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Fadraersada J, Alva-Gallegos R, Skořepa P, Musil F, Javorská L, Matoušová K, Krčmová LK, Paclíková M, Carazo A, Blaha V, Mladěnka P. Head-to-head ex vivo comparison of clinically used direct anticoagulant drugs. Naunyn Schmiedebergs Arch Pharmacol 2024; 397:4461-4470. [PMID: 38112731 DOI: 10.1007/s00210-023-02891-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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023]
Abstract
An imbalance in coagulation is associated with cardiovascular events. For prevention and treatment, anticoagulants, currently mainly xabans and gatrans, are used. The purpose of the present study was to provide a head-to-head comparison since there are no studies directly evaluating these novel anticoagulants. An additional aim was to find whether selected anthropological and biochemical factors can affect their anticoagulant properties as they are used in fixed doses. In this cross-sectional study, blood from 50 generally healthy donors was collected, and coagulation responses to dabigatran, argatroban, rivaroxaban, and apixaban, at a concentration of 1 μM, were analyzed. Heparin was used as a positive control. Prothrombin time (PT) expressed as international normalized ratio (INR) and activated partial thromboplastin time (aPTT) were measured and compared. Rivaroxaban was the most active according to PT/INR while argatroban according to aPTT. The ex vivo anticoagulant effect measured by INR correlated inversely with body mass index (BMI) in all four anticoagulants tested. Shortening of aPTT was associated with higher cholesterol and triglyceride levels. No sex-related differences were observed in response to the anticoagulant treatments. As this was an ex vivo study and pharmacokinetic factors were not included, the influence of BMI is of high therapeutic importance.
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Affiliation(s)
- Jaka Fadraersada
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Raúl Alva-Gallegos
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Pavel Skořepa
- 3rd Department of Internal Medicine-Metabolic Care and Gerontology, University Hospital and Faculty of Medicine in Hradec Králové, Charles University, Sokolská 581, 50005, Hradec Králové, Czech Republic
- Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Králové, Czech Republic
| | - František Musil
- Department of Occupational Medicine, University Hospital and Faculty of Medicine in Hradec Králové, Charles University, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Lenka Javorská
- Department of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Kateřina Matoušová
- Department of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Lenka Kujovská Krčmová
- Department of Clinical Biochemistry and Diagnostics, University Hospital Hradec Králové, Hradec Králové, Czech Republic
- Department of Analytical Chemistry, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Markéta Paclíková
- 3rd Department of Internal Medicine-Metabolic Care and Gerontology, University Hospital and Faculty of Medicine in Hradec Králové, Charles University, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Alejandro Carazo
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic
| | - Vladimír Blaha
- 3rd Department of Internal Medicine-Metabolic Care and Gerontology, University Hospital and Faculty of Medicine in Hradec Králové, Charles University, Sokolská 581, 50005, Hradec Králové, Czech Republic
| | - Přemysl Mladěnka
- Department of Pharmacology and Toxicology, Faculty of Pharmacy in Hradec Králové, Charles University, Hradec Králové, Czech Republic.
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Staniszewska M, Myslitska D, Romański M, Polak S, Garbacz G, Dobosz J, Smoleński M, Paszkowska J, Danielak D. In Vitro Simulation of the Fasted Gastric Conditions and Their Variability to Elucidate Contrasting Properties of the Marketed Dabigatran Etexilate Pellet-Filled Capsules and Loose Pellets. Mol Pharm 2024; 21:2456-2472. [PMID: 38568423 DOI: 10.1021/acs.molpharmaceut.4c00025] [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: 05/07/2024]
Abstract
Variability of the gastrointestinal tract is rarely reflected in in vitro test protocols but often turns out to be crucial for the oral dosage form performance. In this study, we present a generation method of dissolution profiles accounting for the variability of fasted gastric conditions. The workflow featured 20 biopredictive tests within the physiological variability. The experimental array was constructed with the use of the design of experiments, based on three parameters: gastric pH and timings of the intragastric stress event and gastric emptying. Then, the resulting dissolution profiles served as a training data set for the dissolution process modeling with the machine learning algorithms. This allowed us to generate individual dissolution profiles under a customizable gastric pH and motility patterns. For the first time ever, we used the method to successfully elucidate dissolution properties of two dosage forms: pellet-filled capsules and bare pellets of the marketed dabigatran etexilate product Pradaxa. We showed that the dissolution of capsules was triggered by mechanical stresses and thus was characterized by higher variability and a longer dissolution onset than observed for pellets. Hence, we proved the applicability of the method for the in vitro and in silico characterization of immediate-release dosage forms and, potentially, for the improvement of in vitro-in vivo extrapolation.
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Affiliation(s)
| | - Daria Myslitska
- Physiolution Polska, 74 Piłsudskiego St., 50-020 Wrocław, Poland
| | - Michał Romański
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 3 Rokietnicka St., 60-806 Poznań, Poland
| | - Sebastian Polak
- Faculty of Pharmacy, Medical College, Jagiellonian University, Medyczna 9 Street, 30-688 Kraków, Poland
| | - Grzegorz Garbacz
- Physiolution Polska, 74 Piłsudskiego St., 50-020 Wrocław, Poland
| | - Justyna Dobosz
- Physiolution Polska, 74 Piłsudskiego St., 50-020 Wrocław, Poland
| | - Michał Smoleński
- Physiolution Polska, 74 Piłsudskiego St., 50-020 Wrocław, Poland
| | | | - Dorota Danielak
- Department of Physical Pharmacy and Pharmacokinetics, Poznan University of Medical Sciences, 3 Rokietnicka St., 60-806 Poznań, Poland
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Xie ZS, Han XY, Zhou ZY, Li SY, Zhu JY, Zhang L, Xue ST. Design and synthesis of dabigatran etexilate derivatives with inhibiting thrombin activity for hepatocellular carcinoma treatment. Biomed Pharmacother 2024; 170:116018. [PMID: 38113628 DOI: 10.1016/j.biopha.2023.116018] [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: 10/16/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most fatal solid malignancies worldwide. Evidence suggests that thrombin stimulates tumor progression via fibrin formation and platelet activation. Meanwhile, we also found a correlation between thrombin and HCC through bioinformatics analysis. Dabigatran is a selective, direct thrombin inhibitor that reversibly binds to thrombin. Dabigatran was used as the lead agent in this study, and 19 dabigatran derivatives were designed and synthesized based on docking mode. The thrombin-inhibitory activity of the derivative AX-2 was slightly better than that of dabigatran. BX-2, a prodrug of AX-2, showed a fairly strong inhibitory effect on thrombin-induced platelet aggregation, and effectively antagonized proliferation of HCC tumor cells induced by thrombin at the cellular level. Furthermore, BX-2 reduced tumor volume, weight, lung metastasis, and secondary tumor occurrence in nude mouse models. BX-2 combined with sorafenib increased sorafenib efficacy. This study lays the foundation for discovering new anti-HCC mechanism based on thrombin. BX-2 can be used as an anti-HCC drug lead for further research.
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Affiliation(s)
- Zhuo-Song Xie
- Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiao-Yang Han
- Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zi-Ying Zhou
- Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Si-Yan Li
- Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiang-Yi Zhu
- Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lei Zhang
- School of Biological & Chemical Engineering, Zhejiang University of Science and Technology, Zhejiang, China.
| | - Si-Tu Xue
- Institute of Medicinal Biotechnology, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Spasov AA, Fedorova OV, Rasputin NA, Ovchinnikova IG, Ishmetova RI, Ignatenko NK, Gorbunov EB, Sadykhov GAO, Kucheryavenko AF, Gaidukova KA, Sirotenko VS, Rusinov GL, Verbitskiy EV, Charushin VN. Novel Substituted Azoloazines with Anticoagulant Activity. Int J Mol Sci 2023; 24:15581. [PMID: 37958560 PMCID: PMC10648877 DOI: 10.3390/ijms242115581] [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: 10/02/2023] [Revised: 10/21/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
Hypercytokinemia, or cytokine storm, often complicates the treatment of viral and bacterial infections, including COVID-19, leading to the risk of thrombosis. However, the use of currently available direct anticoagulants for the treatment of COVID-19 patients is limited due to safety reasons. Therefore, the development of new anticoagulants remains an urgent task for organic and medicinal chemistry. At the same time, new drugs that combine anticoagulant properties with antiviral or antidiabetic activity could be helpfull in the treatment of COVID-19 patients, especially those suffering from such concomitant diseases as arterial hypertension or diabetes. We have synthesized a number of novel substituted azoloazines, some of which have previously been identified as compounds with pronounced antiviral, antibacterial, antidiabetic, antiaggregant, and anticoagulant activity. Two compounds from the family of 1,2,4-triazolo[1,5-a]pyrimidines have demonstrated anticoagulant activity at a level exceeding or at least comparable with that of dabigatran etexilate as the reference compound. 7,5-Di(2-thienyl)-4,5-dihydro-[1,2,4]triazolo[1,5-a]pyrimidine has shown the highest ability to prolong the thrombin time, surpassing this reference drug by 2.2 times. This compound has also exhibited anticoagulant activity associated with the inhibition of thrombin (factor IIa). Moreover, the anticoagulant effect of this substance becomes enhanced under the conditions of a systemic inflammatory reaction.
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Affiliation(s)
- Alexander A. Spasov
- Department of Pharmacology & Bioinformatics, Scientific Center for Innovative Drugs, Volgograd State Medical University, Volgograd 400131, Russia; (A.F.K.); (K.A.G.); (V.S.S.)
| | - Olga V. Fedorova
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
| | - Nikolay A. Rasputin
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
| | - Irina G. Ovchinnikova
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
| | - Rashida I. Ishmetova
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
| | - Nina K. Ignatenko
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
| | - Evgeny B. Gorbunov
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
| | - Gusein A. o. Sadykhov
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
- Department of Organic and Biomolecular Chemistry, Ural Federal University Named after the First President of Russia B. N. Yeltsin, Ekaterinburg 620002, Russia
| | - Aida F. Kucheryavenko
- Department of Pharmacology & Bioinformatics, Scientific Center for Innovative Drugs, Volgograd State Medical University, Volgograd 400131, Russia; (A.F.K.); (K.A.G.); (V.S.S.)
| | - Kseniia A. Gaidukova
- Department of Pharmacology & Bioinformatics, Scientific Center for Innovative Drugs, Volgograd State Medical University, Volgograd 400131, Russia; (A.F.K.); (K.A.G.); (V.S.S.)
| | - Victor S. Sirotenko
- Department of Pharmacology & Bioinformatics, Scientific Center for Innovative Drugs, Volgograd State Medical University, Volgograd 400131, Russia; (A.F.K.); (K.A.G.); (V.S.S.)
| | - Gennady L. Rusinov
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
- Department of Technology & Organic Synthesis, Ural Federal University Named after the First President of Russia B. N. Yeltsin, Ekaterinburg 620002, Russia
| | - Egor V. Verbitskiy
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
- Department of Organic and Biomolecular Chemistry, Ural Federal University Named after the First President of Russia B. N. Yeltsin, Ekaterinburg 620002, Russia
| | - Valery N. Charushin
- I. Ya. Postovsky Institute of Organic Synthesis, Ural Branch of the Russian Academy of Sciences, Ekaterinburg 620108, Russia; (O.V.F.); (I.G.O.); (R.I.I.); (N.K.I.); (E.B.G.); (G.A.o.S.); (G.L.R.); (E.V.V.); (V.N.C.)
- Department of Organic and Biomolecular Chemistry, Ural Federal University Named after the First President of Russia B. N. Yeltsin, Ekaterinburg 620002, Russia
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Rees PA, Castle J, Clouston HW, Lamb R, Singh U, Duff SE, Kirwan CC. The effects of coagulation factors and their inhibitors on proliferation and migration in colorectal cancer. Cancer Med 2023; 12:17184-17192. [PMID: 37455592 PMCID: PMC10501231 DOI: 10.1002/cam4.6332] [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: 05/12/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND/AIM Clotting factors promote cancer development. We investigated if coagulation proteins promote proliferation and migration in colorectal cancer (CRC) cell lines and whether their direct inhibitors can attenuate these effects. MATERIALS AND METHODS DLD-1 and SW620 cells were treated with tissue factor (0, 50, 100 and 500 pg/mL ± 10 μg/mL 10H10 [anti-tissue factor antibody]), thrombin (0.0, 0.1, 1.0 and 10.0 U/mL ± 0.5 μM dabigatran [thrombin inhibitor]) and Factor Xa, FXa (0.0, 0.1, 1.0 and 10.0 U/mL ± 100 ng/mL rivaroxaban [FXa inhibitor]) and their effects on proliferation and migration were quantified using the PrestoBlue® and transwell migration assays, respectively. RESULTS Thrombin increased proliferation from 48 h treatment compared to its control (48 h 6.57 ± 1.36 u vs. 2.42 ± 0.13 u, p = 0.001, 72 h 9.50 ± 1.54 u vs. 4.50 ± 0.47 u, p = 0.004 and 96 h 10.77 ± 1.72 u vs. 5.57 ± 0.25 u, p = 0.008). This increase in proliferation was attenuated by dabigatran at 72 h (2.23 ± 0.16 u vs. 3.26 ± 0.43 u, p = 0.04). Tissue factor (0 pg/mL 20.7 ± 1.6 cells/view vs. 50 pg/mL 32.4 ± 1.9 cells/view, p = 0.0002), FXa (0.0 U/mL 8.9 ± 1.1 cells/view vs. 10.0 U/mL 17.7 ± 1.7 cells/view, p < 0.0001) and thrombin (0.0 U/mL 8.9 ± 1.3 cells/view vs. 10.0 U/mL 20.2 ± 2.0 cells/view, p < 0.0001) all increased migration compared to their controls. However, their direct inhibitors did not attenuate these increases. CONCLUSION Thrombin, FXa and TF all increase migration in CRC in vitro. Thrombin induced increase in proliferation is abrogated by dabigatran. Dabigatran may have potential as an anti-cancer therapy in CRC.
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Affiliation(s)
- Peter Adam Rees
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Manchester University NHS Foundation TrustManchesterUK
| | - John Castle
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - Hamish William Clouston
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- The Christie NHS Foundation TrustManchesterUK
| | - Rebecca Lamb
- Department of Life SciencesManchester Metropolitan UniversityManchesterUK
| | - Urvashi Singh
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Manchester University NHS Foundation TrustManchesterUK
| | - Sarah Elizabeth Duff
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Manchester University NHS Foundation TrustManchesterUK
| | - Cliona Clare Kirwan
- Division of Cancer Sciences, School of Medical Sciences, Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Manchester University NHS Foundation TrustManchesterUK
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Akter T, Annamalai B, Obert E, Simpson KN, Rohrer B. Dabigatran and Wet AMD, Results From Retinal Pigment Epithelial Cell Monolayers, the Mouse Model of Choroidal Neovascularization, and Patients From the Medicare Data Base. Front Immunol 2022; 13:896274. [PMID: 35784301 PMCID: PMC9248746 DOI: 10.3389/fimmu.2022.896274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/17/2022] [Indexed: 12/02/2022] Open
Abstract
Background Age-related macular degeneration (AMD), the leading cause of irreversible blindness in elderly Caucasian populations, includes destruction of the blood-retina barrier (BRB) generated by the retinal pigment epithelium-Bruch’s membrane complex (RPE/BrM), and complement activation. Thrombin is likely to get access to those structures upon BRB integrity loss. Here we investigate the potential role of thrombin in AMD by analyzing effects of the thrombin inhibitor dabigatran. Material and Methods MarketScan data for patients aged ≥65 years on Medicare was used to identify association between AMD and dabigatran use. ARPE-19 cells grown as mature monolayers were analyzed for thrombin effects on barrier function (transepithelial resistance; TER) and downstream signaling (complement activation, expression of connective tissue growth factor (CTGF), and secretion of vascular endothelial growth factor (VEGF)). Laser-induced choroidal neovascularization (CNV) in mouse is used to test the identified downstream signaling. Results Risk of new wet AMD diagnosis was reduced in dabigatran users. In RPE monolayers, thrombin reduced TER, generated unique complement C3 and C5 cleavage products, led to C3d/MAC deposition on cell surfaces, and increased CTGF expression via PAR1-receptor activation and VEGF secretion. CNV lesion repair was accelerated by dabigatran, and molecular readouts suggest that downstream effects of thrombin include CTGF and VEGF, but not the complement system. Conclusions This study provides evidence of association between dabigatran use and reduced exudative AMD diagnosis. Based on the cell- and animal-based studies, we suggest that thrombin modulates wound healing and CTGF and VEGF expression, making dabigatran a potential novel treatment option in AMD.
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Affiliation(s)
- Tanjina Akter
- Department of Ophthalmology, Medical University of South Carolina, Charleston, SC, United States
- *Correspondence: Tanjina Akter, ; Bärbel Rohrer,
| | | | - Elisabeth Obert
- Department of Ophthalmology, Medical University of South Carolina, Charleston, SC, United States
| | - Kit N. Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC, United States
| | - Bärbel Rohrer
- Department of Ophthalmology, Medical University of South Carolina, Charleston, SC, United States
- Department of Neurosciences, Medical University of South Carolina, Charleston, SC, United States
- Ralph H. Johnson VA Medical Center, Division of Research, Charleston, SC, United States
- *Correspondence: Tanjina Akter, ; Bärbel Rohrer,
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7
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Gorzelak-Pabiś P, Broncel M, Pawlos A, Wojdan K, Gajewski A, Chałubiński M, Woźniak E. Dabigatran: its protective effect against endothelial cell damage by oxysterol. Biomed Pharmacother 2022; 147:112679. [PMID: 35121342 DOI: 10.1016/j.biopha.2022.112679] [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: 12/19/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/17/2022] Open
Abstract
Recent data showed that dabigatran can reduce not only procoagulatory effects but also block proinflammatory stimuli by inhibiting the expression of cytokines and chemokines and reducing thrombin-induced endothelial permeability. The aim of our study was to assess the effect of dabigatran on the integrity and inflammatory properties of endothelial cells stimulated by 25-hydroxycholesterol (25-OHC, oxysterol). HUVECs (Human Umbilical Vein Endothelial Cells) were stimulated with 25-hydroxycholesterol 10 µg/ml, dabigatran 100 ng/ml or 500 ng/ml and 25-hydroxycholesterol + dabigatran (100 ng/ml, 500 ng/ml). HUVEC integrity and permeability was measured in the RTCA-DP xCELLigence system and by the paracellular flux system. The mRNA expression of ICAM-1, VEGF, IL-33, MCP-1 and TNF-α was analyzed by Real-time PCR. Cell apoptosis and viability was measured by flow cytometry. VEGF protein concentration was assessed in supernatants by ELISA. VE-cadherin expression in endothelial cells was evaluated by confocal microscopy. Pre-stimulation of HUVECs with 25-OHC decreased endothelial cell integrity (p < 0.001) and increased the expression of IL-33, ICAM-1, MCP-1, VEGF, TNF-α mRNA (p < 0.01) compared to unstimulated controls. Following stimulation of HUVECs with dabigatran 100 ng/ml or 500 ng/ml restored HUVEC integrity interrupted by 25-OHC (p < 0.001). In HUVECs pre-stimulated with oxysterol, dabigatran stimulation decreased mRNA expression of the proinflammatory cytokines IL-33 and TNF-α, chemokines MCP-1 ICAM-1 and VEGF (p < 0.01). Dabigatran 500 mg/ml+ 25-OHC increased the endothelial expression of VE-cadherin as compared to 25-OHC (p < 0.01). Our findings suggest that dabigatran stabilizes the endothelial barrier and inhibits the inflammation caused by oxysterol.
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Affiliation(s)
- Paulina Gorzelak-Pabiś
- Dept. of Internal Diseases and Clinical Pharmacology, The Laboratory of Tissue Immunopharmacology, Medical University of Lodz, Poland.
| | - Marlena Broncel
- Dept. of Internal Diseases and Clinical Pharmacology, The Laboratory of Tissue Immunopharmacology, Medical University of Lodz, Poland
| | - Agnieszka Pawlos
- Dept. of Internal Diseases and Clinical Pharmacology, The Laboratory of Tissue Immunopharmacology, Medical University of Lodz, Poland
| | - Katarzyna Wojdan
- Dept. of Internal Diseases and Clinical Pharmacology, The Laboratory of Tissue Immunopharmacology, Medical University of Lodz, Poland
| | - Adrian Gajewski
- Department of Immunology and Allergy, Medical University of Lodz, Lodz, Poland
| | - Maciej Chałubiński
- Department of Immunology and Allergy, Medical University of Lodz, Lodz, Poland
| | - Ewelina Woźniak
- Dept. of Internal Diseases and Clinical Pharmacology, The Laboratory of Tissue Immunopharmacology, Medical University of Lodz, Poland
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Kij A, Bar A, Przyborowski K, Proniewski B, Mateuszuk L, Jasztal A, Kieronska-Rudek A, Marczyk B, Matyjaszczyk-Gwarda K, Tworzydlo A, Enggaard C, Hansen PBL, Jensen B, Walczak M, Chlopicki S. Thrombin Inhibition Prevents Endothelial Dysfunction and Reverses 20-HETE Overproduction without Affecting Blood Pressure in Angiotensin II-Induced Hypertension in Mice. Int J Mol Sci 2021; 22:ijms22168664. [PMID: 34445374 PMCID: PMC8395447 DOI: 10.3390/ijms22168664] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 07/24/2021] [Revised: 08/05/2021] [Accepted: 08/07/2021] [Indexed: 02/02/2023] Open
Abstract
Angiotensin II (Ang II) induces hypertension and endothelial dysfunction, but the involvement of thrombin in these responses is not clear. Here, we assessed the effects of the inhibition of thrombin activity by dabigatran on Ang II-induced hypertension and endothelial dysfunction in mice with a particular focus on NO- and 20-HETE-dependent pathways. As expected, dabigatran administration significantly delayed thrombin generation (CAT assay) in Ang II-treated hypertensive mice, and interestingly, it prevented endothelial dysfunction development, but it did not affect elevated blood pressure nor excessive aortic wall thickening. Dabigatran’s effects on endothelial function in Ang II-treated mice were evidenced by improved NO-dependent relaxation in the aorta in response to acetylcholine in vivo (MRI measurements) and increased systemic NO bioavailability (NO2− quantification) with a concomitant increased ex vivo production of endothelium-derived NO (EPR analysis). Dabigatran treatment also contributed to the reduction in the endothelial expression of pro-inflammatory vWF and ICAM-1. Interestingly, the fall in systemic NO bioavailability in Ang II-treated mice was associated with increased 20-HETE concentration in plasma (UPLC-MS/MS analysis), which was normalised by dabigatran treatment. Taking together, the inhibition of thrombin activity in Ang II-induced hypertension in mice improves the NO-dependent function of vascular endothelium and normalises the 20-HETE-depedent pathway without affecting the blood pressure and vascular remodelling.
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Affiliation(s)
- Agnieszka Kij
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Anna Bar
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Kamil Przyborowski
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Bartosz Proniewski
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Lukasz Mateuszuk
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Agnieszka Jasztal
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Anna Kieronska-Rudek
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Brygida Marczyk
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Karolina Matyjaszczyk-Gwarda
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Anna Tworzydlo
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
| | - Camilla Enggaard
- Department of Cardiovascular and Renal Research, University of Southern Denmark, J.B. Winsløws Vej 21, 5000 Odense, Denmark; (C.E.); (P.B.L.H.); (B.J.)
| | - Pernille B. Lærkegaard Hansen
- Department of Cardiovascular and Renal Research, University of Southern Denmark, J.B. Winsløws Vej 21, 5000 Odense, Denmark; (C.E.); (P.B.L.H.); (B.J.)
| | - Boye Jensen
- Department of Cardiovascular and Renal Research, University of Southern Denmark, J.B. Winsløws Vej 21, 5000 Odense, Denmark; (C.E.); (P.B.L.H.); (B.J.)
| | - Maria Walczak
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
- Chair and Department of Toxicology, Jagiellonian University Medical College, Medyczna 9, 30-688 Krakow, Poland
| | - Stefan Chlopicki
- Jagiellonian Centre for Experimental Therapeutics (JCET), Jagiellonian University, Bobrzynskiego 14, 30-348 Krakow, Poland; (A.K.); (A.B.); (K.P.); (B.P.); (L.M.); (A.J.); (A.K.-R.); (B.M.); (K.M.-G.); (A.T.); (M.W.)
- Chair of Pharmacology, Jagiellonian University Medical College, Grzegorzecka 16, 31-531 Krakow, Poland
- Correspondence:
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9
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Grossmann K. Alzheimer's Disease-Rationales for Potential Treatment with the Thrombin Inhibitor Dabigatran. Int J Mol Sci 2021; 22:ijms22094805. [PMID: 33946588 PMCID: PMC8125318 DOI: 10.3390/ijms22094805] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 04/28/2021] [Accepted: 04/28/2021] [Indexed: 12/16/2022] Open
Abstract
Alzheimer's disease (AD) is caused by neurodegenerative, but also vascular and hemostatic changes in the brain. The oral thrombin inhibitor dabigatran, which has been used for over a decade in preventing thromboembolism and has a well-known pharmacokinetic, safety and antidote profile, can be an option to treat vascular dysfunction in early AD, a condition known as cerebral amyloid angiopathy (CAA). Recent results have revealed that amyloid-β proteins (Aβ), thrombin and fibrin play a crucial role in triggering vascular and parenchymal brain abnormalities in CAA. Dabigatran blocks soluble thrombin, thrombin-mediated formation of fibrin and Aβ-containing fibrin clots. These clots are deposited in brain parenchyma and blood vessels in areas of CAA. Fibrin-Aβ deposition causes microvascular constriction, occlusion and hemorrhage, leading to vascular and blood-brain barrier dysfunction. As a result, blood flow, perfusion and oxygen and nutrient supply are chronically reduced, mainly in hippocampal and neocortical brain areas. Dabigatran has the potential to preserve perfusion and oxygen delivery to the brain, and to prevent parenchymal Aβ-, thrombin- and fibrin-triggered inflammatory and neurodegenerative processes, leading to synapse and neuron death, and cognitive decline. Beneficial effects of dabigatran on CAA and AD have recently been shown in preclinical studies and in retrospective observer studies on patients. Therefore, clinical studies are warranted, in order to possibly expand dabigatran approval for repositioning for AD treatment.
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Affiliation(s)
- Klaus Grossmann
- Center for Plant Molecular Biology (ZMBP), University of Tübingen, 72076 Tübingen, Germany
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10
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Qian LL, Ji JJ, Guo JQ, Wu YP, Ma GS, Yao YY. Protective role of serpina3c as a novel thrombin inhibitor against atherosclerosis in mice. Clin Sci (Lond) 2021; 135:447-463. [PMID: 33458764 DOI: 10.1042/cs20201235] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 10/02/2020] [Revised: 01/13/2021] [Accepted: 01/18/2021] [Indexed: 12/26/2022]
Abstract
Abnormal vascular smooth muscle cell (VSMC) proliferation is a critical step in the development of atherosclerosis. Serpina3c is a serine protease inhibitor (serpin) that plays a key role in metabolic diseases. The present study aimed to investigate the role of serpina3c in atherosclerosis and regulation of VSMC proliferation and possible mechanisms. Serpina3c is down-regulated during high-fat diet (HFD)-induced atherosclerosis. An Apoe-/-/serpina3c-/--double-knockout mouse model was used to determine the role of serpina3c in atherosclerosis after HFD for 12 weeks. Compared with Apoe-/- mice, the Apoe-/-/serpina3c-/- mice developed more severe atherosclerosis, and the number of VSMCs and macrophages in aortic plaques was significantly increased. The present study revealed serpina3c as a novel thrombin inhibitor that suppressed thrombin activity. In circulating plasma, thrombin activity was high in the Apoe-/-/serpina3c-/- mice, compared with Apoe-/- mice. Immunofluorescence staining showed thrombin and serpina3c colocalization in the liver and aortic cusp. In addition, inhibition of thrombin by dabigatran in serpina3c-/- mice reduced neointima lesion formation due to partial carotid artery ligation. Moreover, an in vitro study confirmed that thrombin activity was also decreased by serpina3c protein, supernatant and cell lysate that overexpressed serpina3c. The results of experiments showed that serpina3c negatively regulated VSMC proliferation in culture. The possible mechanism may involve serpina3c inhibition of ERK1/2 and JNK signaling in thrombin/PAR-1 system-mediated VSMC proliferation. Our results highlight a protective role for serpina3c as a novel thrombin inhibitor in the development of atherosclerosis, with serpina3c conferring protection through the thrombin/PAR-1 system to negatively regulate VSMC proliferation through ERK1/2 and JNK signaling.
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Affiliation(s)
- Ling-Lin Qian
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao, Nanjing, Jiangsu 210009, China
| | - Jing-Jing Ji
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao, Nanjing, Jiangsu 210009, China
| | - Jia-Qi Guo
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao, Nanjing, Jiangsu 210009, China
| | - Yan-Ping Wu
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao, Nanjing, Jiangsu 210009, China
| | - Gen-Shan Ma
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao, Nanjing, Jiangsu 210009, China
| | - Yu-Yu Yao
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao, Nanjing, Jiangsu 210009, China
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11
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Abstract
Currently licenced direct oral anticoagulants selectively target thrombin (eg, dabigatran) or coagulation factor Xa (eg, apixaban, betrixaban, edoxaban, and rivaroxaban). Designed to be given in fixed doses without routine monitoring, direct oral anticoagulants have a lower propensity for food and drug interactions than do vitamin K antagonists, and in randomised controlled trials involving around 250 000 patients, they were at least as effective for prevention and treatment of thrombosis and were associated with a lower risk of life-threatening bleeding. The absolute benefits of direct oral anticoagulants over vitamin K antagonists are modest; however, guidelines recommend them in preference to vitamin K antagonists for most indications because of their ease of use and superior safety. The greatest benefits of direct oral anticoagulants are likely to be in patients who were previously deemed unsuitable for vitamin K antagonist therapy. The emergence of generic preparations is expected to further increase the uptake of direct oral anticoagulants, particularly in countries where they are currently not widely used because of cost. Direct oral anticoagulants are contraindicated in patients with mechanical heart valves and should be used with caution or avoided in patients with advanced kidney or liver disease. In this Therapeutics paper, we review the pharmacology of direct oral anticoagulants, summarise the evidence that led to their approval and incorporation into treatment guidelines, and explore key unresolved issues. We also briefly discuss future perspectives for the development of oral anticoagulants.
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Affiliation(s)
- Noel Chan
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Hamilton General Hospital and McMaster University, Hamilton, ON, Canada.
| | | | - John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Hamilton General Hospital and McMaster University, Hamilton, ON, Canada
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12
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Cho HJ, Kang YJ, Sung SM, Ahn SH, Jung YH, Lee KY, Seo JH, Han SW, Park JH, Choi HY, Kwon JH, Kim WJ, Park HJ, Choi JK, Nam HS, Heo JH, Kim YD. Effects of dabigatran and rivaroxaban on stroke severity according to the results of routine coagulation tests. PLoS One 2020; 15:e0240483. [PMID: 33044991 PMCID: PMC7549802 DOI: 10.1371/journal.pone.0240483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 09/25/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Prior use of direct oral anticoagulants has been associated with reduced stroke severity in patients with non-valvular atrial fibrillation (NVAF). The aim of this study was to investigate the impact of prothrombin time (PT) and activated partial thromboplastin time (aPTT) on stroke severity in patients who were receiving dabigatran or rivaroxaban at the time of stroke onset. Materials and methods We enrolled 107 patients with NVAF who developed acute ischemic stroke while on dabigatran or rivaroxaban and presented within 24 hours to nine hospitals between January 2014 and December 2018. The results of PT and aPTT assays were obtained within 24 hours of stroke onset in all patients. We analyzed PT and aPTT in relation to stroke severity and ischemic lesion volume using correlation and multivariable regression analyses. Results Of the 107 patients included, 46 (43.0%) were on dabigatran and 61 (57.0%) were on rivaroxaban. In patients with prior dabigatran use, while aPTT was inversely correlated with admission National Institutes of Health Stroke Scale (NIHSS) score (r = -0.369, p = 0.012) and ischemic lesion volume (r = -0.480, p = 0.005), there was no correlation between PT and either of these variables. Multivariable analysis confirmed the existence of a significant independent inverse relationship between aPTT and NIHSS score at admission (B, -0.201; 95% confidence interval [CI], -0.370 to -0.032; p = 0.005) and between aPTT and ischemic lesion volume (B, -0.076; 95% CI, -0.130 to -0.023; p = 0.007). In patients with prior rivaroxaban use, neither PT nor aPTT was associated with admission NIHSS score or ischemic lesion volume in the correlation and multivariable analyses. Conclusions In patients with NVAF who were receiving dabigatran, prolonged aPTT was associated with reduced stroke severity.
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Affiliation(s)
- Han-Jin Cho
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Yoon Jung Kang
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Sang Min Sung
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, Korea
| | - Sung-Ho Ahn
- Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Yo Han Jung
- Department of Neurology, Changwon Fatima Hospital, Changwon, Korea
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Severance Institute for Vascular and Metabolic Research, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Hwa Seo
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sang Won Han
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Joong Hyun Park
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hye-Yeon Choi
- Department of Neurology, Kyung Hee University School of Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan University College of Medicine, Ulsan, Korea
| | - Hyung Jong Park
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Jin Kyo Choi
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
- * E-mail:
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13
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Wong EKC, Belza C, Naimark DMJ, Straus SE, Wijeysundera HC. Cost-effectiveness of antithrombotic agents for atrial fibrillation in older adults at risk for falls: a mathematical modelling study. CMAJ Open 2020; 8:E706-E714. [PMID: 33158928 PMCID: PMC7661050 DOI: 10.9778/cmajo.20200107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antithrombotic drugs decrease stroke risk in patients with atrial fibrillation, but they increase bleeding risk, particularly in older adults at high risk for falls. We aimed to determine the most cost-effective antithrombotic therapy in older adults with atrial fibrillation who are at high risk for falls. METHODS We conducted a mathematical modelling study from July 2019 to March 2020 based on the Ontario, Canada, health care system. We derived the base-case age, sex and fall risk distribution from a published cohort of older adults at risk for falls, and the bleeding and stroke risk parameters from an atrial fibrillation trial population. Using a probabilistic microsimulation Markov decision model, we calculated quality-adjusted life years (QALYs), total cost and incremental cost-effectiveness ratios (ICERs) for each of acetylsalicylic acid (ASA), warfarin, apixaban, dabigatran, rivaroxaban and edoxaban. Cost data were adjusted for inflation to 2018 values. The analysis used the Ontario public payer perspective with a lifetime horizon. RESULTS In our model, the most cost-effective antithrombotic therapy for atrial fibrillation in older patients at risk for falls was apixaban, with an ICER of $8517 per QALY gained (5.86 QALYs at $92 056) over ASA. It was a dominant strategy over warfarin and the other antithrombotic agents. There was moderate uncertainty in cost-effectiveness ranking, with apixaban as the preferred choice in 66% of model iterations (given willingness to pay of $50 000 per QALY gained); edoxaban, 30 mg, was preferred in 31% of iterations. Sensitivity analysis across ranges of age, bleeding risk and fall risk still favoured apixaban over the other medications. INTERPRETATION From a public payer perspective, apixaban is the most cost-effective antithrombotic agent in older adults at high risk for falls. Health care funders should implement strategies to encourage use of the most cost-effective medication in this population.
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Affiliation(s)
- Eric K C Wong
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.
| | - Christina Belza
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
| | - David M J Naimark
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
| | - Sharon E Straus
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
| | - Harindra C Wijeysundera
- Knowledge Translation Program (Wong, Straus), Li Ka Shing Knowledge Institute, St. Michael's Hospital; Institute for Health Policy Management and Evaluation (Wong, Belza, Naimark, Straus, Wijeysundera), Dalla Lana School of Public Health, Division of Nephrology (Naimark), Sunnybrook Health Sciences Centre and Division of Cardiology and Cardiac Surgery (Wijeysundera), Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
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14
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Li X, Liu L, Xu B, Xiang Q, Li Y, Zhang P, Wang Y, Xie Q, Mao Y, Cui Y. Bioequivalence and pharmacodynamics of a generic dabigatran etexilate capsule in healthy Chinese subjects under fasting and fed conditions. Pharmacol Res Perspect 2020; 8:e00593. [PMID: 32338459 PMCID: PMC7184321 DOI: 10.1002/prp2.593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/23/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 01/12/2023] Open
Abstract
To assess bioequivalence of a generic dabigatran etexilate capsule in healthy Chinese subjects under fasting and fed conditions. This was an open-label, single-center, randomized four-period crossover study with a 7-day washout period. A single oral dose of 150 mg generic dabigatran etexilate capsule (test drug) or a commercial dabigatran etexilate capsule (Pradaxa® , reference drug) was given to healthy volunteers under the fasting and fed conditions. Plasma concentrations of total and free dabigatran were detected using a validated HPLC-MS/MS method. A noncompartmental method was used for pharmacokinetic analysis and established coagulation assays were applied for pharmacodynamic analysis. The 90% CIs of the test/reference ratios of Cmax , AUC0-t , and AUC0-∞ for the total dabigatran concentration were 92.57%-106.58%, 91.63%-106.32%, and 92.54%-106.17%, respectively, under fasting condition, and 99.30%-110.74%, 98.58%-105.37%, and 97.75%-103.99%, respectively, under fed conditions. The 90% CIs of the ratios of the parameters for the free dabigatran were 93.18%-106.98%, 92.13%-107.10%, 92.89%-106.48%, respectively, under fasting condition, and 100.05%-110.89%, 99.37%-106.23%, 97.59%-103.98%, respectively, under the fed condition. Additionally, the upper limit of the 90% CIs for σWT/σWR was below 2.5. There were no significant differences in the coagulation parameters including thrombin clotting time, activated partial thromboplastin time, and anti-IIa activity between the two preparations. The generic dabigatran etexilate capsule is bioequivalent to the brand-named product in healthy Chinese volunteers under fasting and fed conditions. The two products have comparable pharmacodynamic parameters, with a good safety profile. In addition, food intake influences absorption of both products in a similar way.
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Affiliation(s)
- Xin Li
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Lihua Liu
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Bing Xu
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Qian Xiang
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| | - Yuan Li
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Ping Zhang
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Yangyang Wang
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Qiufen Xie
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| | - Yong Mao
- Chengdu Brilliant Pharmaceutical Co. LtdChengduThe People’s Republic of China
| | - Yimin Cui
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
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15
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Woźniak E, Broncel M, Bukowska B, Gorzelak-Pabiś P. The Protective Effect of Dabigatran and Rivaroxaban on DNA Oxidative Changes in a Model of Vascular Endothelial Damage with Oxidized Cholesterol. Int J Mol Sci 2020; 21:ijms21061953. [PMID: 32182973 PMCID: PMC7139915 DOI: 10.3390/ijms21061953] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 02/01/2020] [Revised: 03/10/2020] [Accepted: 03/11/2020] [Indexed: 12/13/2022] Open
Abstract
Background: Atherosclerotic plaques are unstable, and their release may result in thrombosis; therefore, currently, antiplatelet therapy with anticoagulants is recommended for the treatment of acute coronary syndrome. The aim of this study was to assess the effect of oxidized cholesterol on human umbilical vascular endothelial cells (HUVECs). The study also examines the protective and repairing effect of dabigatran and rivaroxaban in a model of vascular endothelial damage with 25-hydroxycholesterol (25-OHC). Methods: HUVECs were treated with compounds induce DNA single-strand breaks (SSBs) using the comet assay. Oxidative DNA damage was detected using endonuclease III (Nth) or human 8 oxoguanine DNA glycosylase (hOOG1). Reactive oxygen species (ROS) formation was determined using flow cytometry. Results: 25-hydroxycholesterol caused DNA SSBs, induced oxidative damage and increased ROS in the HUVECs; ROS level was lowered by dabigatran and rivaroxaban. Only dabigatran was able to completely repair the DNA SSBs induced by oxysterol. Dabigatran was able to reduce the level of oxidative damage of pyrimidines induced by oxysterol to the level of control cells. Conclusions: Observed changes strongly suggest that the tested anticoagulants induced indirect repair of DNA by inhibiting ROS production. Furthermore, dabigatran appears to have a higher antioxidant activity than rivaroxaban.
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Affiliation(s)
- Ewelina Woźniak
- Laboratory of Tissue Immunopharmacology, Department of Internal Diseases and Clinical Pharmacology, Medical University of Lodz, Kniaziewicza 1/5, 91-347 Lodz, Poland; (E.W.); (M.B.)
| | - Marlena Broncel
- Laboratory of Tissue Immunopharmacology, Department of Internal Diseases and Clinical Pharmacology, Medical University of Lodz, Kniaziewicza 1/5, 91-347 Lodz, Poland; (E.W.); (M.B.)
| | - Bożena Bukowska
- Department of Biophysics of Environmental Pollution, Faculty of Biology and Environmental Protection, University of Lodz, Pomorska 141/143, 90-236 Lodz, Poland;
| | - Paulina Gorzelak-Pabiś
- Laboratory of Tissue Immunopharmacology, Department of Internal Diseases and Clinical Pharmacology, Medical University of Lodz, Kniaziewicza 1/5, 91-347 Lodz, Poland; (E.W.); (M.B.)
- Correspondence:
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16
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Jha VK, Jairam A, Mahapatra D. Newer Oral Anticoagulant in Chronic Kidney Disease: What we Should Know. J Assoc Physicians India 2019; 67:60-65. [PMID: 31793271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Oral anticoagulants are commonly prescribed in patients with kidney diseases having atrial fibrillation and thromboembolic risk. It is very important to understand their clinical pharmacology and changes that may occur as GFR declines. Risks and benefits of newer oral anticoagulants are different in patients with CKD and patients with ESRD. Patients with GFR < 30 ml/min per 1.73 m2, including those on dialysis, were systematically excluded from landmark trials. All of the NOACs are dependent on renal clearance to some degree and so the risk of NOAC associated bleeding may be expected to be greater in patients with renal failure. Apixaban may be at least as safe as (or possibly safer than) warfarin in individuals with ESRD. Until more data become available, use of dabigatran, rivaroxaban, and edoxaban in patients with CKD stage 5 and ESRD is not indicated. Available strategies for reversing the anticoagulant effect of NOAC are - specific reversal agents available for dabigatran (idarucizumab) and for the oral direct factor Xa inhibitors - andexanet alfa, antifibrinolytic agents, DDAVP and prothrombin complex concentrates (PCCs). In this review clinical and pharmacological aspects of newer oral anticoagulants in the setting of chronic kidney disease will be discussed.
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Affiliation(s)
| | | | - D Mahapatra
- Consultant Medicine and Nephrologist, Command Hospital Airforce, Bangalore, Karnataka
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Abstract
There are no clear and consistent guidelines on how to utilize DOAC assays, and reports on the use of DOAC levels in clinical practice is limited. The objective of this study was to analyze why DOAC levels are ordered, how the results affect clinical decision-making, and to determine if DOAC assays are utilized appropriately. This was a retrospective chart review study analyzing 150 dabigatran, rivaroxaban, and apixaban levels performed at a single institution. The majority of DOAC assays were ordered in situations or special patient populations where confirming absence or detecting presence of drug may be useful. The most common indication for ordering assays was prior to an invasive procedure. Most DOAC levels were timed appropriately but peak levels were most likely to be incorrectly ordered. Clinical decisions following level results depended on indication for ordering and were most commonly used to determine whether or not to proceed with an invasive procedure. The results of our study suggest while DOAC assays are generally ordered for useful indications, there is still a lack of understanding of when levels should be drawn and how to interpret DOAC assay results.
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Affiliation(s)
- Tina M Gu
- Department of Pharmacy, University of Washington, 1959 NE Pacific St., EA-146, Seattle, WA, 98195, USA.
| | - David A Garcia
- Division of Hematology, University of Washington, Seattle, WA, USA
| | - Daniel E Sabath
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
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Huang S, Ren Y, Peng X, Qian P, Meng L. Computer-aid drug design, synthesis, and anticoagulant activity evaluation of novel dabigatran derivatives as thrombin inhibitors. Eur J Pharm Sci 2019; 137:104965. [PMID: 31247296 DOI: 10.1016/j.ejps.2019.104965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 04/15/2019] [Revised: 06/03/2019] [Accepted: 06/20/2019] [Indexed: 12/11/2022]
Abstract
In this study, computer-aided drug design techniques were adopted to explore the structural and chemical features for dabigatran and design novel derivatives. The built 3D-QSAR models demonstrated significant statistical quality and excellent predictive ability by internal and external validation. Based on QSAR information, 11 novel dabigatran derivatives (12a-12k) were designed and predicted, then ADME prediction and molecular docking were performed. Furthermore, all designed compounds were synthesized and characterized by 1H NMR, 13C NMR and HR-MS. Finally, they were evaluated for anticoagulant activity in vitro. The activity results showed that the 10 obtained compounds exhibited comparable activity to the reference dabigatran (IC50 = 9.99 ± 1.48 nM), except for compound 12i. Further analysis on molecular docking was performed on three compounds (12a, 12c and 12g) with better activity (IC50 = 11.19 ± 1.70 nM, IC50 = 10.94 ± 1.85 nM and IC50 = 11.19 ± 1.70 nM). MD simulations (10 ns) were carried out, and their binding free energies were calculated, which showed strong hydrogen bond and pi-pi stacking interactions with key residues Gly219, Asp189 and Trp60D. The 10 novel dabigatran derivatives obtained can be further studied as anticoagulant candidate compounds.
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Affiliation(s)
- Shanshan Huang
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China
| | - Yujie Ren
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China.
| | - Xiuxiu Peng
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China
| | - Pingping Qian
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China
| | - Lingwei Meng
- College of Chemical and Environmental Engineering, Shanghai Institute of Technology, 100 Haiquan Road, Shanghai 201418, China
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Buijs JT, Laghmani EH, van den Akker RFP, Tieken C, Vletter EM, van der Molen KM, Crooijmans JJ, Kroone C, Le Dévédec SE, van der Pluijm G, Versteeg HH. The direct oral anticoagulants rivaroxaban and dabigatran do not inhibit orthotopic growth and metastasis of human breast cancer in mice. J Thromb Haemost 2019; 17:951-963. [PMID: 30929299 PMCID: PMC6849835 DOI: 10.1111/jth.14443] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/18/2019] [Indexed: 12/21/2022]
Abstract
Essentials Factor Xa (FXa)-targeting direct oral anticoagulants (DOACs) reduce venous thromboembolism (VTE) The effects of FXa-targeting DOACs on cancer progression remain to be studied In xenograft models, a FXa-targeting DOAC did not inhibit breast cancer growth and metastasis A thrombin-targeting DOAC, dabigatran, also did not inhibit breast cancer growth and metastasis ABSTRACT: Background Factor Xa-targeting DOACs were recently found to reduce recurrent VTE efficiently in cancer patients when compared to the standard treatment with low-molecular-weight heparins (LMWHs). While the anticancer effects of LMWHs have been extensively studied in preclinical cancer models, the effects of FXa-targeting DOACs on cancer progression remain to be studied. Objective We investigated whether the FXa-targeting DOAC rivaroxaban and the thrombin-targeting DOAC dabigatran etexilate (DE) affected human breast cancer growth and metastasis in orthotopic xenograft models. Methods/results Mice that were put on a custom-made chow diet supplemented with rivaroxaban (0.4 or 1.0 mg/g diet) or dabigatran etexilate (DE) (10 mg/g diet) showed prolonged ex vivo coagulation times (prothrombin time [PT] and activated partial thromboplastin time [aPTT] assay, respectively). However, rivaroxaban and DE did not inhibit MDA-MB-231 tumor growth and metastasis formation in lungs or livers of 7-week-old fully immunodeficient NOD/SCID/ƴC-/- (NSG) mice. Comparable data were obtained for rivaroxaban-treated mice when using NOD-SCID mice. Rivaroxaban and DE treatment also did not significantly inhibit tumor growth and metastasis formation when using another human triple negative breast cancer (TNBC) cell line (HCC1806) in NOD-SCID mice. The FXa and thrombin-induced gene expression of the downstream target CXCL8 in both cell lines, but FXa and thrombin, did not significantly stimulate migration, proliferation, or stemness in vitro. Conclusion Although effectively inhibiting coagulation, the DOACs rivaroxaban and DE did not inhibit orthotopic growth and metastasis of human TNBC. It remains to be investigated whether DOACs exert antitumorigenic effects in other types of cancer.
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Affiliation(s)
- Jeroen T. Buijs
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - El H. Laghmani
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Rob F. P. van den Akker
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Chris Tieken
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Esther M. Vletter
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Kim M. van der Molen
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Juliette J. Crooijmans
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Chantal Kroone
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
| | - Sylvia E. Le Dévédec
- Division of Drug Discovery and SafetyLeiden Academic Center for Drug ResearchLeiden UniversityLeidenThe Netherlands
| | | | - Henri H. Versteeg
- Einthoven Laboratory for Vascular and Regenerative MedicineDivision of Thrombosis and HemostasisDepartment of Internal MedicineLeiden University Medical CenterLeidenThe Netherlands
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Lerche CJ, Christophersen LJ, Goetze JP, Nielsen PR, Thomsen K, Enevold C, Høiby N, Jensen PØ, Bundgaard H, Moser C. Adjunctive dabigatran therapy improves outcome of experimental left-sided Staphylococcus aureus endocarditis. PLoS One 2019; 14:e0215333. [PMID: 31002679 PMCID: PMC6474597 DOI: 10.1371/journal.pone.0215333] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 03/29/2019] [Indexed: 12/13/2022] Open
Abstract
Background Staphylococcus aureus is the most frequent and fatal cause of left-sided infective endocarditis (IE). New treatment strategies are needed to improve the outcome. S. aureus coagulase promotes clot and fibrin formation. We hypothesized that dabigatran, could reduce valve vegetations and inflammation in S. aureus IE. Methods We used a rat model of severe aortic valve S. aureus IE. All infected animals were randomized to receive adjunctive dabigatran (10 mg/kg b.i.d., n = 12) or saline (controls, n = 11) in combination with gentamicin. Valve vegetation size, bacterial load, cytokine, cell integrins expression and peripheral platelets and neutrophils were assessed 3 days post-infection. Results Adjunctive dabigatran treatment significantly reduced valve vegetation size compared to controls (p< 0.0001). A significant reduction of the bacterial load in aortic valves was seen in dabigatran group compared to controls (p = 0.02), as well as expression of key pro-inflammatory markers keratinocyte-derived chemokine, IL-6, ICAM-1, TIMP-1, L-selectin (p< 0.04). Moreover, the dabigatran group had a 2.5-fold increase of circulating platelets compared to controls and a higher expression of functional and activated platelets (CD62p+) unbound to neutrophils. Conclusion Adjunctive dabigatran reduced the vegetation size, bacterial load, and inflammation in experimental S. aureus IE.
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Affiliation(s)
- Christian J. Lerche
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Immunology and Microbiology, University of Copenhagen, Denmark
- * E-mail:
| | - Lars J. Christophersen
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jens Peter Goetze
- Department of Clinical Biochemistry, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Pia R. Nielsen
- Department of Pathology, Zealand University Hospital, Roskilde, Denmark
| | - Kim Thomsen
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Christian Enevold
- Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Immunology and Microbiology, University of Copenhagen, Denmark
| | - Peter Ø. Jensen
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Immunology and Microbiology, University of Copenhagen, Denmark
- Institute for Inflammation Research, Department of Rheumatology and Spine Disease, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Institute of Immunology and Microbiology, University of Copenhagen, Denmark
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Prinzivalli M, Sammarco G, Rampoldi B, Costa E, Corsi Romanelli MM. Comparison between specific and nonspecific assay in the evaluation of the anticoagulant effect of the Direct Oral Anticoagulants: Our experience in a cardiovascular hospital. Eur J Intern Med 2019; 60:e20-e22. [PMID: 30322687 DOI: 10.1016/j.ejim.2018.10.005] [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: 10/02/2018] [Accepted: 10/09/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Marco Prinzivalli
- UOC SMeL-1 Clinical Pathology, IRCCS Policlinico San Donato, 20097 S. Donato Milanese, Italy.
| | - Graziella Sammarco
- UOC SMeL-1 Clinical Pathology, IRCCS Policlinico San Donato, 20097 S. Donato Milanese, Italy
| | - Benedetta Rampoldi
- UOC SMeL-1 Clinical Pathology, IRCCS Policlinico San Donato, 20097 S. Donato Milanese, Italy
| | - Elena Costa
- UOC SMeL-1 Clinical Pathology, IRCCS Policlinico San Donato, 20097 S. Donato Milanese, Italy
| | - Massimiliano M Corsi Romanelli
- UOC SMeL-1 Clinical Pathology, IRCCS Policlinico San Donato, 20097 S. Donato Milanese, Italy; Department of Biomedical Sciences for Health, Section of General and Clinical Pathology, University of Milan, Milan, Italy
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22
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Molteni M, Crippa M, Orenti A, Polo Friz H, Menghini A, Tramacere P, Marano G, Cimminiello C, Boracchi P. Investigation on Dabigatran Etexilate and Worsening of Renal Function in Patients with Atrial fibrillation: The IDEA Study. Clin Drug Investig 2019; 39:355-362. [PMID: 30697670 DOI: 10.1007/s40261-018-0742-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Warfarin-related nephropathy is an unexplained acute kidney injury, and may occur in patients with supratherapeutic INR, in the absence of overt bleeding. Similar findings have been observed in rats treated with dabigatran etexilate. We conducted a prospective study in dabigatran etexilate-treated patients to assess the incidence of dabigatran-related nephropathy and to investigate the possible correlation between dabigatran plasma concentration (DPC) and worsening renal function. METHOD One hundred and seven patients treated long term with dabigatran etexilate for non-valvular atrial fibrillation (NVAF) were followed up for 90 days. DPC, serum creatinine (SCr) and serum cystatin C were prospectively measured. Ninety five patients had complete follow-up data and were evaluable for primary endpoint. RESULTS Eleven patients had supratherapeutic DPC, defined as DPC higher than 200 ng/ml at study enrolment, but at the end of follow-up no patient showed a persistent increase in SCr. No patients experienced acute kidney injury. CONCLUSIONS Our study shows that no persistent renal detrimental effect is associated with dabigatran treatment. An increase in SCr during dabigatran treatment is reversible and it seems to be unrelated to dabigatran itself.
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Affiliation(s)
- Mauro Molteni
- UOC Cure Subacute, IRCCS, Istituti Clinici Scientifici Maugeri, via Camaldoli 64, 20138, Milan, Italy.
| | - Matteo Crippa
- Internal Medicine, Vimercate Hospital, A.S.S.T. di Vimercate, via Santi Cosma e Damiano 10, 20871, Vimercate, MB, Italy
| | - Annalisa Orenti
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Epidemiology, and Biometry G. A. Maccacaro, University of Milan, via Vanzetti 5, 20133, Milan, Italy
| | - Hernan Polo Friz
- Internal Medicine, Vimercate Hospital, A.S.S.T. di Vimercate, via Santi Cosma e Damiano 10, 20871, Vimercate, MB, Italy
- Studies and Research Office of Italian Society of Angiology and Vascular Pathology (SIAPAV), via Gorizia 22, 20144, Milan, Italy
| | - Anna Menghini
- Internal Medicine, Vimercate Hospital, A.S.S.T. di Vimercate, via Santi Cosma e Damiano 10, 20871, Vimercate, MB, Italy
| | - Pierluigi Tramacere
- Clinical Pathology, Vimercate Hospital, A.S.S.T. di Vimercate, via Santi Cosma e Damiano 10, 20871, Vimercate, MB, Italy
| | - Giuseppe Marano
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Epidemiology, and Biometry G. A. Maccacaro, University of Milan, via Vanzetti 5, 20133, Milan, Italy
| | - Claudio Cimminiello
- Studies and Research Office of Italian Society of Angiology and Vascular Pathology (SIAPAV), via Gorizia 22, 20144, Milan, Italy
| | - Patrizia Boracchi
- Department of Clinical Sciences and Community Health, Laboratory of Medical Statistics, Epidemiology, and Biometry G. A. Maccacaro, University of Milan, via Vanzetti 5, 20133, Milan, Italy
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Strandberg K. [Not Available]. Lakartidningen 2018; 115:FDF4. [PMID: 30512144] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Karin Strandberg
- Institution of Laboratory Medicine - Clinical Chemistry Malmö, Sweden - Clinical Chemistry, Institution of Laboratory Medicine Malmö, Sweden
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Aljohani MM, Chinnappan R, Eissa S, Alsager OA, Weber K, Cialla-May D, Popp J, Zourob M. In Vitro Selection of Specific DNA Aptamers Against the Anti-Coagulant Dabigatran Etexilate. Sci Rep 2018; 8:13290. [PMID: 30185972 PMCID: PMC6125329 DOI: 10.1038/s41598-018-31327-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/02/2018] [Indexed: 01/10/2023] Open
Abstract
Dabigatran Etexilate (PRADAXA) is a new oral anticoagulant increasingly used for a number of blood thrombosis conditions, prevention of strokes and systemic emboli among patients with atrial fibrillation. It provides safe and adequate anticoagulation for prevention and treatment of thrombus in several clinical settings. However, anticoagulation therapy can be associated with an increased risk of bleeding. There is a lack of specific laboratory tests to determine the level of this drug in blood. This is considered the most important obstacles of using this medication, particularly for patients with trauma, drug toxicity, in urgent need for surgical interventions or uncontrolled bleeding. In this work, we performed Systematic evolution of ligands by exponential enrichment (SELEX) to select specific DNA aptamers against dabigatran etexilate. Following multiple rounds of selection and enrichment with a randomized 60-mer DNA library, specific DNA aptamers for dabigatran were selected. We investigated the affinity and specificity of generated aptamers to the drug showing dissociation constants (Kd) ranging from 46.8-208 nM. The most sensitive aptamer sequence was selected and applied in an electrochemical biosensor to successfully achieve 0. 01 ng/ml level of detection of the target drug. With further improvement of the assay and optimization, these aptamers would replace conventional antibodies for developing detection assays in the near future.
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Affiliation(s)
- Maher M Aljohani
- Department of Chemistry, Alfaisal University, Al Zahrawi Street, Al Maather, Al Takhassusi Rd, Riyadh, 11533, Saudi Arabia
- Collage of Medicine, Taibah University, Madinah, Saudi Arabia
- InfectoGnostics Research Campus Jena, Center for Applied Research, Friedrich-Schiller-University, Philosophenweg7, Jena, 07743, Germany
| | - Raja Chinnappan
- Department of Chemistry, Alfaisal University, Al Zahrawi Street, Al Maather, Al Takhassusi Rd, Riyadh, 11533, Saudi Arabia
| | - Shimaa Eissa
- Department of Chemistry, Alfaisal University, Al Zahrawi Street, Al Maather, Al Takhassusi Rd, Riyadh, 11533, Saudi Arabia
| | - Omar A Alsager
- King Abdulaziz City for Science and Technology (KACST), P.O Box 6086, Riyadh, 11442, Saudi Arabia
| | - Karina Weber
- InfectoGnostics Research Campus Jena, Center for Applied Research, Friedrich-Schiller-University, Philosophenweg7, Jena, 07743, Germany
- Institute of Physical Chemistry and Abbe Center of Photonics, Friedrich Schiller University Jena, Helmholtzweg 4, 07743, Jena, Germany
- Leibniz Institute of Photonic Technology, Albert-Einstein-Straße 9, 07745, Jena, Germany
| | - Dana Cialla-May
- InfectoGnostics Research Campus Jena, Center for Applied Research, Friedrich-Schiller-University, Philosophenweg7, Jena, 07743, Germany
- Institute of Physical Chemistry and Abbe Center of Photonics, Friedrich Schiller University Jena, Helmholtzweg 4, 07743, Jena, Germany
- Leibniz Institute of Photonic Technology, Albert-Einstein-Straße 9, 07745, Jena, Germany
| | - Jürgen Popp
- InfectoGnostics Research Campus Jena, Center for Applied Research, Friedrich-Schiller-University, Philosophenweg7, Jena, 07743, Germany
- Institute of Physical Chemistry and Abbe Center of Photonics, Friedrich Schiller University Jena, Helmholtzweg 4, 07743, Jena, Germany
- Leibniz Institute of Photonic Technology, Albert-Einstein-Straße 9, 07745, Jena, Germany
| | - Mohammed Zourob
- Department of Chemistry, Alfaisal University, Al Zahrawi Street, Al Maather, Al Takhassusi Rd, Riyadh, 11533, Saudi Arabia.
- King Faisal Specialist Hospital and Research Center, Zahrawi Street, Al Maather, Riyadh, 12713, Saudi Arabia.
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Kooiman J, van der Hulle T, Maas H, Wiebe S, Formella S, Clemens A, van Buren M, Janssen M, Rabelink TJ, Huisman MV. Pharmacokinetics and Pharmacodynamics of Dabigatran 75 mg b.i.d. in Patients With Severe Chronic Kidney Disease. J Am Coll Cardiol 2018; 67:2442-2444. [PMID: 27199067 DOI: 10.1016/j.jacc.2016.03.516] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 02/24/2016] [Accepted: 03/01/2016] [Indexed: 11/19/2022]
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Glund S, Stangier J, van Ryn J, Schmohl M, Moschetti V, Haazen W, De Smet M, Gansser D, Norris S, Lang B, Reilly P, Kreuzer J. Restarting Dabigatran Etexilate 24 h After Reversal With Idarucizumab and Redosing Idarucizumab in Healthy Volunteers. J Am Coll Cardiol 2018; 67:1654-1656. [PMID: 27150693 DOI: 10.1016/j.jacc.2016.01.043] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/04/2016] [Accepted: 01/12/2016] [Indexed: 11/16/2022]
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Devereaux PJ, Duceppe E, Guyatt G, Tandon V, Rodseth R, Biccard BM, Xavier D, Szczeklik W, Meyhoff CS, Vincent J, Franzosi MG, Srinathan SK, Erb J, Magloire P, Neary J, Rao M, Rahate PV, Chaudhry NK, Mayosi B, de Nadal M, Iglesias PP, Berwanger O, Villar JC, Botto F, Eikelboom JW, Sessler DI, Kearon C, Pettit S, Sharma M, Connolly SJ, Bangdiwala SI, Rao-Melacini P, Hoeft A, Yusuf S. Dabigatran in patients with myocardial injury after non-cardiac surgery (MANAGE): an international, randomised, placebo-controlled trial. Lancet 2018; 391:2325-2334. [PMID: 29900874 DOI: 10.1016/s0140-6736(18)30832-8] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/23/2018] [Accepted: 03/28/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Myocardial injury after non-cardiac surgery (MINS) increases the risk of cardiovascular events and deaths, which anticoagulation therapy could prevent. Dabigatran prevents perioperative venous thromboembolism, but whether this drug can prevent a broader range of vascular complications in patients with MINS is unknown. The MANAGE trial assessed the potential of dabigatran to prevent major vascular complications among such patients. METHODS In this international, randomised, placebo-controlled trial, we recruited patients from 84 hospitals in 19 countries. Eligible patients were aged at least 45 years, had undergone non-cardiac surgery, and were within 35 days of MINS. Patients were randomly assigned (1:1) to receive dabigatran 110 mg orally twice daily or matched placebo for a maximum of 2 years or until termination of the trial and, using a partial 2-by-2 factorial design, patients not taking a proton-pump inhibitor were also randomly assigned (1:1) to omeprazole 20 mg once daily, for which results will be reported elsewhere, or matched placebo to measure its effect on major upper gastrointestinal complications. Research personnel randomised patients through a central 24 h computerised randomisation system using block randomisation, stratified by centre. Patients, health-care providers, data collectors, and outcome adjudicators were masked to treatment allocation. The primary efficacy outcome was the occurrence of a major vascular complication, a composite of vascular mortality and non-fatal myocardial infarction, non-haemorrhagic stroke, peripheral arterial thrombosis, amputation, and symptomatic venous thromboembolism. The primary safety outcome was a composite of life-threatening, major, and critical organ bleeding. Analyses were done according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, number NCT01661101. FINDINGS Between Jan 10, 2013, and July 17, 2017, we randomly assigned 1754 patients to receive dabigatran (n=877) or placebo (n=877); 556 patients were also randomised in the omeprazole partial factorial component. Study drug was permanently discontinued in 401 (46%) of 877 patients allocated to dabigatran and 380 (43%) of 877 patients allocated to placebo. The composite primary efficacy outcome occurred in fewer patients randomised to dabigatran than placebo (97 [11%] of 877 patients assigned to dabigatran vs 133 [15%] of 877 patients assigned to placebo; hazard ratio [HR] 0·72, 95% CI 0·55-0·93; p=0·0115). The primary safety composite outcome occurred in 29 patients (3%) randomised to dabigatran and 31 patients (4%) randomised to placebo (HR 0·92, 95% CI 0·55-1·53; p=0·76). INTERPRETATION Among patients who had MINS, dabigatran 110 mg twice daily lowered the risk of major vascular complications, with no significant increase in major bleeding. Patients with MINS have a poor prognosis; dabigatran 110 mg twice daily has the potential to help many of the 8 million adults globally who have MINS to reduce their risk of a major vascular complication [corrected]. FUNDING Boehringer Ingelheim and Canadian Institutes of Health Research.
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Affiliation(s)
- P J Devereaux
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada.
| | - Emmanuelle Duceppe
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, University of Montreal, Montreal, QC, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Reitze Rodseth
- Department of Anaesthesia, University of KwaZulu-Natal, Pietermaritzburg, South Africa
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Denis Xavier
- Department of Pharmacology, St John's Medical College and Research Institute, Bangalore, India
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Maria Grazia Franzosi
- Department of Cardiovascular Research, IRCCS Istituto di Ricerche Farmacologiche Mario Negri, Milan, Italy
| | | | - Jason Erb
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ON, Canada
| | - Patrick Magloire
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - John Neary
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mangala Rao
- Department of Pharmacology, St John's Medical College and Research Institute, Bangalore, India
| | | | - Navneet K Chaudhry
- Department of Surgery, Christian Medical College Hospital, Ludhiana, India
| | - Bongani Mayosi
- Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Miriam de Nadal
- Department of Anesthesiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | - Otavio Berwanger
- Instituto de Ensino e Pesquisa do Hospital do Coração (IEP-HCor), São Paulo, Brazil
| | - Juan Carlos Villar
- Departamento de Investigaciones, Fundación Cardioinfantil-Instituto de Cardiología (Bogotá) and Facultad de Ciencias de la Salud, Universidad Autónoma de Bucaramanga, Colombia
| | - Fernando Botto
- Estudios Clínicos Latinoamérica (ECLA), Rosario and Hospital Austral, Pilar, Argentina
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Anesthesiology Institute, Cleveland, OH, United States
| | - Clive Kearon
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shirley Pettit
- Population Health Research Institute, Hamilton, ON, Canada
| | - Mukul Sharma
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Stuart J Connolly
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | - Shrikant I Bangdiwala
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
| | | | - Andreas Hoeft
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Salim Yusuf
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada
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Xing XF, Liu NN, Han YL, Zhou WW, Liang M, Wang ZL. Anticoagulation efficacy of dabigatran etexilate for left atrial appendage thrombus in patients with atrial fibrillation by transthoracic and transesophageal echocardiography. Medicine (Baltimore) 2018; 97:e11117. [PMID: 29952953 PMCID: PMC6039616 DOI: 10.1097/md.0000000000011117] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
To evaluate the anticoagulation efficacy of dabigatran etexilate for left atrial appendage (LAA) thrombus resolution in patients with atrial fibrillation by transthoracic echocardiography and transesophageal echocardiography, and to investigate the anticoagulation factors.A total of 58 atrial fibrillation patients with LAA thrombus in our hospital were enrolled. After dabigatran etexilate anticoagulation for 3 months, the patients were divided into the effective group and ineffective group according to dissolution of thrombosis. The baseline data and the left atrial diameter (LAD), left atrial ejection fraction (LAEF), left ventricular ejection fraction, LAA flow velocity (LAA-v), and LAA thrombus size before and after anticoagulation treatment were recorded, and the measurement index were statistically analyzed.After the patients received anticoagulation treatment for 3 months, 15 patients had complete dissolution, thrombus in 21 patients reduced significantly, and the complete dissolution rate was 25.9% (15/58), the effective rate of dissolution was 62.1% (36/58). Compared with the ineffective group, the proportion of persistent atrial fibrillation and LAD in effective group were lower than those in the ineffective group, the LAEF and LAA-v in the effective group were higher than those in the ineffective group, and the differences were statistically significant (P < .05). Multivariate logistic regression analysis on the baseline data and each ultrasound index showed that the type of atrial fibrillation, LAD, LAEF, and LAA-v were independently associated with the efficacy of anticoagulation (P < .05).Dabigatran etexilate is effective in dissolution of LAA thrombus in patients with atrial fibrillation, and the atrial fibrillation type, LAD, LAEF, and LAA-v are significantly related with the efficacy of anticoagulation.
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Ohya Y, Makihara N, Wakisaka K, Morita T, Ago T, Kitazono T, Takaba H. Thrombolytic Therapy in Severe Cardioembolic Stroke After Reversal of Dabigatran with Idarucizumab: Case Report and Literature Review. J Stroke Cerebrovasc Dis 2018; 27:e128-e131. [PMID: 29555397 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [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: 01/25/2018] [Accepted: 02/12/2018] [Indexed: 02/04/2023] Open
Abstract
Whether idarucizumab, an antidote of dabigatran, can be used effectively and safely before thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with stroke undergoing treatment with dabigatran remains unknown. We herein describe a 57-year-old man who developed severe cardioembolic stroke with a National Institutes of Health Stroke Scale score of 22 in the left middle cerebral artery territory while undergoing treatment with dabigatran for nonvalvular atrial fibrillation and who was treated with rt-PA after the reversal of dabigatran with idarucizumab. The thrombolytic therapy following the use of idarucizumab significantly improved the patient's neurological symptoms without hemorrhagic complications, although acute arterial occlusion of the right lower limb was found during the clinical course.
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Affiliation(s)
- Yuichiro Ohya
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan; Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Noriko Makihara
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - Kayo Wakisaka
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - Takao Morita
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hitonori Takaba
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
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Scridon A, Perian M, MĂrginean A, Huţanu A, Gherţescu D, Vântu A, FişcĂ PC, Chevalier P, Şerban RC, Dobreanu D. Plasma lipids affect dabigatran etexilate anticoagulation in rats with unbalanced diabetes mellitus. J Diabetes 2018; 10:240-248. [PMID: 28671757 DOI: 10.1111/1753-0407.12580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 12/30/2016] [Revised: 05/12/2017] [Accepted: 06/09/2017] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Dabigatran etexilate (DE) has similar stroke prevention efficacy in patients with and without diabetes mellitus (DM). However, the benefit of reducing major bleeding was not seen in diabetics. Thus, this study investigated anticoagulant responses to DE and the biological predictors of this response in a DM model. METHODS Experiments were performed in six control (C), eight DE-treated control (CD), five diabetic (D), and eight DE-treated diabetic (DD) rats. Dabigatran etexilate (50 mg/kg/day) was administered in chow for 12 weeks. At the end of the study, plasma glucose, triglycerides, total cholesterol (TC), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-C), and plasma creatinine were measured. Correlations were ascertained with the diluted thrombin time (dTT). RESULTS When corrected for similar DE intake, dTT was significantly higher in DD than CD rats (P < 0.001). There was a significant negative correlation between creatinine clearance (CCr) and dTT (r = -0.91, P < 0.01) in DD rats. In addition, dTT was positively correlated with TC (r = 0.96, P < 0.01), LDL-C (r = 0.75, P = 0.04), and glucose (r = 0.83, P = 0.02). In multiple regression analysis, CCr (r = -0.81, P = 0.01), TC (r = 0.93, P < 0.001), and LDL-C (r = 0.74, P < 0.01) remained the only independent predictors of dTT. CONCLUSIONS The results show a significantly more intense DE-induced anticoagulation in diabetic rats that does not seem to be solely related to altered kidney function, and demonstrate that plasma cholesterol can significantly affect DE anticoagulation in this setting.
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Affiliation(s)
- Alina Scridon
- Laboratory of Functional Explorations, Center for Advanced Medical and Pharmaceutical Research, Tîrgu Mureş, Romania
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Marcel Perian
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Alina MĂrginean
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
- Department of Medical Laboratory, Emergency Military Hospital "Dr. Constantin Papilian,", Cluj-Napoca, Romania
| | - Adina Huţanu
- Laboratory of Functional Explorations, Center for Advanced Medical and Pharmaceutical Research, Tîrgu Mureş, Romania
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
- Department of Medical Laboratory, Emergency Clinical County Hospital, Tîrgu Mureş, Romania
| | - Doina Gherţescu
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Adriana Vântu
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | - Paul C FişcĂ
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
| | | | - Răzvan C Şerban
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
- Laboratory of Cardiac Catheterization, Angiography, and Electrophysiology, Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureş, Romania
| | - Dan Dobreanu
- Physiology Department, University of Medicine and Pharmacy of Tîrgu Mureş, Tîrgu Mureş, Romania
- Laboratory of Cardiac Catheterization, Angiography, and Electrophysiology, Emergency Institute for Cardiovascular Diseases and Transplantation, Tîrgu Mureş, Romania
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31
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Chaussade E, Hanon O, Boully C, Labourée F, Caillard L, Gerotziafas G, Vidal JS, Elalamy I. Real-Life Peak and Trough Dabigatran Plasma Measurements over Time in Hospitalized Geriatric Patients with Atrial Fibrillation. J Nutr Health Aging 2018; 22:165-173. [PMID: 29300437 DOI: 10.1007/s12603-017-0982-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 12/17/2022]
Abstract
BACKGROUND Few geriatric patients were included in studies on direct oral anticoagulants and data on dabigatran concentration and safety are needed in this population. Our objectives were to evaluate peak and trough dabigatran plasma concentrations over time in a geriatric population and to identify factors associated with dabigatran plasma concentrations and to assess the relationship with bleeding events. METHODS Peak and trough dabigatran plasma concentration were performed 4,8,15,30,45 days after inception of dabigatran treatment in 68 consecutive patients ≥75 years old hospitalized in a geriatric hospital with atrial fibrillation. Bleeding events were monitored for 1 year. RESULTS Mean age was 85.8(5.1) years old and 76.5% were women. Overall, 541 dabigatran plasma measurements (270 peak, 271 trough) were performed. Mean dabigatran concentrations of the 5 sequential measurements ranged 106-146ng/mL for peak and 66-84ng/mL for trough. Renal failure was associated with high peak and trough dabigatran concentration. Inter- and intra-individual coefficients of variation were 59.5% and 44.7% for peak and 74.5% and 44.6% for trough. Participants in the lower two tertiles of dabigatran concentration at day 8 (D8) remained below the 90th percentile (243.9ng/ml) on the next measurements. Bleeding events were associated with high trough dabigatran concentrations. Trough dabigatran concentration at D8>243.9ng/mL significantly predicted bleeding. CONCLUSION In this geriatric population, renal function and low albumin were associated with dabigatran concentrations. Despite large variability, participants in the lower two tertiles of dabigatran concentration at D8 remained below the 90th percentile on the following measurements. D8 dabigatran trough concentration≥243.9ng/mL identified patients at risk of bleeding.
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Affiliation(s)
- E Chaussade
- Prof. Olivier Hanon, Hôpital Broca, 54-56 Pascal, 75013 Paris, France, Tel: +33 1 44 08 30 00, Fax: +33 1 44 08 36 18,
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Lindeman E. [Goal-directed administration of antidote for reversal of dabigatran anticoagulation]. Lakartidningen 2017; 114:ESF3. [PMID: 29292966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Goal-directed administration of antidote for reversal of dabigatran anticoagulation Idarucizumab is a monoclonal antibody fragment that acts as an antidote to dabigatran. Idarucizumab is indicated in dabigatran-associated serious bleeds and to reverse dabigatran anticoagulation before acute surgical interventions or invasive medical procedures. The recommended dose of 5 g idarucizumab is sufficient to achieve a lasting restoration of coagulation in most patients. In a number of cases however, notably in deliberate overdoses and in accumulation of dabigatran in renal failure, repeated doses of idarucizumab may be necessary to avoid persisting or rebound anticoagulation. This article gives a brief explanation of the mechanisms responsible for this phenomenon and argues that it should be anticipated. Serial monitoring of APTT or dTT in patients treated with idarucizumab should enable the early detection of treatment failure or rebound anticoagulation and, if clinically indicated, prompt administration of additional doses of antidote.
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Affiliation(s)
- Erik Lindeman
- Läkemedelsverket - Giftinformationscentralen Stockholm, Sweden Läkemedelsverket - Giftinformationscentralen Stockholm, Sweden
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Sciascia S, Radin M, Schreiber K, Fenoglio R, Baldovino S, Roccatello D. Chronic kidney disease and anticoagulation: from vitamin K antagonists and heparins to direct oral anticoagulant agents. Intern Emerg Med 2017; 12:1101-1108. [PMID: 28929298 DOI: 10.1007/s11739-017-1753-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [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: 06/28/2017] [Accepted: 09/11/2017] [Indexed: 01/18/2023]
Abstract
Anticoagulation in patients with impaired kidney function can be challenging since drugs' pharmacokinetics and bioavailability are altered in this setting. Patients with chronic kidney disease (CKD) treated with conventional anticoagulant agents [vitamin K antagonist (VKA), low-molecular weight heparin (LMWH) or unfractionated heparin (UFH)] are at high risk of bleeding events (both non-major and major clinically relevant bleeding). While anticoagulation reduces the risk of thromboembolic events, the co-existing bleeding risk and the fact that the most commonly used anticoagulation agents are eliminated via the kidneys pose additional challenges. More recently, two classes of direct oral anticoagulant agents (DOACs) have been investigated for the prevention and management of venous thromboembolic events: the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban, and the direct thrombin inhibitor dabigatran. In this review, we discuss the complex challenges and the practical considerations associated with the management of anticoagulation treatment in patients with CKD, with a special focus on DOACs.
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Affiliation(s)
- Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy.
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy.
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
| | - Karen Schreiber
- Centre for Thrombosis and Haemostasis, St. Thomas' Hospital, London, UK
- Department of Rheumatology, Copenhagen University Hospital at Rigshospitalet, Copenhagen, Denmark
| | - Roberta Fenoglio
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Simone Baldovino
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, S. Giovanni Bosco Hospital, Department of Clinical and Biological Sciences, University of Turin, Piazza del Donatore di Sangue 3, 10154, Turin, Italy
- Nephrology and Dialysis, Department of Clinical and Biological Sciences, S. Giovanni Bosco Hospital, University of Turin, Turin, Italy
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Oertel LB, Fogerty AE. Use of direct oral anticoagulants for stroke prevention in elderly patients with nonvalvular atrial fibrillation. J Am Assoc Nurse Pract 2017; 29:551-561. [PMID: 28805310 DOI: 10.1002/2327-6924.12494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/13/2017] [Accepted: 06/17/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Lynn B Oertel
- Anticoagulant Management Service, Department of Nursing, Massachusetts General Hospital, Boston, Massachusetts
| | - Annemarie E Fogerty
- Department of Hematology, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
In the Hokusai-VTE trial, 733 patients were treated with the reduced dose edoxaban regimen, which maintained efficacy and safety compared with the 60 mg dose, and was safer than warfarin. The prophylactic doses of apixaban and rivaroxaban reduced the risk of recurrent venous thromboembolism (VTE) in the extended treatment trials. Dabigatran 110 mg was approved by the European Medicine Agency for VTE treatment. Further data from registries and real-world studies will help to clarify whether patients, with other specific characteristics, can benefit from the reduced dose of direct oral anticoagulants.
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Affiliation(s)
- Davide Imberti
- Internal Medicine Department, Piacenza Hospital, Haemostasis and Thrombosis Center, Piacenza, Italy
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Abstract
Bleeding complications are a common concern with the use of anticoagulant agents. In many situations, reversing of neutralizing their effects may be warranted. Prothrombin complex concentrate replaces coagulation factors lowered by warfarin, as does fresh frozen plasma, but in a more concentrated form. Protamine negates the effect of heparin and combines chemically with heparin molecules to form an inactive salt. It also partially reverses the effects of low-molecular-weight heparin. Recombinant activated factor VII is a nonspecific procoagulant that activates the extrinsic clotting pathway, resulting in thrombin generation, but does not directly neutralize the activity of any of the new oral anticoagulants.
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Affiliation(s)
- Joseph Meltzer
- Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA.
| | - Joseph R Guenzer
- Department of Anesthesiology, University of Utah Medical School, 30 North 1900 East, Room 3C444, Salt Lake City, UT 84132-2501, USA
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Prisco D, Ageno W, Becattini C, D'Angelo A, Davì G, De Cristofaro R, Dentali F, Di Minno G, Falanga A, Gussoni G, Masotti L, Palareti G, Pignatelli P, Santi RM, Santilli F, Silingardi M, Tufano A, Violi F. Italian intersociety consensus on DOAC use in internal medicine. Intern Emerg Med 2017; 12:387-406. [PMID: 28191610 DOI: 10.1007/s11739-017-1628-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [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: 11/19/2016] [Accepted: 02/02/2017] [Indexed: 12/15/2022]
Abstract
The direct oral anticoagulants (DOACs) are drugs used in clinical practice since 2009 for the prevention of stroke or systemic embolism in non-valvular atrial fibrillation, and for the treatment and secondary prevention of venous thromboembolism. The four DOACs, including the three factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) and one direct thrombin inhibitor (dabigatran) provide oral anticoagulation therapy alternatives to Vitamin K antagonists (VKAs). Despite their clear advantages, the DOACs require on the part of the internist a thorough knowledge of their pharmacokinetic and pharmacodynamic characteristics to ensure their correct use, laboratory monitoring and the appropriate management of adverse events. This document represents a consensus paper on the use of DOACs by representatives of three Italian scientific societies: the Italian Society of Internal Medicine (SIMI), the Federation of the Associations of Hospital Managers (FADOI), and the Society for the Study of Haemostasis and Thrombosis (SISET). This document formulates expert opinion guidance for pragmatic managing, monitoring and reversing the anticoagulant effect of DOACs in both chronic and emergency settings. This practical guidance may help the internist to create adequate protocols for patients hospitalized ion internal medicine wards, where patients are often elderly subjects affected by poly-morbidities and renal insufficiency, and, thus, require particular attention to drug-drug interactions and peri-procedural protocols.
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Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Armando D'Angelo
- Coagulation Service and Thrombosis Research Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Giovanni Davì
- Clinica Medica, Department of Medicine and Aging Sciences, University of Chieti G.D'Annunzio, Chieti, Italy
| | - Raimondo De Cristofaro
- Institute of Internal Medicine and Geriatrics, Center for Haemorrhagic and Thrombotic Diseases, Haematology, Foundation Policlinico universitario "Agostino Gemelli", Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Giovanni Di Minno
- Clinica Medica, Department of Clinical Medicine and Surgery, AOU Policlinico Federico II, Naples, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, and the Thrombosis and Hemostasis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Florence, Italy
| | | | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto M Santi
- Haemostasis and Thrombosis Unit, Haematology, Az. Osp. "SS.Antonio e Biagio e C. Arrigo", Alessandria, Italy
| | - Francesca Santilli
- Clinica Medica, Department of Medicine and Aging Sciences, University of Chieti G.D'Annunzio, Chieti, Italy
| | - Mauro Silingardi
- Internal Medicine Unit A - Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Antonella Tufano
- Clinica Medica, Department of Clinical Medicine and Surgery, AOU Policlinico Federico II, Naples, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
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Harenberg J. Laboratory determination of old and new targeted anticoagulant agents for prevention of bleeding and thrombotic events in cancer patients. Thromb Res 2017; 140 Suppl 1:S165-7. [PMID: 27067972 DOI: 10.1016/s0049-3848(16)30117-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 12/16/2022]
Abstract
A two-fold prolongation of activated partial thromboplastin time (APTT) is established as therapeutic range for therapy with unfractionated heparin, hirudin and argatroban. The international normalized ratio (INR) of 2 to 3 is required to maintain anticoagulation in the therapeutic range of vitamin K antagonists. The therapeutic range of anti-factor Xa activity during therapy with low-molecular weight heparins and danaparoid are less well and of direct oral anticoagulants (DOAC) poorly defined. The relation of aPTT and INR values to thrombotic and bleeding events are well established despite a large variation of values in affected patients. The relation of coagulation values of the other anticoagulants to clinical events is open. The value of determination in cancer patients is higher because of the increased risk for thrombotic and bleeding events of this patient group. Several activities are currently undertaken to certify methods for in vitro diagnostic testing for DAOCs.
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Affiliation(s)
- Job Harenberg
- Medical Faculty Mannheim, University of Heidelberg, Maybachstrasse 14, 68169 Mannheim, Germany.
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Abstract
Warfarin has had a thin margin of benefit over risk for the prevention of stroke and systemic embolism in patients with ESRD because of higher bleeding risks and complications of therapy. The successful use of warfarin has been dependent on the selection of patients with nonvalvular atrial fibrillation at relatively high risk of stroke and systemic embolism and lower risks of bleeding over the course of therapy. Without such selection strategies, broad use of warfarin has not proven to be beneficial to the broad population of patients with ESRD and nonvalvular atrial fibrillation. In a recent meta-analysis of use of warfarin in patients with nonvalvular atrial fibrillation and ESRD, warfarin had no effect on the risks of stroke (hazard ratio, 1.12; 95% confidence interval, 0.69 to 1.82; P=0.65) or mortality (hazard ratio, 0.96; 95% confidence interval, 0.81 to 1.13; P=0.60) but was associated with increased risk of major bleeding (hazard ratio, 1.30; 95% confidence interval, 1.08 to 1.56; P<0.01). In pivotal trials, novel oral anticoagulants were generally at least equal to warfarin for efficacy and safety in nonvalvular atrial fibrillation and mild to moderate renal impairment. Clinical data for ESRD are limited, because pivotal trials excluded such patients. Given the very high risk of stroke and systemic embolism and the early evidence of acceptable safety profiles of novel oral anticoagulants, we think that patients with ESRD should be considered for treatment with chronic anticoagulation provided that there is an acceptable bleeding profile. Apixaban is currently indicated in ESRD for this application and may be preferable to warfarin given the body of evidence for warfarin and its difficulty of use and attendant adverse events.
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Affiliation(s)
- Peter A. McCullough
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
- The Heart Hospital Baylor Plano, Plano, Texas; and
| | - Timothy Ball
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
| | - Katy Mathews Cox
- Department of Clinical Pharmacology, Baylor University Medical Center, Dallas, Texas
| | - Manish D. Assar
- Department of Internal Medicine, Cardiology Division, Baylor University Medical Center, Baylor Heart and Vascular Institute, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas
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Imberti D, Pomero F, Benedetti R, Fenoglio L. Safety ad efficacy of direct oral anticoagulants for extended treatment of venous thromboembolism. Intern Emerg Med 2016; 11:895-900. [PMID: 27550399 DOI: 10.1007/s11739-016-1521-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 03/30/2016] [Accepted: 08/09/2016] [Indexed: 11/27/2022]
Abstract
Currently available anticoagulants have limitations for long-term treatment of venous thromboembolism (VTE). We have evaluated the efficacy and safety of direct oral anticoagulants (DOACs) for extended treatment of VTE. Four randomized controlled trials (RCTs) comparing DOACs (apixaban, rivaroxaban, and dabigatran) with placebo or warfarin for extended treatment of VTE were published. Primary efficacy outcome was recurrent VTE or VTE-related death, and primary safety outcome was major bleeding. DOACs significantly lower the risk of recurrent VTE or VTE-related death compared to placebo/warfarin, as well as all-cause mortality. Risk of major bleeding is not different with DOACs compared to placebo/warfarin. However, DOACs are associated with a significantly higher rate of the composite of major and clinically relevant bleeding compared to placebo. In conclusion, DOACs are effective and safe for the extended treatment of VTE, and may reduce the risk of all-cause mortality.
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Affiliation(s)
- Davide Imberti
- Haemostasis and Thrombosis Center, Internal Medicine Department, Piacenza Hospital, Via Taverna 49, Piacenza, Italy.
| | - Fulvio Pomero
- Internal Medicine Department, Hospital 'Santa Croce e Carle', Cuneo, Italy
| | - Raffaella Benedetti
- Haemostasis and Thrombosis Center, Internal Medicine Department, Piacenza Hospital, Via Taverna 49, Piacenza, Italy
| | - Luigi Fenoglio
- Internal Medicine Department, Hospital 'Santa Croce e Carle', Cuneo, Italy
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41
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Eriksson BI, Mikuska Z, Feuring M, Amiral J, Haertter S, Stangier J, Nehmiz G, Weitz JI. An open-label study of the pharmacokinetics and pharmacodynamics of dabigatran etexilate 150mg once daily in Caucasian patients with moderate renal impairment undergoing primary unilateral elective total knee or hip replacement surgery. Thromb Res 2016; 144:158-64. [PMID: 27352238 DOI: 10.1016/j.thromres.2016.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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: 11/17/2015] [Revised: 06/08/2016] [Accepted: 06/15/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND In adults with moderate renal impairment (creatinine clearance [CrCl] 30-50mL/min) undergoing total hip or knee replacement (THR/TKR), the recommended dose of dabigatran etexilate is 150mg once daily (qd). We investigated the steady state pharmacokinetics, pharmacodynamics and safety in these patients. METHODS Single-arm, open-label phase 4 study (NCT01184989) in Caucasian patients receiving dabigatran etexilate 75mg 1-4h after surgery and 150mg qd on days 2-10 (TKR) or days 2-35 (THR). Plasma total dabigatran concentrations (day 6±1) were determined by high-performance liquid chromatography tandem mass spectrometry and indirectly using the commercially available diluted thrombin time (dTT) assay (Hemoclot® Thrombin Inhibitors). RESULTS Of 112 patients (mean CrCl 42.5mL/min, age 79.1years, 69.6% female), 100 completed the study. Geometric mean trough and peak dabigatran concentrations were 47.5ng/mL (10th-90th percentile 19.7-120) and 166ng/mL (49.1-364), respectively. There were four major bleeding events and no venous thromboembolic events. Dabigatran concentrations determined from dTT (and falling within the assay range of 50-500ng/mL) underestimated actual values by 7.6% (90% confidence interval 5.3, 9.9), which is within the acceptance limits of ±15%. CONCLUSIONS These findings in Caucasians with moderate renal impairment undergoing THR or TKR support the use of the 150mg qd dose of dabigatran etexilate. With adequate set-up, calibration and quality control the dTT assay might be appropriate for situations, such as serious bleeding or a need for urgent surgery, where determination of dabigatran levels would be helpful.
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Affiliation(s)
- Bengt I Eriksson
- University of Gothenburg, Sahlgrenska University Hospital/Mölndal, Mölndal, Sweden.
| | - Zsolt Mikuska
- Boehringer Ingelheim RCV GmbH & Co. KG, Vienna, Austria.
| | - Martin Feuring
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim am Rhein, Germany.
| | | | | | - Joachim Stangier
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riß, Germany.
| | - Gerhard Nehmiz
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach an der Riß, Germany.
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
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Tsantes AE, Kyriakou E, Ikonomidis I, Katogiannis K, Papadakis I, Douramani P, Kopterides P, Kapsimali V, Lekakis J, Tsangaris I, Bonovas S. Comparative Assessment of the Anticoagulant Activity of Rivaroxaban and Dabigatran in Patients With Nonvalvular Atrial Fibrillation: A Noninterventional Study. Medicine (Baltimore) 2016; 95:e3037. [PMID: 27057830 PMCID: PMC4998746 DOI: 10.1097/md.0000000000003037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
There is a shortage of data in everyday clinical practice about the anticoagulant effects caused by the new oral anticoagulants (NOAs). Our aim was to estimate the intensity of anticoagulant activity induced by rivaroxaban 20 mg qd and dabigatran 110 mg bid among patients with nonvalvular atrial fibrillation (NV-AF).We studied 20 patients with NV-AF treated with dabigatran, and 20 patients treated with rivaroxaban. We performed conventional coagulation tests, thrombin generation (TG) test, thromboelastometry (ROTEM), and epinephrine-induced light transmission aggregometry (LTA) in all 40 patients and 20 controls. Hemoclot Thrombin Inhibitors (HTI) and Factor Xa Direct Inhibitor (DiXaI) assay were used to measure dabigatran and rivaroxaban plasma levels, respectively.Measurements of all assays estimating anticoagulant activity across the 2 patient groups were similar, except for aPTT. Patients on dabigatran exhibited statistically significantly prolonged aPTT values (P < 0.001). In LTA, patients on dabigatran also showed decreased aggregation compared to those on rivaroxaban (P = 0.045). Regarding the TG test, there was no association between endogenous thrombin potential (ETP) and rivaroxaban plasma levels (P = 0.33) as opposed to dabigatran levels (P < 0.001), but significant correlations were observed between rivaroxaban plasma concentrations and kinetic parameters of TG assay (Tlag, P = 0.045; Tmax, P = 0.016; and Cmax, P = 0.003).Based on ROTEM and TG assays, the anticoagulant effects induced by the 2 drugs given in the specific dose regimens in real-world patients were comparable. Only platelet aggregation was found to be more affected by dabigatran as compared to rivaroxaban.
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Affiliation(s)
- Argirios E Tsantes
- From the Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital(AET, EK, PD); Second Cardiology Department, "Attiko" Hospital(II, KK, IP, JL); Second Department of Critical Care Medicine, "Attiko" Hospital(PK, IT); Department of Microbiology (VK), School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; and Humanitas Clinical and Research Center (SB), Rozzano, Milan, Italy
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Teleb M, Salire K, Wardi M, Alkhateeb H, Said S, Mukherjee D. Idarucizumab: Clinical Role of a Novel Reversal Agent for Dabigatran. Cardiovasc Hematol Disord Drug Targets 2016; 16:25-29. [PMID: 27477871 DOI: 10.2174/1871529x16666160701112448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 06/13/2016] [Accepted: 06/27/2016] [Indexed: 06/06/2023]
Abstract
Atrial fibrillation (AF), a common cardiac arrhythmia associated with increased risk of heart failure, thromboembolic phenomena and death, is a leading cause of hospitalization of adults. A major complication of AF is an increased risk of ischemic stroke leading to long-term disability and in severe cases, death. Historically, Coumadin has been the drug of choice for chronic anticoagulation and stroke prevention in AF patients however, given the need for constant monitoring and multiple drug interactions, newer anticoagulants have been developed. One such drug is dabigatran, with the promise of less frequent monitoring and decreased bleeding tendencies as compared to Coumadin. The main disadvantage of dabigatran has been the lack of a reversal agent in case of severe bleeding or emergent surgical intervention. This was until the recent The Food and Drug Administration approval of idarucizumab, a potential reversal agent for dabigatran. In this article, we discuss the evidence addressing idarucizumab safety, tolerability and its efficacy for reversing effect of dabigatran.
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Affiliation(s)
- Mohamed Teleb
- Texas Tech University Health Sciences Center. Paul L. Foster School of Medicine. Department of Internal Medicine. El Paso, TX, 4800 Alberta Ave, El Paso, Tx, 79905
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Jacquemin M, Toelen J, Schoeters J, van Horenbeeck I, Vanlinthout I, Debasse M, Peetermans M, Vanassche T, Peerlinck K, van Ryn J, Verhamme P. The addition of idarucizumab to plasma samples containing dabigatran allows the use of routine coagulation assays for the diagnosis of hemostasis disorders. J Thromb Haemost 2015; 13:2087-92. [PMID: 26347330 DOI: 10.1111/jth.13138] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [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: 05/11/2015] [Accepted: 08/30/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The anticoagulant effect of dabigatran can be approximated by its prolongation of routine coagulation assays. Consequently, dabigatran also interferes with thrombophilia screening or with diagnosing hemostasis disorders that have developed after the initiation of anticoagulant treatment, such as vitamin K deficiency or acquired hemophilia A. OBJECTIVES This study was carried out to determine whether idarucizumab, a humanized antibody fragment that binds dabigatran, could fully neutralize dabigatran in routine diagnostic coagulation assays conducted in vitro, thereby preventing false-positive or false-negative diagnostic readouts. METHODS Preliminary experiments identified coagulation assays that were sensitive to dabigatran, and identified a concentration of idarucizumab that neutralized the effects of dabigatran. These assays were then carried out with patient and control plasma samples spiked with dabigatran, with or without a molar excess of idarucizumab. RESULTS Dabigatran altered the prothrombin time, activated partial thromboplastin time and thrombin time, and the measurement of intrinsic and extrinsic factor levels. Screening and confirmation tests used for lupus anticoagulant detection were prolonged by dabigatran, falsely suggesting the presence of lupus anticoagulant. Conversely, the addition of dabigatran falsely corrected an abnormal activated protein C resistance ratio. Addition of idarucizumab completely normalized these measurements, and allowed the correct identification of normal and abnormal samples with these assays. CONCLUSIONS In vitro addition of idarucizumab to plasma samples containing dabigatran fully neutralizes the drug, and facilitates the use of routine coagulation assays to allow the diagnosis of hemostasis disorders that may be concurrently present in patients taking dabigatran.
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Affiliation(s)
- M Jacquemin
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - J Toelen
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - J Schoeters
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - I van Horenbeeck
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - I Vanlinthout
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - M Debasse
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - M Peetermans
- Clinical Department of Laboratory Medicine, University Hospitals of Leuven, Leuven, Belgium
| | - T Vanassche
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
- Vascular Medicine and Hemostasis, University Hospitals of Leuven, Leuven, Belgium
| | - K Peerlinck
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
- Vascular Medicine and Hemostasis, University Hospitals of Leuven, Leuven, Belgium
| | - J van Ryn
- Department of CardioMetabolic Disease Research, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - P Verhamme
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, University of Leuven, Leuven, Belgium
- Vascular Medicine and Hemostasis, University Hospitals of Leuven, Leuven, Belgium
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McCarthy M. Report questions FDA approval of controversial anticoagulant. BMJ 2015; 351:h5557. [PMID: 26481822 DOI: 10.1136/bmj.h5557] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Atrial fibrillation (AF) is a significant problem for the aging population and remains a major factor underlying stroke risk. Warfarin anticoagulation has been proven effective for stroke prevention in AF, but can be difficult to manage and requires frequent monitoring. The non-vitamin K antagonist oral anticoagulants (NOACs) have been shown to be as effective as warfarin for stroke prevention in nonvalvular AF (NVAF) and are associated with a reduced risk of bleeding compared with warfarin. Dabigatran, rivaroxaban, apixaban, and edoxaban have been approved in the USA for reducing the risk of stroke in patients with NVAF. In this article, AF risk assessment is discussed and NOAC phase III clinical trials for the prevention of stroke and systemic embolic events are reviewed. Further, differences in stroke and bleeding outcomes between NOACs are highlighted, the use of NOACs for cardioversion and special patient populations is discussed, and management considerations for patients with AF are reviewed.
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Affiliation(s)
- Walid Saliba
- Cleveland Clinic Main Campus, Mail Code J2-2, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.
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47
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Fusaro M, Dalle Carbonare L, Dusso A, Arcidiacono MV, Valenti MT, Aghi A, Pasho S, Gallieni M. Differential Effects of Dabigatran and Warfarin on Bone Volume and Structure in Rats with Normal Renal Function. PLoS One 2015; 10:e0133847. [PMID: 26241483 PMCID: PMC4524674 DOI: 10.1371/journal.pone.0133847] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 07/03/2015] [Indexed: 01/03/2023] Open
Abstract
Background Warfarin, a widely used anticoagulant, is a vitamin K antagonist impairing the activity of vitamin K-dependent Bone Gla Protein (BGP or Osteocalcin) and Matrix Gla Protein (MGP). Because dabigatran, a new anticoagulant, has no effect on vitamin K metabolism, the aim of this study was to compare the impact of warfarin and dabigatran administration on bone structure and vascular calcification. Methods Rats with normal renal function received for 6 weeks warfarin, dabigatran or placebo. Bone was evaluated immuno-histochemically and hystomorphometrically after double labelling with declomycin and calcein. Aorta and iliac arteries were examined histologically. Results Histomorphometric analysis of femur and vertebrae showed significantly decreased bone volume and increased trabecular separation in rats treated with warfarin. Vertebra analysis showed that the trabecular number was higher in dabigatran treated rats. Osteoblast activity and resorption parameters were similar among groups, except for maximum erosion depth, which was higher in warfarin treated rats, suggesting a higher osteoclastic activity. Therefore, warfarin treatment was also associated with higher bone formation rate/bone surface and activation frequency. Warfarin treatment may cause an increased bone turnover characterized by increased remodelling cycles, with stronger osteoclast activity compared to the other groups. There were no differences among experimental groups in calcium deposition either in aortic or iliac arteries. Conclusions These findings suggest for the first time that dabigatran has a better bone safety profile than warfarin, as warfarin treatment affects bone by reducing trabecular size and structure, increasing turnover and reducing mineralization. These differences could potentially result in a lower incidence of fractures in dabigatran treated patients.
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Affiliation(s)
- Maria Fusaro
- National Research Council (CNR)–Neuroscience Institute, Padova, Italy
- * E-mail:
| | - Luca Dalle Carbonare
- Department of Medicine, Section of Internal Medicine D, University of Verona, Verona, Italy
| | - Adriana Dusso
- Division of Experimental Nephrology, IRB Lleida (Lleida Institute for Biomedical Research), Lleida, Spain
| | - Maria Vittoria Arcidiacono
- Division of Experimental Nephrology, IRB Lleida (Lleida Institute for Biomedical Research), Lleida, Spain
| | - Maria Teresa Valenti
- Department of Medicine, Section of Internal Medicine D, University of Verona, Verona, Italy
| | - Andrea Aghi
- Nephrology Unit, University of Padua, Padua, Italy
| | - Sabina Pasho
- Nephrology and Dialysis Unit, Ospedale San Carlo Borromeo and Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milano, Milano, Italy
| | - Maurizio Gallieni
- Nephrology and Dialysis Unit, Ospedale San Carlo Borromeo and Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milano, Milano, Italy
- Department of Clinical and Biomedical Sciences "Luigi Sacco", University of Milano, Milano, Italy
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Rasmussen LE, Viberg BL, Pottegård A. [Fatal outcome for a patient in treatment with dabigatran suffering a subtrochanteric femoral fracture]. Ugeskr Laeger 2015; 177:V11140612. [PMID: 25872605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
An 82-year-old woman in treatment with the thrombin inhibitor dabigatran etexilate (a new oral anticoagulant (NOAC)) was admitted with a subtrochanteric femoral fracture and surgery was initiated 15 hours after admittance. She had a blood loss of 6,000 ml and died the next morning from multi-organ failure. In 2013 1.8% of hip fracture patients in Funen received NOACs. Surgery is recommended within 24 hours for hip fracture patients to reduce mortality, but patients in treatment with NOACs should wait at least 48 hours before major surgery. Care should be taken when prescribing NOACs to patients with high risk of falling.
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Kung SL, Shen CY, Ling TT. Migraine-like Visual Aura Rriggered by a Large Aneurysm in the Left Extracranial Internal Carotid Artery with Successful Prevention of Recurrence by the new Anticoagulant Dabigatran: First Case Report. Acta Neurol Taiwan 2015; 24:19-24. [PMID: 26179686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
PURPOSE We present a rare case of late-onset migraine-like visual aura triggered by a large aneurysm in the left extracranial internal carotid artery. To the best of our knowledge, this is the first case of migraine-like visual aura triggered by an extracranial internal carotid artery (ICA) aneurysm. This is also the first case of migraine-like visual aura with probable thromboembolic trigger being successfully treated with a new anticoagulant, dabigatran. CASE REPORT A 61-year-old woman complained about stereotypical episodes of a short-lasting flickering light in the right visual field for about half a year. Magnetic resonance imaging (MRI) of the head revealed a large aneurysm arising from the mid-cervical portion of the left internal carotid artery (ICA). After anticoagulant therapy with 110 mg of dabigatran twice a day, she became free from the visual symptom. CONCLUSION Late-onset migraine with aura, especially typical aura without headache should be diagnosed carefully since it can be a challenge to distinguish it from signaling something serious. Micro-thromboembolism, commonly cardiogenic, but rarely arising from a carotid aneurysm, can trigger cerebral ischemic injury, causing transient neuronal hyperexcitability and cortical spreading depression (CSD)-like ''spontaneous'' waves propagating through the penumbra of the injured region into normally perfused tissue. The resultant symptoms may semiologically mimic visual aura. Migraine-like visual aura in this patient was successfully treated with dabigatran. It may not only imply that the patient's migraine-like visual aura was a thromboembolic event, but may also suggest the potential efficacy of the new anticoagulant, dabigatran, as the optimal alternative of warfarin in treating a thromboembolic event arising from a carotid aneurysm.
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Affiliation(s)
- Sheng-Ling Kung
- Department of Neurology, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Chao-Yu Shen
- School of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - Ting-Ting Ling
- School of Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan
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Thachil J, Gagg J. Problem-Based Review: Non Vitamin K Antagonist Oral Anticoagulants for the Acute Physician. Acute Med 2015; 14:83-89. [PMID: 26305087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs), are direct anticoagulants which inhibit specific coagulation factors and function as anticoagulants. Three NOACs are currently licensed in the United Kingdom: dabigatran, a thrombin inhibitor, and rivaroxaban and apixaban, antagonists of factor Xa. They are set to change the anticoagulant landscape, which was previously ruled by warfarin and heparins. Their advantages including oral formulations, rapid onset and offset of action, predictable pharmacokinetics, no requirement for routine blood monitoring or dose adjustment and very few drug interactions. The increasing use of these drugs means the acute medicine physicians are likely to encounter patients who have been taking them. This article reviews some of the challenging clinical situations in which this may arise.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology Manchester Royal Infirmary Oxford road, Manchester
| | - James Gagg
- Department of Haematology Manchester Royal Infirmary Oxford road, Manchester
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