Epidemiology and Treatment Patterns of Venous Thromboembolism: an Observational Study of Nationwide Time-Series Trends in Japan

INTRODUCTION

Previous studies on anticoagulation treatment trends have mostly focused on hospitalized patients. This study aimed to clarify the treatment status of patients with venous thromboembolism (VTE) in Japan from 2011 to 2018, including outpatients, and to assess adherence with current guidelines.

METHODS

Data of inpatients and outpatients who were treated for VTE were extracted from a nationwide claims database (Medical Data Vision Co., Ltd., Tokyo, Japan) and analyzed.

RESULTS

The study included 79,330 patients with VTE; half were diagnosed during hospitalization for diseases other than VTE. The proportion of outpatient treatment increased significantly from 2015 to 2018 (Cochran-Armitage trend test, P < 0.0001), while 80% were anticoagulated in hospital after pulmonary embolism (PE) diagnosis. The proportion of patients with VTE treated as outpatients was no lower than the proportion of inpatients, even in the presence of active cancer, and there were no clear differences in anticoagulant choices. Treatment with direct oral anticoagulants (DOACs) did not always include the recommended initial intensification therapy. There was wide variation in the duration of DOAC treatment and the median duration of use was shorter than that recommended in VTE treatment guidelines.

CONCLUSION

While the gradual increase in VTE outpatient treatment appears to be in line with guideline recommendations, PE outpatient treatment could be further facilitated. The large proportion of patients diagnosed with VTE during hospitalization for other conditions suggests the importance of further utilizing in-hospital manuals for thrombosis prevention. The presence or absence of cancer did not appear to affect the basic treatment strategy of anticoagulation for VTE. Future studies are expected to better define the characteristics of patients who can be safely and effectively treated in an outpatient setting, and to examine whether anticoagulation for a shorter treatment period than recommended by the guidelines or DOAC therapy without initial intensification would improve patient outcomes.

Epidemiological Study Regarding the Incidence of Venous Thromboembolism in Patients After Cancer Remission

INTRODUCTION

The time course of reduction in the risk of venous thromboembolism (VTE) in patients who were diagnosed with cancer, treated with anticancer therapy, and in remission is unclear. We hypothesized that the risk of VTE will decrease over time after cancer remission.

METHODS

We conducted a retrospective analysis using claims data for cancer remission in Japan. Background information of patients who developed VTE after cancer remission was collected, and the VTE incidence rate after cancer remission was analyzed. Subgroup analysis based on VTE history, cancer type, and the presence or absence of surgery during hospitalization was conducted.

RESULTS

A total of 638,908 patients were eligible for the analysis. VTE occurred in 5533 of 638,908 cases, pulmonary embolism occurred in 779 cases, and deep vein thrombosis occurred in 5084 cases after cancer remission. The mean age of patients who developed VTE was 70.1 ± 12.5 years, and the proportion of men was 47.5%. All comorbidities and medications were higher in the VTE group (P < 0.001) than in the non-VTE group after cancer remission. The incidence of VTE was 2.4% per year in the first 30 days, 1.35% per year in 31-60 days, and gradually decreased to 0.48% per year in 181-360 days, becoming almost constant (annual rate 0.3%) 2 years after cancer remission.

CONCLUSION

Risk of developing VTE decreased to the same level as that in patients without cancer 2 years after cancer remission. Although the guidelines do not specify the duration of anticoagulant prophylaxis for new onset or recurrent VTE after cancer remission and the appropriate duration of such prophylaxis may vary depending on VTE risk factors, determining the period of high risk of VTE for each patient and preventing VTE is considered important.

Safety and effectiveness of non-vitamin K oral anticoagulants versus warfarin in real-world patients with non-valvular atrial fibrillation: a retrospective analysis of contemporary Japanese administrative claims data

Objective

To assess the safety (ie, risk of bleeding) and effectiveness (ie, risk of stroke/systemic embolism (SE)) separately for four non-vitamin K oral anticoagulants (NOACs; apixaban, dabigatran, edoxaban and rivaroxaban) versus warfarin in Japanese patients with non-valvular atrial fibrillation (NVAF), including those at high risk of bleeding and treated with reduced doses of NOACs.

Methods

We conducted a retrospective analysis of electronic health records and claims data from 372 acute care hospitals in Japan for patients with NVAF newly initiated on NOACs or warfarin. Baseline characteristics were balanced using inverse probability of treatment weighting with stabilised weights (s-IPTW). Bleeding risk and stroke/SE risk were expressed as HRs with 95% CIs. Two sensitivity analyses were conducted.

Results

A total of 73 989 patients were eligible for analysis. Notably, 52.8%-81.9% of patients received reduced doses of NOACs. After applying s-IPTW, patient characteristics were well balanced across warfarin/NOAC cohorts. The mean within-cohort age, CHADS₂ score and CHA₂DS₂-VASc score were 76 years, 2.2-2.3 and 3.8, respectively. In all age categories, the majority of the HRs for major bleeding, any bleeding and stroke/SE were equal to or below 1 for all NOACs versus warfarin. Apixaban was the only NOAC associated with a significantly lower risk of any bleeding. There was a trend towards increased risk reduction with NOACs versus warfarin in patients with body weight ≥60 kg. In patients with renal disease, the HRs for apixaban versus warfarin were below 1 for major bleeding, any bleeding and stroke/SE, with statistical significance observed for the risk reduction in stroke/SE versus warfarin. In the sensitivity analysis, there were no large differences in HRs between the two observational periods.

Conclusions

In patients with NVAF primarily treated with reduced-dose NOACs, the risks of stroke/SE and major bleeding were significantly lower with NOACs versus warfarin.

Potential of machine learning methods to identify patients with nonvalvular atrial fibrillation

Aim: Nonvalvular atrial fibrillation (NVAF) is associated with an increased risk of stroke however many patients are diagnosed after onset. This study assessed the potential of machine-learning algorithms to detect NVAF. Materials & methods: A retrospective database study using a Japanese claims database. Patients with and without NVAF were selected. 41 variables were included in different classification algorithms. Results: Machine learning algorithms identified NVAF with an area under the curve of >0.86; corresponding sensitivity/specificity was also high. The stacking model which combined multiple algorithms outperformed single-model approaches (area under the curve ≥0.90, sensitivity/specificity ≥0.80/0.82), although differences were small. Conclusion: Machine-learning based algorithms can detect atrial fibrillation with accuracy. Although additional validation is needed, this methodology could encourage a new approach to detect NVAF.

Effects of active smoking on postoperative outcomes in hospitalised patients undergoing elective surgery: a retrospective analysis of an administrative claims database in Japan

OBJECTIVES

The purpose of this study was to investigate the effects of smoking on prognosis after elective surgeries. Incidence of 30-day postoperative complications was compared between propensity score-matched 'ever-smoker' and 'never-smoker' cohorts. Thirty-day mortality and medical costs during the hospital stay were also compared.

DESIGN AND SETTING

A large-scale retrospective study using deidentified administrative claims data obtained from 372 acute care hospitals across Japan using the Diagnosis Procedure Combination system (ie, a flat-fee payment system).

PARTICIPANTS

Inpatients who were hospitalised to undergo elective surgery.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint of this study was incidence of 30-day postoperative complications. Secondary endpoints were 30-day mortality and total medical costs during hospitalisation. Comparison between ever-smokers and never-smokers was conducted using matched cohorts created by 1:1 propensity score matching.

RESULTS

Using 561 598 eligible patients, matched ever-smoker and never-smoker cohorts (n=1 55 593 each) were created. Ever-smokers were defined as patients with Brinkman Index ≥1. The percentage of patients who were male was 76.7%, and mean ages for ever-smokers and never-smokers were 65.1±13.8 years old and 66.4±15.3 years old, respectively. The Brinkman Index of the ever-smoker cohort was 677.6±553.4. Smoking was significantly associated with higher risk of 30-day postoperative complications compared with not smoking (OR 1.15, 95% CI 1.13 to 1.17, p<0.001). Similarly, smoking was significantly associated with postoperative 30-day mortality, with OR of 1.22 (95% CI 1.08 to 1.39, p=0.002).

CONCLUSIONS

Our results suggest that smoking could be associated with risk of poor postoperative outcomes. In particular, a history of smoking may increase the risk of 30-day postoperative complications as well as that of 30-day mortality. The results suggest that smoking might have a harmful effect on postoperative outcomes irrespective of types of surgery.

Safety and effectiveness of apixaban in comparison to warfarin in patients with nonvalvular atrial fibrillation: a propensity-matched analysis from Japanese administrative claims data

OBJECTIVE

To investigate the risk of bleeding events and stroke/systemic embolism (SE) among Japanese patients with nonvalvular atrial fibrillation (NVAF), focusing on the initial dosage of apixaban and patient age.

METHODS

This retrospective cohort study used de-identified electronic health records based claims data from 314 acute-care hospitals in Japan. NVAF patients newly initiated on warfarin or apixaban, with no prescription during the 180-day blanking period, were eligible. Patients were allocated to receive warfarin or 5 or 2.5 mg twice daily (BID) apixaban. One-to-one propensity-score matching was used to balance patient characteristics between apixaban and warfarin.

RESULTS

Among 31,006 eligible patients, 11,972 matched pairs were identified for apixaban versus warfarin. Mean age ± standard deviation was 77.7 ± 10.0 and 77.6 ± 10.0 years and CHADS₂ score was 2.2 ± 1.4 and 2.2 ± 1.4 for warfarin and apixaban, respectively. In the apixaban cohort, 39.4% of patients received the standard dose (5 mg BID) and 60.6% received the reduced dose (2.5 mg BID). Incidence rates (events per 100 person-years) of major bleeding, any bleeding and stroke/SE were 3.7, 23.1 and 3.1, and 2.5, 18.6 and 2.0 for warfarin and apixaban cohorts, respectively. Apixaban was associated with a significantly lower risk of any bleeding (hazard ratio [HR] 0.809, 95% confidence interval [CI] 0.731-0.895; p < .001), major bleeding (HR 0.655, 95% CI 0.505-0.849; p = .001) and stroke/SE (HR 0.637, 95% CI 0.478-0.850; p = .002).

CONCLUSIONS

Our observational data from clinical practice broadly confirms the safety and efficacy results of pivotal randomized controlled trials of apixaban for stroke prevention among NVAF patients.

Bleeding risk of apixaban, dabigatran, and low-dose rivaroxaban compared with warfarin in Japanese patients with non-valvular atrial fibrillation: a propensity matched analysis of administrative claims data

OBJECTIVES

There is scarce evidence comparing novel oral anticoagulants (NOACs) with warfarin in real-world settings in Japan. This study compared the risk of bleeding events among patients with non-valvular atrial fibrillation (NVAF) initiating treatment with NOACs versus warfarin.

METHODS

A retrospective cohort study was conducted using a de-identified electronic health record based database of health claims and Diagnosis Procedure Combination data from 275 consenting hospitals in Japan. NVAF patients newly initiated on oral anticoagulants were eligible. Based on the first prescription, patients were assigned to 5/2.5 mg BID apixaban, 150/110 mg BID dabigatran, 15/10 mg QD rivaroxaban (approved dose lower in Japan compared to Western countries [20/15 mg QD]) or warfarin groups. One-to-one propensity score matching (PSM) was used to balance patient characteristics between warfarin and each NOAC. Patients were followed up to 1 year post-first prescription.

RESULTS

Among 38,662 eligible patients, a total of 5977, 5090, and 6726 matched pairs were identified for warfarin versus apixaban, warfarin versus dabigatran, and warfarin versus rivaroxaban, respectively after PSM. Compared to warfarin, apixaban (hazard ratio [HR] 0.586; 95% CI 0.421-0.815), dabigatran (HR 0.617; 0.425-0.895) and rivaroxaban (HR 0.693; 0.514-0.933) were associated with a significantly lower risk of major bleeding. The risk of any bleeding was significantly lower for apixaban (HR 0.782; 0.682-0.896), but not for dabigatran (HR 0.988; 0.860-1.135) or rivaroxaban (HR 0.938; 0.832-1.057) when comparing to warfarin.

CONCLUSIONS

Among Japanese patients with NVAF, treatment with apixaban 5/2.5 mg BID was associated with a significantly lower risk of major bleeding and any bleeding when compared to warfarin. Treatment with dabigatran 150/110 mg BID or rivaroxaban 15/10 mg QD was associated with a significantly lower risk of major bleeding, but not any bleeding, than warfarin. The potential benefit of individual NOACs in real-world practice needs to be assessed further.

Effects of mineralocorticoid receptor antagonists in patients with hypertension and diabetes mellitus: a systematic review and meta-analysis

Blood pressure (BP) control is important to ameliorate cardiovascular events in patients with diabetes mellitus (DM). However, achieving the target BP with a single drug is often difficult. The objective of this study was to evaluate the antihypertensive effects of mineralocorticoid receptor antagonists (MRAs) as add-on therapy to renin–angiotensin system (RAS) inhibitor(s) in patients with hypertension and DM. Studies were searched through October 2014 in MEDLINE, Embase and the Cochrane Central Register of Controlled Trials. Randomized, controlled trials or prospective, observational studies regarding concomitant administration of MRA and RAS inhibitor(s) in patients with DM were included. Articles were excluded if the mean systolic BP (SBP) was <130 mm Hg before randomization for interventional studies or at baseline for prospective cohort studies. We identified nine eligible studies (486 patients): five randomized placebo-controlled trials; three randomized active drug-controlled trials; and one single-arm observational study. The mean differences in office SBP and diastolic BP (DBP) between the MRA and placebo groups were −9.4 (95% confidence interval (CI) −12.9 to −5.9) and −3.8 (95% CI, −5.5 to −2.2) mm Hg, respectively. Subgroup analysis results for study type, age, baseline office SBP and follow-up duration were similar to those of the main analysis. MRA mildly increased serum potassium (0.4 mEq l⁻¹; 95% CI, 0.3–0.5 mEq l⁻¹). A consistent reduction of albuminuria across these studies was also demonstrated. MRA further reduced SBP and DBP in patients with hypertension and DM already taking RAS inhibitors. Serum potassium levels should be monitored to prevent hyperkalemia.

Persistent Cardiac Aldosterone Synthesis in Angiotensin II Type 1A Receptor–Knockout Mice After Myocardial Infarction

Background— The renin-angiotensin-aldosterone system is implicated in the pathogenesis of heart failure. Pharmacological blockade of angiotensin II (Ang II)–dependent signaling is clinically effective in reducing cardiovascular events after myocardial infarction (MI) but still fails to completely prevent remodeling. The molecular basis underlying this Ang II–independent remodeling is unclear.

Methods and Results— Acute MI was induced by coronary ligation in wild-type (WT) and angiotensin II type IA receptor–knockout (AT 1A -KO) mice. Left ventricular (LV) geometry, hemodynamics, and cardiac gene expression were evaluated on day 28. Severe LV remodeling and resultant cardiac dysfunction were observed in WT mice, whereas less marked, but still significant, LV remodeling and cardiac dysfunction were induced in AT 1A -KO mice. Gene expression levels of aldosterone synthase and the cardiac aldosterone content were both elevated in the MI hearts, even in AT 1A -KO mice. In AT 1A -KO mice treated with spironolactone (20 mg/kg per day), LV remodeling, cardiac dysfunction, and cardiac gene expression of collagens and natriuretic peptides were almost normalized.

Conclusions— Our results indicate that genetic blockade of AT 1A signaling fails to arrest aldosterone production in cardiac tissues and that cardiac aldosterone plays a critical role in post-MI LV remodeling. The results suggest that spironolactone could be potentially effective in patients with MI, when used in combination with renin-angiotensin system blockade, by blocking the actions of aldosterone produced by Ang II–independent mechanisms.

Significance of cyclooxygenase-2 induced via p38 mitogen-activated protein kinase in mechanical stimulus-induced peritoneal adhesion in mice

Postoperative peritoneal adhesion represents a major complication of surgery, but the molecular mechanism underlying pathogenesis of adhesion is not fully understood. The present study investigated the roles of cyclooxygenase (COX)-1 and COX-2 in peritoneal adhesion induced by scraping the surface of the cecum and abdominal wall in mice. Slight, but macroscopically observable, peritoneal adhesion was induced even on day 1, and the extent of adhesion reached a maximum on day 7 and beyond. COX-1 mRNA was constitutively expressed in the intact cecum, and its expression level was not altered after the mechanical stimulus. In contrast, expression of the COX-2 gene was markedly increased after the stimulus, and maximum expression was observed on days 3 to 7. Mofezolac, a specific COX-1 inhibitor, had no effect on peritoneal adhesion at 30 mg/kg and had only marginal effects on prostaglandin (PG)E2 levels in the cecum or peritoneal fluid. On the other hand, two highly selective inhibitors for COX-2, NS-398 (N-[2-(cyclohexyloxy)-4-nitrophenyl]-methanesulfonamide) and CAY10404 [3-(4-methylsulphonylphenyl)-4-phenyl-5-trifluoromethylisoxazole], dose-dependently inhibited both adhesion formation and the increase in PGE2 levels (3-30 mg/kg). The effects of NS-398 were eliminated when PGE2 or (R)-butaprost was administered exogenously. A COX-2 antisense oligonucleotide also attenuated adhesion formation. Activation of p38 mitogen-activated protein (MAP) kinase was observed in the traumatized cecum, and an MAP kinase inhibitor, SB202190 [4-(4-fluorophenyl)-2-(4-hydroxyphenyl)-5-(4-pyridyl)-1H-imidazole], inhibited adhesion formation (54% inhibition at 15 microM) and also reduced the COX-2 mRNA level and PGE2 levels. In conclusion, COX-2, but not COX-1, plays a significant role in mechanical stimulus-induced peritoneal formation in the mouse cecum.

Bioinformatics Research on Inter-racial Difference in Drug Metabolism I. Analysis on Frequencies of Mutant Alleles and Poor Metabolizers on CYP2D6 and CYP2C19

The enzyme activities of CYP2D6 and CYP2C19 show a genetic polymorphism, and the frequency of poor metabolizers (PMs) on these enzymes depends on races. In the present study, the frequencies of mutant alleles and PMs in each race were analyzed based on information from published studies, considering the genetic polymorphisms of CYP2D6 and CYP2C19 as the causal factors of racial and inter-individual differences in pharmacokinetics. As a result, it was shown that there were racial differences in the frequencies of each mutant allele and PMs. The frequencies of PMs on CYP2D6 are 1.9% of Asians and 7.7% of Caucasians, and those of PMs on CYP2C19 are 15.8% of Asians and 2.2% of Caucasians. Based on the results, it was suggested that there would be racial differences in the frequencies of PM subjects whose blood concentrations might be higher for drugs metabolized by these enzymes. Additionally, it was suggested that enzyme activities would vary according to the number of functional alleles even in subjects judged to be extensive metabolizers (EMs). In the bridging study, genetic information regarding CYP2D6 and CYP2C19 of the subjects will help extrapolate foreign clinical data to a domestic population.

Significance of vascular endothelial cell growth factor up-regulation mediated via a chymase-angiotensin-dependent pathway during angiogenesis in hamster sponge granulomas

Chymase is a serine protease responsible for local production of angiotensin (Ang) II from its precursor Ang I in several species, including humans, dogs, and hamsters. We have previously reported that chymase facilitates angiogenesis in sponge granulation tissues via local production of Ang II. Herein, we report the significance of vascular endothelial growth factor (VEGF) up-regulation mediated by Ang II during angiogenesis in hamster sponge granulomas. Treatment of granulation tissues with an anti-VEGF neutralizing antibody or antisense oligomers against VEGF mRNA significantly reduced Ang II-induced angiogenesis, supporting a significant role for VEGF during angiogenesis. In cultured fibroblasts prepared from granulation tissues, VEGF mRNA was up-regulated in response to Ang II within 2 h and this enhanced expression was abolished in the presence of an Ang II type 1 receptor-selective antagonist, an inhibitor of nuclear factor-kappaB activation, or an activator protein-1 inhibitor. To study the significance of local production of Ang II by chymase, we examined the effects of chymostatin on in vivo angiogenesis. We found that chymostatin markedly inhibited both up-regulation of VEGF mRNA and angiogenesis in granulation tissues treated by compound 48/80 or basic fibroblast growth factor. Our results suggest that Ang II directly acts on fibroblasts in granulation tissue to up-regulate VEGF mRNA and thereby induce angiogenesis. Furthermore, a chymase-Ang II-VEGF pathway may operate in granulation tissue as the primary mediator of angiogenesis.

AT(2) receptor-dependent vasodilation is mediated by activation of vascular kinin generation under flow conditions

Physiological roles of angiotensin II type 2 receptor (AT(2)) are not well defined. This study was designed to investigate the mechanisms of AT(2)-dependent vascular relaxation by studying vasodilation in pressurized and perfused rat mesenteric arterial segments. Perfusion of angiotensin II in the presence of AT(1) antagonist elicited vascular relaxation, which was completely dependent on AT(2) receptors on endothelium. FR173657 (>1 microM), a bradykinin (BK) B(2)-specific antagonist, significantly suppressed AT(2)-dependent vasodilation (maximum inhibition: 68.5% at 10 microM). Kininogen-deficient Brown Norway Katholiek rats showed a significant reduction in AT(2)-mediated vasodilatory response compared with normal wild-type Brown Norway rats. Indomethacin (>1 microM), aprotinin (10 microM) and soybean trypsin inhibitor (10 microM) also reduced AT(2)-dependent vasodilation. Our results demonstrated that stimulation of AT(2) receptors caused a significant vasodilation through local production of BK in resistant arteries of rat mesentery in a flow-dependent manner. Such vasodilation counterbalances AT(1)-dependent vasoconstriction to regulate the vascular tone.

Chymase mediates mast cell-induced angiogenesis in hamster sponge granulomas

We investigated the contribution of mast cell chymase in mast cell-dependent angiogenesis using the hamster sponge-implant model, where angiogenesis in the granulation tissue surrounding the subcutaneously implanted sponge was evaluated by measuring the hemoglobin content. Daily local injection of compound 48/80 (3-100 microg/site/day), a potent mast cell activator, induced formation of granulomas and angiogenesis in time- and dose-dependent manners. This angiogenic response was inhibited by chymase inhibitors including chymostatin (> or = 1 nmol/site/day), soybean trypsin inhibitor (SBTI; > or = 1.4 nmol/site/day) and lima bean trypsin inhibitor (LBTI; > or = 3.3 nmol/site/day), but not by a tryptase inhibitor like leupeptin (> or = 700 nmol/site/day). Although pyrilamine (> or = 2,580 nmol/site/day), a histamine H1 receptor antagonist, and protamine (300 microg/site/day) also inhibited angiogenesis, these effects were much less pronounced than those by chymase inhibitors. Furthermore, antigen-induced angiogenesis in hamsters pre-sensitized with ovalbumin was also inhibited by the chymase inhibitors by 60-70%. Our results suggest that chymase is a major mediator in mast cell-mediated angiogenesis.

Cyclo-oxygenase-2 enhances basic fibroblast growth factor-induced angiogenesis through induction of vascular endothelial growth factor in rat sponge implants

Angiogenesis is reportedly enhanced by prostaglandins (PGs). In the present study, we investigated whether or not cyclo-oxygenase (COX)-2 mediated angiogenesis in chronic and proliferate granuloma. In rat sponge implants, angiogenesis was gradually developed over a 14-day experimental period as granuloma formed. This angiogenesis was enhanced by topical injections of human recombinant basic fibroblast growth factor (bFGF). In sponge granuloma, mRNA of COX-1 was constitutively expressed, whereas that of COX-2 was increased with neovascularization in parallel with that of vascular endothelial growth factor (VEGF). Topical injections of bFGF increased the expression of COX-2 mRNA. bFGF-stimulated angiogenesis was inhibited by indomethacin or selective COX-2 inhibitors, NS-398, nimesulide, and JTE-522. The levels of PGE(2) and 6-keto-PGF(1alpha) in the sponge granuloma were increased with bFGF 13 fold and 9 fold, respectively, and these levels were markedly reduced by NS-398. The expression of VEGF mRNA in the granuloma was also enhanced by bFGF, and was reduced by NS-398. Topical injections of PGE(2) and beraprost sodium, a PGI(2) analogue, increased the expression of VEGF mRNA, with angiogenesis enhancement. The enhanced angiogenesis by bFGF was significantly inhibited by topical injections of VEGF anti-sense oligonucleotide. These results suggested that COX-2 may enhance bFGF-induced neovascularization in sponge granuloma by PG-mediated expression of VEGF, and that a COX-2 inhibitor would facilitate the management of conditions involving angiogenesis.

Chymase as a proangiogenic factor. A possible involvement of chymase-angiotensin-dependent pathway in the hamster sponge angiogenesis model

We investigated the profound involvement of chymase, an alternative angiotensin II-generating enzyme, in angiogenesis using a hamster sponge implant model. In vivo transfection of human pro-chymase cDNA or a direct injection of purified chymase into the sponges implanted resulted in marked increment of hemoglobin contents in the sponge granuloma tissues, demonstrating that chymase has an ability to elicit angiogenesis and is a potent angiogenic factor. Daily injection of basic fibroblast growth factor into the sponges implanted also induced angiogenesis, which was suppressed by the treatment with chymostatin, an inhibitor of chymase, or TCV-116, an antagonist of angiotensin II (Ang II) type 1 receptor. Expression of chymase mRNA and production of Ang II in the granuloma tissues were enhanced by the stimulation with basic fibroblast growth factor. Chymase activity in the sponge granulomas increased in parallel with the rise in hemoglobin contents, and mast cells observed in the granuloma tissues were positively stained with anti-chymase antibody. Exogenous administration not only of Ang II but of angiotensin I (Ang I) directly into the sponges could enhance angiogenesis. Chymostatin inhibited the angiogenesis induced by Ang I but not Ang II, suggesting the presence of a chymase-like Ang II-generating activity in the sponge granulomas. Our results may suggest a potential ability of chymase to promote angiogenesis through the local chymase-dependent and angiotensin-converting enzyme-dependent Ang II generating system in pathophysiological angiogenesis.

Structure-activity relationship studies of chloromethyl ketone derivatives for selective human chymase inhibitors

Based on the SAR study of a classical chloromethyl ketone derivative, Z-PheCH2Cl 1, a series of compounds were synthesized. Among all the derivatives, compound 21 was found to be a potent human chymase inhibitor with no inhibitory activity against human leukocyte cathepsin G.

[Involvement of chymase in angiogenesis in hamster sponge granulomas]

We investigated the angiogenic effect of chymase, an alternative angiotensin II-generating enzyme, on angiogenesis using hamster sponge implant model. Exogenous administration of angiotensin II (Ang II) or angiotensin I (Ang I) directly into the sponges enhanced angiogenesis, as determined from the hemoglobin contents in the sponge granuloma tissues. Chymostatin, an inhibitor of chymase, inhibited angiogenesis induced by Ang I but not by Ang II, suggesting the presence of a chymase-like Ang II-generating activity in the sponge granuloma. TCV-116 (5 mg/kg p.o.), an antagonist of Ang II type 1 receptor, and chymostatin suppressed bFGF-induced angiogenesis, suggesting the significance of the endogenous angiotensin system. Chymase activity in the sponge granuloma increased in parallel with the rise in hemoglobin contents induced by bFGF. We also examined the effects of direct administration of human pro-chymase gene or purified hamster chymase, and demonstrated that in vivo human pro-chymase gene transfection and direct injection of purified chymase enhanced angiogenesis, which was 50% inhibited by TCV-116. Sponge granulomas treated with Ang II was supressed by vascular endothelial growth factor (VEGF) antisense. Our results suggest that chymase enhanced angiogenesis partly through the local production of Ang II, followed by up-regulation of VEGF.

Role of mast cell chymase in angiotensin-induced vascular contraction of hamster cheek pouch microvessels

We investigated the contribution of chymase-dependent conversion of angiotensin I to angiotensin II in hamster cheek pouch. To investigate the converting activities in intact tissues, angiotensin I or II was applied to microvessels of the intact cheek pouch, and the vascular contractile response was recorded. Angiotensin I or angiotensin II (20 nM) induced a rapid contraction of arterioles, irrespective of their diameter. In the presence of I mM captopril, there was no contraction in response to angiotensin I in arterioles < 25 microm in diameter, whereas contraction was still observed in larger arterioles. Chymostatin (100 microM) treatment also reduced the response to angiotensin I in arterioles > 40 microm in diameter. Treatment with 1 mM captopril and 100 microM chymostatin resulted in the loss of response to angiotensin I, but not to angiotensin II, in all arterioles. Treatment of microvessels with 100 microg/ml compound 48/80 enhanced angiotensin I-induced vascular contraction response, suggesting the significance of mast cells as a source of cheek pouch chymase.

Synthesis and biological activities of phenylahistin derivatives

X-ray crystallographic analysis was performed and several phenylahistin derivatives were synthesized to elucidate the structural components necessary for the anti-microtubule activity of phenylahistin. We primarily focused on the unique isoprenylated dehydrohistidine structure. Our results showed that a uniplanar pseudo-three-ring structure formed by the hydrogen bonding of diketopiperazine and imidazole rings is important for the anti-microtubule activity of phenylahistin.

Antitumor activity of phenylahistin in vitro and in vivo

Phenylahistin is a new cell cycle inhibitor produced by Aspergillus ustus. Since phenylahistin was produced as a scalemic mixture of (-)-phenylahistin and its enantiomer, we separated each enantiomer and evaluated their antitumor activity in vitro. (-)-Phenylahistin exhibited antitumor activity against 8 tumor cell lines with IC50 values ranging from 1.8 x 10(-7) to 3.7 x 10(-6), while (+)-phenylahistin exhibited 33-100-fold less potent activity than (-)-phenylahistin did. (-)-Phenylahistin also showed antitumor activity against P388 leukemia and Lewis lung carcinoma cells in vivo.

Cytotoxic effects of NSL-1406, a new thienopyrimidine derivative, on leukocytes and osteoclasts

We synthesized a series of thienopyrimidine derivatives and examined their cytotoxic effects on several cell lines. One of the derivatives, NSL-1406, was shown to exert potent cytotoxic effects on leukemia cell line including P388 cells and J774 cells. It was also inhibitory on mouse osteoclasts and suppressed the in vitro bone resorption by osteoclasts at nanomolar concentrations.

Symmetrical anhydride-type serine protease inhibitors: structure-activity relationship studies of human chymase inhibitors

We prepared a potent and relatively selective human chymase inhibitor 9 (-), based on the study of SAR of a symmetrical anhydride-type serine protease inhibitor 1. Kinetic studies suggested that 9 (-) reacts with the Ser residue at the active site of the enzyme, forming a stable acyl enzyme complex. We also showed the importance of the tri-substituted beta-amino acid structure for the potent anti-enzymatic activity.

(-)-Phenylahistin arrests cells in mitosis by inhibiting tubulin polymerization

(-)-Phenylahistin, a fungal diketopiperazine metabolite composed of phenylalanine and isoprenylated dehydrohistidine, arrested cells in mitosis and inhibited the proliferation of A549 cells. The microtubule network in A549 cells was disrupted by (-)-phenylahistin, which also inhibited the polymerization of both microtubule protein from bovine brain and phosphocellulose-purified tubulin in vitro. Competitive binding studies indicated that (-)-phenylahistin interacted with the colchicine binding site on tubulin but not with the vinblastine binding site.

N-[2,2-dimethyl-3-(N-(4-cyanobenzoyl)amino)nonanoyl]-L-phenylalanine ethyl ester as a stable ester-type inhibitor of chymotrypsin-like serine proteases: structural requirements for potent inhibition of alpha-chymotrypsin

We introduce a new potent inhibitor, N-[2, 2-dimethyl-3-(N-(4-cyanobenzoyl)amino)nonanoyl]-L-phenylalanine ethyl ester (3), which preferentially inhibits serine proteases belonging to a chymotrypsin superfamily. This inhibitor, despite consisting of a stable ethyl ester structure, showed strong inhibitory activities toward bovine alpha-chymotrypsin, human cathepsin G, and porcine elastase by acting as an acylating agent. The calculated inactivation rate constant (kinact) and enzyme-inhibitor dissociation constant (Ki) against alpha-chymotrypsin were 0.0028 s-1 and 0.0045 microM, respectively (kinact/Ki = 630 000 M-1 s-1). These kinetic parameters indicate that this inhibitor is one of the most powerful alpha-chymotrypsin inactivators ever reported. On the basis of structure-activity relationship (SAR) and structure-stability relationship studies of analogues of 3, which were modified in three parts of the molecule, i.e., the 4-cyanophenyl group, beta-substituent at the beta-amino acid residue, and ester structure, we suggest that the potent inhibitory activity of 3 is due to the following structural features: (1) the ethyl ester which enforces specific acyl-enzyme formation, (2) the n-hexyl group at the beta-position and 4-cyanophenyl group which stabilize the acyl-enzyme, and (3) the phenylalanine residue which functions for the specific recognition of S1 site in the enzyme. In particular, the action of 3 as a potent inhibitor, but poor substrate, can be ascribed largely to the very slow deacylation rate depending on the structure factors cited in feature 2. The results of inhibition by 3 and its analogues against different serine proteases such as chymase, cathepsin G, and elastase suggest that these compounds recognize common parts in the active sites among these chymotrypsin-like serine proteases, and 3 is one of the most suitable structures to recognize those common parts. Our results provide an intriguing basis for further developments in the design of a stable ester-based selective serine protease inhibitor.

GPIIb/IIIa integrin antagonists with the new conformational restriction unit, trisubstituted beta-amino acid derivatives, and a substituted benzamidine structure

Ethyl N-[3-(2-fluoro-4-(thiazolidin-3-yl(imino)methyl)benzoyl)amino-2, 2-dimethylpentanoyl]piperidine-4-acetate 40 (NSL-96184) is a highly potent and orally active fibrinogen receptor antagonist, which is characterized by the presence of the trisubstituted beta-amino acid residue, 3-ethyl-2,2-dimethyl-beta-alanine. This compound was developed on the basis of the SAR study of N-[3-(N-4-amidinobenzoyl)amino-2, 2-dimethyl-3-phenylpropionyl]piperidine-4-acetic acid 1(NSL-95301) with the derivatization focused on the central trisubstituted beta-amino acid unit as well as the basic amidinobenzoyl unit, and the esterification of the carboxyl group for prodrug composition. Compound 1, which was reported in our previous study, was discovered by the application of combinatorial chemistry. The molecular modeling study suggests that the trisubstituted beta-amino acid unit is responsible for fixing the molecule to its active conformation. Compound 40 showed an excellent profile in the in vitro and in vivo studies for its human platelet aggregation inhibitory activity and oral availability in guinea pigs. This oral availability largely depends on the modification of the amidino group with a cyclic secondary amine, i.e., thiazolidine in 40. In in vivo studies, the onset of the antiplatelet action of 40 is very fast after oral administration, whereas its duration of action is relatively short. These results suggest that 40 has an excellent therapeutic potential, especially for antithrombotic treatment in the acute phase. 3-Substituted-2,2-dimethyl-beta-amino acid residues would serve as new and useful linear templates to restrict the conformational flexibility of peptidomimetics.

Discovery and structure--activity relationship studies of a novel and specific peptide motif, Pro-X-X-X-Asp-X, as a platelet fibrinogen receptor antagonist

A novel hexapeptide, H-Pro-Ser-Nva-Gly-Asp-Trp-OH 6, a specific antagonist of platelet fibrinogen receptor (GpIIb/IIIa), was discovered in a structure-activity relationship (SAR) study where the role of the N-terminal Pro moiety of an RGD-containing peptide, H-Pro-Ser-Arg-Gly-Asp-Trp-OH 1, which is a potent but not specific antagonist toward GpIIb/IIIa integrin, was investigated. This novel peptide 6 exhibits very high activity as a human platelet aggregation inhibitor (IC50 0.59 microM, human PRP/collagen) as well as marked specificity for GpIIb/IIIa. A series of substitutions at the third position (Nva residue) in this hexapeptide, focused on the conformational rigidity, led to compounds which are superior to the original novel peptide 6 with regard to anti-platelet activity. The peptides, H-Pro-Ser-Hyp-Gly-Asp-Trp-OH 17 and H-Pro-Ser-delta Pro-Gly-Asp-Trp-OH 18 with the 5-membered ring structure, which restricted the conformation of the peptide backbone at the third position, inhibited the aggregation of human platelets at submicromolar concentrations (IC50 0.39 and 0.30 microM, respectively). Further structure-activity relationship studies at each position of the peptide sequence suggest a novel motif sequence, Pro-X1-X2-X3-Asp-X4, for specific GpIIb/IIIa integrin recognition, in which the N-terminal free Pro residue and the Asp residue at the fifth position are essential to the activity. This motif sequence is summarized as follows: (1) a small amino acid such as Ser, Ala or Gly is preferable at X1 position; (2) X2 may be any amino acid, preferably a bulky amino acid such as Tle or a cyclic amino acid such as Pro; (3) X3 must be a small amino acid such as Gly; and (4) X4 is preferably an amino acid with an aromatic side chain.

Potent inactivator of alpha-chymotrypsin: 2,2-dimethyl-3-(N-4-cyanobenzoyl)amino-5-phenyl pentanoic anhydride

We synthesized a novel potent alpha-chymotrypsin inactivator, 2,2-dimethyl-3-(N-4-cyanobenzoyl) amino-5-phenyl pentanoic anhydride, which fulfilled the criteria of a mechanism-based inactivator: first-order kinetics, irreversibility, saturation kinetics and substrate protection. The inactivation rate constant (kinact) and the enzyme-inhibitor dissociation constant (KI) were calculated to be 0.017s-1 and 0.071 microM, respectively (kinact/KI = 242,000 M-1s-1). These kinetic parameters indicate that this compound is one of the most powerful alpha-chymotrypsin inactivators ever reported. The average number of alpha-chymotrypsin turnovers per inactivation (partition ratio) was calculated to be 1, which indicates that it is a stoichiometrically ideal inactivator of alpha-chymotrypsin. We compared the IC50 values of this compound with those of several chymotrypsin-like serine proteinases (bovine alpha-chymotrypsin, recombinant human chymase and human neutrophil cathepsin G) and a metallo proteinase, rabbit angiotensin converting enzyme (ACE). Our compound, 2,2-dimethyl-3-(N-4-cyanobenzoyl) amino-5-phenyl pentanoic anhydride, inhibited bovine alpha-chymotrypsin potently (IC50 = 1.0 (+/- 0.2) x 10(-9) M) as well as other chymotrypsin-like serine proteinase; recombinant human chymase (IC50 = 7.0 (+/- 1.0) x 10(-8) M) and human neutrophil cathepsin G (IC50 = 1.8 (+/- 0.2) x 10(-7) M). However, rabbit ACE was not inhibited by this compound (IC50 > 1 x 10(-4) M).

The in vitro and in vivo pharmacological profiles of a platelet glycoprotein IIb/IIIa antagonist, NSL-9403

The in vitro and in vivo pharmacological profiles of NSL-9403 [orotyl-serylarginyl-glycyl-asparatyl-tryptophane], a platelet glycoprotein IIb/IIIa (GpIIb/IIIa) antagonist, has been studied. NSL-9403 inhibited platelet aggregation of human platelet-rich plasma (PRP) with IC50 values of 4.3 +/- 0.4 microM (collagen) and 1.8 +/- 0.3 microM (ADP), which was about 100 times more potent than RGDS. It also inhibited the binding of fibrinogen to activated platelets. Ex vivo collagen and ADP-induced platelet aggregation in a guinea pig was inhibited after a bolus intravenous administration of NSL-9403 at 1.25 mg/kg and above. NSL-9403 had an anti-thrombotic effect in in vivo thrombosis models. In a platelet agonist-induced pulmonary embolic sudden death model, where a bolus injection of collagen and epinephrine induced sudden death in mice, intravenous administration of NSL-9403 before an injection of collagen and epinephrine inhibited this platelet-agonist induced death in a dose dependent manner. In an arterio-venous shunt, infusion of NSL-9403 at 3 mg/kg/hour prevented an increase in circulation pressure due to thrombus formation in the shunt circuit and platelet loss. Infusion of NSL-9403 at 1 to 10 mg/kg/hour produced a complete inhibition of platelet-dependent arterial thrombosis in a dog femoral arterial thrombosis model. Thus NSL-9403 is a potent inhibitor or platelet aggregation in vitro and a potent anti-thrombotic agent in vivo with a relatively short duration of action.

A novel peptide motif for platelet fibrinogen receptor recognition

To develop a specific antagonist of platelet alphaIIbbeta3 using small linear peptides, we synthesized a series of hexapeptides that did not have an Arg-Gly-Asp (RGD) sequence and examined their anti-platelet activity and their specificity for alphaIIbbeta3. We found a novel motif sequence, Pro-X1-X2-X3-Asp-X4, where X1 to X4 were all L-form alpha-amino acids, which specifically inhibited aggregation of human platelets at submicromolar concentrations. The Pro residue at the N terminus was essential to the anti-platelet activity, and the acetylation of the imino group of this residue also resulted in the complete loss of the activity. The results of the binding assay using purified human platelet alphaIIbbeta3 and placental alphavbeta3 and those of the cell adhesion assay suggest that this motif peptide is highly specific for platelet alphaIIbbeta3 among other integrins. Flow cytometric studies using an fluorescein isothiocyanate-labeled RGD peptide showed that this motif peptide inhibited the binding of an RGD peptide to activated platelets, suggesting that it has the same inhibitory mode as RGD peptides. Conformational analysis of this motif peptide and an RGD-containing peptide suggests that the imino group of the Pro residue may substitute for the role of the guanidino group of the Arg residue of the RGD sequence.

Polarity in spontaneous unwinding after prior rotation of the flagellar beat plane in sea-urchin spermatozoa

The flagellar beat plane of live and reactivated sea-urchin sperm held by their heads in the tip of a vibrating micropipette will rotate along with the plane of the imposed vibration for up to 10 revolutions in either a clockwise or a counterclockwise direction. Subsequent cessation of the imposed vibration is followed by spontaneous unwinding of the flagellar beat plane. Nearly complete unwinding occurs after prior counterclockwise winding. The unwinding of the beat plane after prior clockwise winding is incomplete, but the number of revolutions that remain unwound affects the response of the flagellar beat plane to a second set of imposed revolutions. The initial angular velocity of spontaneous unwinding is approximately proportional to the number of prior winding cycles, independent of their direction. The maximum initial velocity of unwinding was 27 rad s-1 and 20 rad s-1 for live and reactivated sperm, respectively. These data suggest that the force responsible for unwinding of the beat plane is derived from the elastic distortion of some component in the axonemal structure. The difference in completeness of spontaneous unwinding between the two directions of rotation is consistent with the previously suggested hypothesis that imposed rotation of the beat plane reflects the forced rotation of the central pair within the axoneme.

Rotating the plane of imposed vibration can rotate the plane of flagellar beating in sea-urchin sperm without twisting the axoneme

When the head of a sea-urchin sperm is held in the tip of a micropipette and vibrated laterally, the flagellum beats in phase with the imposed vibration. Rotation of the plane of pipette vibration around the head axis induces a corresponding rotation of the plane of beating, in both live and reactivated sperm. Detailed analysis of the waveforms occurring at different stages of this rotation shows that the characteristic asymmetry of the flagellar bending waves rotates along with the plane of beat. The positions of small polystyrene beads attached as markers on the axonemes of demembranated sperm flagella appear unaffected by the rotation of the beat plane and asymmetry. The imposed rotation of the waveform is thus the result of a rotation of the coordinated pattern of sliding among the doublet tubules of the axoneme, and is not accompanied by a twisting of the whole axonemal structure. These data indicate that neither the plane of flagellar beat nor the direction of beat asymmetry is tightly dependent upon a structural or chemical specialization of particular members of the nine outer doublet microtubules, but that both are the result of some regulatory structure that can be forced to rotate relative to the outer structure of the axoneme.