinese medicine were studied. RESULTS The active components extracted from the Chinese medicinal herbs, Salvia miltiorrhiza, Chuanxiong rhizoma, safflower and Panax notoginseng have obvious anticoagulant effects and can be used as potential anticoagulant drugs, but the risk of bleeding is unclear. TF/FVIIa, FVIII, FIX, FXI, FXII, and FXIII have all been evaluated as targets in animal studies or clinical trials. FIX and FXI are the most studied anticoagulant targets, but FXI inhibitors have shown stronger advantages. CONCLUSION This review of potential anticoagulants provides a comprehensive resource. Literature analysis suggests that FXI inhibitors can be used as potential anticoagulant candidates. In addition, we should not ignore the anticoagulant effect of traditional Chinese medicine, and look forward to more research and the emergence of new drugs.
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Affiliation(s)
- Qinan Yin
- Department of Pharmacy, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China; Personalized Drug Therapy Key Laboratory of Sichuan Province, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China
| | - Xiaoqin Zhang
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China
| | - Suqing Liao
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China
| | - Xiaobo Huang
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China
| | - Chunpeng Craig Wan
- College of Agronomy, Jiangxi Agricultural University, Jiangxi Key Laboratory for Post-Harvest Technology and Nondestructive Testing of Fruits & Vegetables, Nanchang 330045, PR. China.
| | - Yi Wang
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu 610072, PR. China.
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13
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Litvak M, Shamanaev A, Zalawadiya S, Matafonov A, Kobrin A, Feener EP, Wallisch M, Tucker EI, McCarty OJT, Gailani D. Titanium is a potent inducer of contact activation: implications for intravascular devices. J Thromb Haemost 2023; 21:1200-1213. [PMID: 36696212 PMCID: PMC10621279 DOI: 10.1016/j.jtha.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/07/2022] [Accepted: 12/15/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Titanium (Ti) and its alloys are widely used in manufacturing medical devices because of their strength and resistance to corrosion. Although Ti compounds are considered compatible with blood, they appear to support plasma contact activation and may be thrombogenic. OBJECTIVES The objective of this study was to compare Ti and titanium nitride (TiN) with known activators of contact activation (kaolin and silica) in plasma-clotting assays and to assess binding and activation of factor XII, (FXII), factor XI (FXI), prekallikrein, and high-molecular-weight kininogen (HK) with Ti/TiN. METHODS Ti-based nanospheres and foils were compared with kaolin, silica, and aluminum in plasma-clotting assays. Binding and activation of FXII, prekallikrein, HK, and FXI to surfaces was assessed with western blots and chromogenic assays. RESULTS Using equivalent surface amounts, Ti and TiN were comparable with kaolin and superior to silica, for inducing coagulation and FXII autoactivation. Similar to many inducers of contact activation, Ti and TiN are negatively charged; however, their effects on FXII are not neutralized by the polycation polybrene. Antibodies to FXII, prekallikrein, or FXI or coating Ti with poly-L-arginine blocked Ti-induced coagulation. An antibody to FXII reduced FXII and PK binding to Ti, kallikrein generation, and HK cleavage. CONCLUSION Titanium compounds induce contact activation with a potency comparable with that of kaolin. Binding of FXII with Ti shares some features with FXII binding to soluble polyanions but may have unique features. Inhibitors targeting FXII or FXI may be useful in mitigating Ti-induced contact activation in patients with titanium-based implants that are exposed to blood.
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Affiliation(s)
- Maxim Litvak
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aleksandr Shamanaev
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip Zalawadiya
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anton Matafonov
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anton Kobrin
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Edward P Feener
- KalVista Pharmaceuticals, Inc., Cambridge, Massachusetts, USA
| | - Michael Wallisch
- Aronora, Inc., Portland, Oregon, USA; Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - Erik I Tucker
- Aronora, Inc., Portland, Oregon, USA; Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, Oregon, USA
| | - David Gailani
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Galli M, Laborante R, Ortega-Paz L, Franchi F, Rollini F, D'Amario D, Capodanno D, Tremoli E, Gibson CM, Mehran R, Angiolillo DJ. Factor XI Inhibitors in Early Clinical Trials: A Meta-analysis. Thromb Haemost 2023; 123:576-584. [PMID: 36841245 DOI: 10.1055/a-2043-0346] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
BACKGROUND Phase II randomized controlled trials (RCTs) on factor(F)XI inhibitors have shown promising results but they were burdened by low statistical power for clinical outcomes. METHODS We performed a systematic review and meta-analysis of RCT comparing FXI inhibitors versus other anticoagulants (enoxaparin or direct oral anticoagulants, DOACs) or versus placebo on top of antiplatelet therapy. RESULTS Eight RCTs testing FXI inhibitors (ISIS 416858, osocimab, abelacimab, milvexian, asundexian) and enrolling 9,216 patients were included. Compared with enoxaparin, FXI inhibitors were associated with reduced any-bleeding (risk ratio [RR]: 0.49, 95% confidence interval [CI]: 0.31-0.77), no difference in major bleeding (RR: 0.96, 95% CI: 0.41-2.28), and reduced trial-defined efficacy endpoint (RR: 0.62, 95% CI: 0.49-0.79), the latter driven by the high-dose regimens. Compared with DOACs, FXI inhibitors were associated with a trend toward reduced any-bleeding (RR: 0.66, 95% CI: 0.31-1.38) and no difference in major bleeding (RR: 1.03, 95% CI: 0.22-4.78) or in trial-defined efficacy endpoint (RR: 1.23, 95% CI: 0.88-1.70). Compared with placebo, FXI inhibitors were associated with increased any-bleeding (RR: 1.25, 95% CI: 1.08-1.43) and a trend toward increased major bleeding (RR: 1.21, 95% CI: 0.75-1.93), both driven by high-dose regimens, with no difference in trial-defined efficacy endpoint (RR: 1.02, 95% CI: 0.92-1.13). CONCLUSION Results of this meta-analysis on FXI inhibitors suggest increased safety and efficacy compared with enoxaparin and modest increased safety compared with DOACs. The use of FXI inhibitors in adjunct to antiplatelet therapy versus placebo appears to be associated with a dose-dependent increase in bleeding without any difference in efficacy. STUDY REGISTRATION This study is registered in PROSPERO (CRD42022367706).
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Affiliation(s)
- Mattia Galli
- Catholic University of the Sacred Heart, Rome, Italy
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | | | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Francesco Franchi
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Fabiana Rollini
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
| | - Domenico D'Amario
- Dipartimento Universitario di Medicina Traslazionale, Università Piemonte Orientale, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Catania, Italy
| | - Elena Tremoli
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Charles Micheal Gibson
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, United States
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, Florida, United States
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15
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Koulas I, Spyropoulos AC. A Review of FXIa Inhibition as a Novel Target for Anticoagulation. Hamostaseologie 2023; 43:28-36. [PMID: 36807817 DOI: 10.1055/a-1984-7021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Limitations of vitamin K antagonists as chronic oral anticoagulant therapy have largely been supplanted by direct factor IIa and factor Xa inhibitor oral anticoagulants with similar efficacy but an overall better safety profile, lack of routine monitoring, and very limited drug-drug interactions compared with agents such as warfarin. However, an increased risk of bleeding remains even with these new-generation oral anticoagulants in fragile patient populations, in patients requiring dual or triple antithrombotic therapy, or high bleed risk surgeries. Epidemiologic data in patients with hereditary factor XI deficiency and preclinical studies support the notion that factor XIa inhibitors have the ability to be an effective but potentially safer alternative to existing anticoagulants, based on their ability to prevent thrombosis directly within the intrinsic pathway without affecting hemostatic mechanisms. As such, various types of factor XIa inhibitors have been studied in early phase clinical studies, including inhibitors of the biosynthesis of factor XIa with antisense oligonucleotides or direct inhibitors of factor XIa using small peptidomimetic molecules, monoclonal antibodies, aptamers, or natural inhibitors. In this review, we discuss how different types of factor XIa inhibitors work and present findings from recently published Phase II clinical trials across multiple indications, including stroke prevention in atrial fibrillation, dual pathway inhibition with concurrent antiplatelets post-myocardial infarction, and thromboprophylaxis of orthopaedic surgery patients. Finally, we refer to ongoing Phase III clinical trials of factor XIa inhibitors and their potential to provide definitive answers regarding their safety and efficacy in preventing thromboembolic events in specific patient groups.
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Affiliation(s)
- Ioannis Koulas
- The Institute of Health Systems Science at the Feinstein Institutes for Medical Research, Manhasset, New York, United States
| | - Alex C Spyropoulos
- The Institute of Health Systems Science at the Feinstein Institutes for Medical Research, Manhasset, New York, United States.,Northwell Health at Lenox Hill Hospital, New York, New York, United States.,The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
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16
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Presume J, Ferreira J, Ribeiras R, Mendes M. Achieving higher efficacy without compromising safety with factor XI inhibitors versus low molecular weight heparin for the prevention of venous thromboembolism in major orthopedic surgery-Systematic review and meta-analysis. J Thromb Haemost 2022; 20:2930-2938. [PMID: 36128769 PMCID: PMC9828034 DOI: 10.1111/jth.15890] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND In recent years, many important advances have been seen in anticoagulation therapy. However, bleeding risk is still a major concern. Factor XI (FXI) inhibition has emerged as a potential advantageous target to minimize this risk. OBJECTIVES We conducted a systematic review and meta-analysis of current evidence on FXI inhibitors for thromboprophylaxis in major orthopedic surgery. METHODS We performed a systematic search of electronic databases (PubMed, CENTRAL, and Scopus) until May of 2022. Studies were considered eligible if they were randomized controlled trials (RCTs) evaluating FXI inhibitors in thromboprophylaxis versus low molecular weight heparin (LMWH). For analysis purposes, we considered efficacy (venous thromboembolism [VTE], symptomatic VTE) and safety (major and clinically relevant non-major [CRNM] bleeding events, major bleeding events, blood transfusion necessities, adverse events, major adverse events) outcomes. RESULTS Overall, four RCTs were included, with a total of 2269 patients, 372 VTE events, and 50 major or CRNM bleeding events. Regarding efficacy outcomes, FXI inhibitors were associated with a significant reduction in the incidence of VTE events (odds ratio [OR] 0.50; 95% confidence interval [CI: 0.36, 0.69]). Concerning safety outcomes, FXI inhibitors significantly reduced major or CRNM bleeding events (OR 0.41; 95% CI [0.22, 0.75]). It was also associated with a lower percentage of patients needing a blood transfusion, despite not meeting statistical significance (OR 0.69; 95% CI [0.32, 1.48]). Incidence of adverse events and major adverse events were similar between groups. CONCLUSION Factor XI inhibitors showed a significant reduction in the incidence of VTE and bleeding events among patients submitted to major orthopedic surgery.
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Affiliation(s)
- João Presume
- Cardiology Department, Hospital de Santa CruzCentro Hospitalar Lisboa OcidentalLisbonPortugal
- Comprehensive Health Research Centre, NOVA Medical SchoolUniversidade Nova de LisboaLisbonPortugal
| | - Jorge Ferreira
- Cardiology Department, Hospital de Santa CruzCentro Hospitalar Lisboa OcidentalLisbonPortugal
| | - Regina Ribeiras
- Cardiology Department, Hospital de Santa CruzCentro Hospitalar Lisboa OcidentalLisbonPortugal
| | - Miguel Mendes
- Cardiology Department, Hospital de Santa CruzCentro Hospitalar Lisboa OcidentalLisbonPortugal
- Comprehensive Health Research Centre, NOVA Medical SchoolUniversidade Nova de LisboaLisbonPortugal
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