Hemodialysis grafts often fail because of stenosis at the venous anastomosis resulting in thrombosis. Percutaneous intervention involves thrombolysis with plasminogen activators, mechanical removal of thrombus, and angioplasty of the stenotic lesions.
This article describes a phase I trial using plasmin (human) TAL 05-00018, a direct-acting fibrinolytic agent, to evaluate safety and, secondarily, to establish effective thrombolytic dosing.
Six cohorts of five patients with acute HD graft occlusion documented by fistulagrams were treated with increasing dosages of plasmin (1, 2, 4, 8, 12, and 24 mg) infused within the graft over 30 min via two criss-crossed pulse-spray catheters. The primary efficacy endpoint was at least 50% thrombolysis, as determined by fistulography.
There was no significant change in plasma alpha-2 antiplasmin or fibrinogen concentration, major bleeding did not occur, and there were no deaths. Serious adverse events in four patients were not related to the study drug. There was a dose-response relationship for the primary efficacy endpoint, all five subjects receiving 24 mg achieving more than 75% lysis.
This first phase I study of plasmin (human) TAL 05-00018, infused into thrombosed HD grafts, documents safety at all doses and an effective thrombolytic dosage of 24 mg indicating that further investigation into locally delivered plasmin is warranted.
Acute thrombosis was induced in the carotid arteries of anaesthetised rabbits by local electrical stimulation (1mA for 2 min) of the vessel wall. Histological findings confirmed the platelet-rich composition of the thrombus. Platelet accumulation at the stimulus site was quantitated with "'Indium-labelling of autologous platelets. In rabbits injected intravenously with either 2 mg/kg dazoxiben or 10 mg/kg aspirin, accumulation of labelled platelets was considerably reduced. Animals which received vehicle injection only, showed no such reduced thrombus formation. In separate experiments in anaesthetised rabbits, the levels of TxB2 and 6KPGF1 alpha in clotting blood were measured in blood samples taken from animals which had received the above drug treatments. Aspirin markedly reduced the production of both arachidonate metabolites. In contrast, dazoxiben almost totally inhibited TxB2 production but caused a 3.5 fold increase in the levels of 6KPGF1 alpha. These findings demonstrate an anti-thrombotic effect and confirm the mechanistic selectivity of a thromboxane synthetase inhibitor.
Venous thromboembolism (VTE) is a common problem in cancer patients. However, the rates of VTE vary widely between different types of malignancies. Furthermore, patient- and treatment-related risk factors contribute to the risk of VTE. The prediction of the individual risk of VTE and the identification of patients with cancer that might benefit from thromboprophylaxis is a major clinical challenge, because the pathogenesis of cancer-associated VTE is multifactorial. Therefore, recent studies have focused on identification of predictive biomarkers for VTE. As there is a close interrelation between cancer and the haemostatic system, which leads to activation of haemostasis and fibrinolysis, biomarkers of the haemostatic system seem to be promising in predicting risk of developing VTE in cancer patients. Some candidate biomarkers or laboratory tests of the haemostatic system including platelet count, soluble P-selectin, tissue factor (TF) and TF-bearing microparticles, coagulation factor VIII, D-dimer, prothrombin fragment 1+2 and the thrombin generation assay have been reported to predict cancer-associated VTE. In addition, it has been shown that risk-scoring models, incorporating clinical parameters and biomarkers, allow risk stratification of cancer patients into groups at high- and at low risk of VTE. The accuracy of a previously established risk scoring model can be improved when it is expanded and biomarkers of the haemostatic system are added. The benefit of a targeted thromboprophylaxis for primary prevention of VTE in cancer patients based on risk assessment by measuring biomarkers or applying risk scoring models has to be shown in interventional clinical trials.
Brazilin (7,11b-dihydrobenz[b]indeno[1,2-d]pyran-3,6a,9,10 (6H)-tetrol), the major component of Caesalpinia sappan L., was reported to show antiplatelet activity through the inhibition of phospholipase A2 (PLA2) activity and the increase in intracellular free Ca2+ concentration ([Ca2+]i). To search more potential antiplatelet agent, brazilin derivatives were synthesized and examined for their effects on the platelet aggregation. Among those compounds, BRX-018, (6aS,cis)-Malonic acid 3-acetoxy-6a9-bis-(2-methoxycarbonyl-acetoxy)-6,6a,7,11b-tetrahydro-indeno[2,1-c]chromen-10-yl ester methylester, was confirmed as one of the potential antiplatelet agents. In the present study, we investigated the antiplatelet mechanism of BRX-018. BRX-018 inhibited the thrombin-, collagen-, and ADP-induced rat platelet aggregation in a concentration-dependent manner, with IC50 values of 35, 15, and 25 microM, respectively. BRX-018 also inhibited thrombin-induced dense granule secretion, thromboxane A2 (TXA2) synthesis, and [Ca2+]i elevation in platelets. BRX-018 was also found to inhibit A23187-induced [Ca2+]i and aggregation in the presence of apyrase (ADP scavenger) but not in the presence of both apyrase and indomethacin (a specific inhibitor of cyclooxygenase, COX). Although BRX-018 significantly inhibited arachidonic acid (AA)-induced aggregation and TXA2 synthesis, it had no significant inhibitory effect on cyclooxygenase activity in vitro. In contrast, BRX-018 inhibited the activity of purified PLA2. Dixon plot showed that this inhibition was mixed type with an inhibition constant of Ki=23 microM. Taken together, the present study suggests that BRX-018 may be a promising antiplatelet agent and that its antiplatelet activity may be based on the inhibitory mechanisms on TXA2 synthesis in stimulated platelets.
All trans-retinoic acid (ATRA) induces apoptosis and/or differentiation in solid tumors, including breast cancer, and has become a therapeutic tool in this disease. In human promyelocytic leukemia ATRA reduces the expression of cellular procoagulant activities (PCA), i.e. tissue factor (TF) and cancer procoagulant (CP). There are no studies on the effects of ATRA on the PCA of solid tumors, i.e. breast cancer cells. We analyzed different human breast cancer cell lines in order to: 1. characterize the expression of TF and CP; 2. evaluate whether these activities are affected by ATRA; and 3. verify whether a reduction in tumor cell procoagulants may occur in association to apoptosis and growth inhibition induced by ATRA. Two estrogen receptor positive (ER-positive; i.e. MCF7 and ZR75.1) and one estrogen receptor negative (ER-negative; i.e. MDA.MB.231) cell lines were included into the study. The results show that ATRA affected TF in a dose-dependent fashion only in ER-positive cell lines. In particular, at 1 uM ATRA, TF significantly (p < 0.05) decreased by 57%, 44% in MCF7, ZR75.1 cells, respectively. Differently the results show that ATRA dose-dependently affected CP expression in all three cell lines. Specifically, at 1 uM ATRA, CP significantly decreased by 44%, 50% and 25% in MCF7, ZR75.1, and MDA.MB.231. Only in ER-positive cell lines, there was a dose-dependent inhibition of cell growth that became statistically significant at 1 uM ATRA, which was associated to a slight but significant increase in the percentage of apoptotic cells. In conclusion, this study demonstrates for the first time that ATRA downregulates the expression of TF and CP in breast cancer cells. Due to the pivotal role of coagulation activation in tumor progression, the capacity of ATRA to affect also tumor procoagulants, in parallel to cell apoptosis, open new perspectives in tumor therapy.
Venous thromboembolism (VTE) is an increasingly frequent complication of cancer and its treatments. One in five cancer patients are estimated to develop venous and arterial events during the natural history of their illness. However, the risk for VTE varies widely between various subgroups of cancer patients and even in the same cancer patient over time. This narrative review focuses on risk factors, biomarkers and risk assessment tools and attempts to clarify approaches to risk stratification. Clinical risk factors include primary site of cancer, chemotherapy, anti-angiogenic therapy, surgery and hospitalization. Predictive and candidate biomarkers include platelet and leukocyte counts, hemoglobin, D-dimer and tissue factor. However, single risk factors or biomarkers have not, in general, been able to identify sufficiently high-risk populations. A clinical risk score, incorporating 5 simple clinical and laboratory variables, has now been studied in over 10,000 patients and can successfully categorize patients at low- and high-risk for VTE. Recent trials have shown that outpatient prophylactic anticoagulation is both safe and effective, but event rates have been highly variable. Targeted thromboprophylaxis provides an optimal risk-benefit ratio and the best opportunity to reduce the burden of VTE and its consequences for patients with cancer.
The risk of recurrent venous thromboembolism (VTE) in young women after a first oestrogen contraception associated VTE episode is unknown. This uncertainty has an impact on the decision whether to stop anticoagulant treatment. Our objective was to assess the risk of recurrent VTE in women after a first VTE episode on oestrogen contraception. This was a prospective cohort study in which we consecutively enrolled between 1992 and 2011 all women under 50years with a first objectively confirmed VTE. The incidence of recurrent VTE during follow-up after stopping anticoagulation was compared between women users and non-users of combined oral contraception (COC) at the time of index VTE. Of the 241 women aged 50 or younger seen for a first VTE and followed-up after stopping anticoagulation, there were 180 COC-users and 61 non-users. Median duration of follow-up off-anticoagulants was 66months (interquartile range: 33-103). There were 14 recurrences in COC-users and 5 cases in non-users. No significant association was found between exposure to COC and the incidence of recurrent VTE after adjustment for age or after restricting the analysis to major unprovoked VTE: incidence rate of recurrence 17.9/1,000/year (95% CI: 9.6-33.2) in women with COC as compared with 17.6/1,000/year (95% CI: 6.6-47) with an incidence ratio of 0.7 (95% CI: 0.2-2.4, p=0.59). The risk of recurrent VTE is low in young women after a first VTE. However, this risk is not significantly lower in women after a first VTE while exposed to combined oral contraception.
The antithrombotic and bleeding time (BT) prolonging effects of TAK-029, a novel GPIIb/IIIa antagonist, were examined in three arterial thrombosis models. In guinea pigs, TAK-029 at 30 micrograms/kg (i.v.) inhibited ADP-induced ex vivo platelet aggregation completely and prolonged BT to 4.5 times the control value 5 min after administration, and it prevented thrombotic occlusion in 2 out of 5 animals in a photochemically-induced basilar thrombosis model. TAK-029 at 100 micrograms/kg (i.v.) prolonged BT more than 9 times 5 min after administration, and it prevented thrombus formation for over 60 min. In dogs, TAK-029 at 30 micrograms/kg (i.v.) inhibited ADP-induced ex vivo platelet aggregation by 87% 5 min after administration, and it prevented thrombotic occlusion in injured and stenosed coronary arteries for 22 min without prolonging the BT. TAK-029 at 100 micrograms/ kg (i.v.) inhibited platelet aggregation completely and prolonged BT 3.6 times 5 min after administration, and it prevented thrombus formation for over 45 min. In monkeys, TAK-029 at 10 micrograms/kg (i.v.) inhibited ADP-induced ex vivo platelet aggregation by 84% and prolonged BT 4.6 times 5 min after the administration, and it prevented thrombotic occlusion in injured and stenosed carotid arteries for 24 min. TAK-029 at 30 micrograms/kg (i.v.) completely inhibited platelet aggregation and thrombus formation for over 60 min, and it prolonged BT more than 7.3 times 60 min after administration. In conclusion, TAK-029 exerted potent antithrombotic effects with BT prolongation in three different arterial thrombosis models. TAK-029 may be effective for the treatment of various arterial thrombotic diseases.
Pelvic deep vein thrombosis (DVT) is difficult to diagnose during pregnancy. In a two-center trial, we evaluated the agreement between ultrasonography and magnetic resonance imaging (MRI) in diagnosing the extent of DVT into the pelvic veins during pregnancy.
Pregnant women with proximal DVT were examined both with ultrasound and MRI as part of a study designed for treatment of DVT during pregnancy. Ultrasound was performed using color flow by specialist in vascular ultrasound with Doppler and compression techniques. The MRI sequences consisted of a 2D Time of Flight angiography with arterial flow suppression and maximum intensity projection reconstructions; a 3D, T1-w-prepared gradient echo sequence with fat saturation for thrombus imaging; a steady-state free precession sequence; and a Turbo-Spin-Echo. No contrast agent was used. Proportion of agreement (kappa) for detection of DVT in individual veins was measured for different ipsilateral veins and inferior vena cava.
All 27 patients were imaged with both techniques at an average gestational age of 29 weeks (range 23-39). Three cases (11.5%) of DVT in the pelvic veins were missed on ultrasound but detected by MRI. The upper limit of the DVT was always depicted at a higher (20 cases, 65.4%) or the same level (seven cases, 34.6%) on MRI than on ultrasound. Agreement expressed as kappa was 0.33 (95% CI 0.27-0.40) demonstrating only fair agreement. In one woman the thrombus had propagated into the inferior vena cava, shown only on MRI.
Our study suggests that in pregnant women there is only fair agreement between ultrasound and MRI for determination of extent of DVT into pelvic veins, with MRI showing consistently more detailed depiction of extension. Our results indicate that MRI has an important role as a complementary technique in the diagnosis of DVT during pregnancy.
The natural history of unsuspected pulmonary embolism (PE) in patients with cancer has not been thoroughly studied.
We used the RIETE Registry data to compare the clinical characteristics, treatment strategies and outcome in cancer patients with unsuspected PE and in those presenting with symptomatic, acute PE.
Up to December 2011, 78 cancer patients with unsuspected PE and 1,994 with symptomatic PE had been enrolled. Patients with unsuspected PE more likely had colorectal cancer than those with symptomatic PE (28% vs. 13%), and less likely had prostate (3.8% vs. 10%) or hematologic (1.3% vs. 6.4%) cancer, or prior venous thromboembolism (3.8% vs. 12%). While the patients were receiving anticoagulant therapy, the incidence of PE recurrences (0% vs. 1.9%) or major bleeding (2.6% vs. 4.8%) were similar. After completion of anticoagulation, recurrent PE developed in 2.6% vs. 1.4% of patients, and major bleeding in 0% vs. 0.4%, respectively.
Our findings suggest that the clinical characteristics and outcome in cancer patients with unsuspected PE are quite similar to those in patients with symptomatic PE.
The diagnosis of cancer during pregnancy or in the post-partum period poses a major burden on the woman and her family. Issues of fetal and neonatal wellbeing are intricate, while mother's health is of primary concern.
Oncogenic events impact interactions of cancer cells with their surroundings. Amongst the most consequential, in this regard, is the influence on angiogenesis, inflammation and hemostasis. Indeed, mutant oncogenes (EGFR, HER2, RAS, MET, PML-RARα) are known to alter the expression of angiogenic and pro-inflammatory factors, as well as change the cancer cell coagulome, including the levels of tissue factor (TF) and other mediators (PAI-1, COX2). Accompanying losses of tumour suppressor genes (PTEN, p53), and changes in microRNA (miR-19b, miR-520) facilitate these effects. Transforming genes may also trigger ectopic production of coagulation factors (e.g. FVII) by cancer cells and their release and properties of procoagulant microparticles (MPs). By deregulating protease activated receptors (PAR1/2) oncogenes may also change tumour cell responses to coagulation factor signalling. These changes act in concert with microenvironmental factors (hypoxia), stress responses (therapy) and differentiation programs, including epithelial-to-mesechymal transitions (EMT) and through tumour initiating cell (TIC) compartment. In so doing, the coagulation system influences early (initiation, angiogenesis), intermediate (growth, invasion) and late stages (metastasis, relapse) of cancer progression. In fact, TF may act as a molecular switch that controls the transition between dormant, latent and progressive/metastatic disease. TIC-like cells may play a role in these effects, as they express TF and PAR-1/2, and respond to stimulation with their agonists. As major human malignancies (e.g. glioblastoma) are increasingly recognized to consist of a spectrum of molecularly distinct disease subtypes driven by specific genetic pathways, so too may their patterns of interaction differ with the coagulation system. A better understanding of these linkages may be a source of new diagnostic, prognostic and therapeutic opportunities.
It has long been recognised that the function of platelets in health and disease span far beyond their roles in haemostasis and thrombosis. The observation that tumour cells induce platelet aggregation was followed by extensive experimental evidence linking platelets to cancer progression. Aggregated platelets coat tumour cells during their transit through the bloodstream and mediate adherence to vascular endothelium, protection from shear stresses, evasion from immune molecules, and release of an array of bioactive molecules that facilitate tumour cell extravasation and growth at metastatic sites. The sialyated membrane glycoprotein podoplanin is found on the leading edge of tumour cells and is thought to influence their migratory and invasive properties. Podoplanin elicits powerful platelet aggregation and is the endogenous ligand for the platelet C-type lectin receptor, CLEC-2, which itself regulates podoplanin signalling. Here, the bidirectional relationship between CLEC-2 and podoplanin is described and considered in the context of tumour growth and metastasis.
The recombinant plasminogen activator BM 06.022 consists of the kringle 2 and the protease domains of human t-PA and is unglycosylated because of its expression in Escherichia coli. The pharmacokinetic properties of BM 06.022 following intravenous injection over 1 min were characterized in anesthetized male New Zealand white rabbits. BM 06.022 was injected at doses of 50, 100, 200, and 400 kU/kg bw (n = 5-6/dose). Activity concentrations in plasma were determined using an indirect spectrophotometric assay. The maximum plasma concentration and the area under the plasma concentration vs. time curve (AUC0-00) of BM 06.022 increased linearly with dose. The systemic clearance ranged from 2.5 to 3.0 ml.min-1.kg-1 and did not show dose-dependency, in contrast to alteplase which was studied at doses of 200, 400, 800, and 1600 kU/kg. A direct comparison of clearance rates of BM 06.022 and alteplase at doses of 200 and 400 kU/kg each revealed a 8.5-fold slower clearance rate of BM 06.022. The majority (18/23) of rabbits with BM 06.022 injection showed a pharmacokinetic profile which was best characterized by a one-compartment model in contrast to alteplase (10/23). The dose-groups of BM 06.022 showed an average dominant half-life ranging from 11.6 to 15.4 min, which was about five-times longer than the dominant half-life values of alteplase (2.3 to 4.5 min). Assuming a two-compartment model in the remaining animals, the initial alpha-phase of BM 06.022 accounted for 40.1 +/- 13.2% (n = 5) of the total AUC, whereas the alpha-phase of alteplase accounted for 82.7 +/- 3% (n = 13) of the total AUC.
Platelets retain megakaryocyte-derived mRNA, an abundant and diverse array of miRNAs, and have evolved unique adaptive signals for maintenance of genetic and protein diversity. Quiescent platelets generally display minimal translational activity, although maximally-activated platelets retain the capacity for protein synthesis. Progressive data using multiple platelet activation models clearly demonstrate that platelet responses to the majority (if not all) agonists are highly variable within the population, demonstrating considerable heritability in siblings, twins, and families with premature coronary artery disease. Research from our laboratory has adapted global profiling strategies to close the knowledge gap currently existing between genetic variability and platelet phenotypic responsiveness. We have applied iterative algorithms for genetic biomarker discovery and class prediction models of platelet phenotypes, with the goal of systematically analyzing integrated mRNA/miRNA/proteomic datasets for identification of regulatory networks that define phenotypic variability in platelet responses. This approach has the potential to define platelet genetic biomarkers predictive of thrombohemorrhagic outcomes in both normal and widely disparate clinical conditions.
This study aimed to characterize the in vitro effect of EV-077, a compound that antagonises the binding of prostanoids and isoprostanes to the thromboxane receptor (TP) and inhibits the thromboxane synthase (TS), on platelet aggregation of patients with type-2 diabetes and coronary artery disease (CAD) on chronic aspirin treatment. The effect of EV-077 on 8-iso-PGE(2)-mediated TP receptor contraction of human arteries was also investigated.
Fifty-two type-2 diabetics with CAD on chronic aspirin (100mg) treatment were studied. Arachidonic acid-induced platelet aggregation was measured by impedance aggregometry in platelet-rich plasma (PRP) and whole blood anticoagulated with hirudin, and by light transmission aggregometry in citrate-anticoagulated PRP following 10-min in vitro exposure to EV-077 (100nmol/l) or control. The effect of EV-077 was measured on isometric contraction of 24 human umbilical arteries induced by isoprostane 8-iso-PGE(2).
Arachidonic acid (1mmol/l) induced substantial aggregation in hirudin-anticoagulated whole blood (63±4AU), which was significantly reduced by in vitro exposure to EV-077 (38±3AU, P<0.001). Virtually no arachidonic acid-induced aggregation in citrate-anticoagulated or hirudin-anticoagulated PRP was observed. EV-077 potently, competitively and reversibly inhibited TP mediated contraction of umbilical arteries by 8-iso-PGE(2) (P<0.01).
Aspirin did not completely inhibit arachidonic acid-induced platelet aggregation in whole blood from type-2 diabetics with CAD. This aggregation is likely induced by prostanoids and/or isoprostanes produced by leukocytes, because it was significantly reduced by EV-077. The TP receptor-mediated contraction of human arteries induced by isoprostane 8-iso-PGE(2) was effectively inhibited by EV-077.
Tumor associated coagulopathy is a complex phenomenon that has been the subject of study for more than a century. Many mechanisms have been implicated in this process including tumor-host interactions, growth factor-, and cytokine-mediated signaling in the tumor microenvironment. Tissue factor (TF), a potent procoagulant, is considered to be critical for physiologic and pathological coagulation. The genetic and microenvironmental features of cancer appear to strongly influence the expression of TF and lead to a procoagulant state both locally within the neoplasm as well as systemically. In association with cytokines and other procoagulants, upregulated TF and its downstream effectors such as thrombin not only lead to abnormal blood clotting in cancer patients but also stimulate a wide number of oncogenic signaling mechanisms that may prove important in cancer progression. In glioblastoma multiforme (GBM), EGFR expression and PTEN loss both lead to increased TF expression and thrombosis in a manner that appears to cause hypoxia-induced tumor progression. This review consolidates aspects of aberrant coagulation in cancer, the relevance of TF and its regulation by oncogenic alterations, with specific reference to GBM.
Cardiovascular disease remains the leading cause of morbidity and premature mortality in most industrialized countries as well as in developing nations. A pro-oxidative state appears to promote and/or exacerbate vascular disease complications. Furthermore, a state of low-grade chronic inflammation can promote increased oxidative stress and lead to endothelial cell and platelet dysfunction ultimately contributing to thrombogenesis.
In this study, the effect of a proprietary astaxanthin prodrug (CDX-085) on thrombus formation was investigated using a mouse model of arterial thrombosis. The influence of free astaxanthin, the active drug of CDX-085, on human endothelial cells and rat platelets was evaluated to investigate potential mechanisms of action.
Oral administration of CDX-085 (0.4% in chow, approximately 500 mg/kg/day) to 6-8 week old C57BL/6 male mice for 14 days resulted in significant levels of free astaxanthin in the plasma, liver, heart and platelets. When compared to control mice, the CDX-085 fed group exhibited significant increases in basal arterial blood flow and significant delays in occlusive thrombus formation following the onset of vascular endothelial injury. Primary human umbilical vein endothelial cells (HUVECs) and platelets isolated from Wistar-Kyoto rats treated with free astaxanthin demonstrated significantly increased levels of released nitric oxide (NO) and significantly decreased peroxynitrite (ONOO-) levels.
Observations of increased NO and decreased ONOO- levels in endothelial cells and platelets support a potential mechanism of action for astaxanthin (CDX-085 active drug). These studies support the potential of CDX-085 and its metabolite astaxanthin in the treatment or prevention of thrombotic cardiovascular complications.
Anti-angiogenic drugs and in particular anti-vascular endothelial growth factor (VEGF) agents have entered the clinical armamentarium against cancer. New unexpected toxicities have emerged. The incidence and the severity of these toxicities have a great variability in the different studies. Among them, bleeding is one of the most severe and difficult to manage. Bevacizumab retains the highest frequency of bleeding complications, in particular epistaxis, hemoptysis and gastrointestinal bleeding. Although a higher incidence of severe hemorrhages has not been consistently demonstrated during the treatment with bevacizumab, mild bleeding episodes appear clearly increased in the experimental arm of most trials. Cases of severe pulmonary hemorrhage were reported in patients with lung cancer; these events occurred mainly intra-tumor and were significantly associated with squamous cell histology. Trials with other small-molecule tyrosine kinase inhibitors like sunitinib or sorafenib showed an overall lower rate of bleeding complications, but still significantly higher than the control arm in many cases. The mechanisms of bleeding induced by anti-VEGF agents are complex and not yet fully clarified: the main hypothesis is that VEGF could promote endothelial cell survival and integrity in the adult vasculature and its inhibition may decrease the renewal capacity of damaged endothelial cells. Management of bleeding in patients treated with anti-VEGF agents is a challenging task because this complication is at least in part inherent to the efficacy of the drug and because there is also an increased risk of thrombosis, both arterial and venous. So far, only few preliminary data are available on a strategy to prevent hemorrhage and thrombotic event.
Post-marketing surveillance of thrombomodulin alfa (TM-α) was performed to evaluate safety and efficacy in patients with disseminated intravascular coagulation (DIC) with hematologic malignancy.
All patients treated with TM-α from May 2008 to April 2010 in Japan were included. Information about baseline characteristics, safety, and efficacy were collected. The DIC resolution rate, survival rate on Day 28 after the last TM-α administration, and changes in DIC score and coagulation tests were evaluated.
The underlying diseases associated with DIC were acute myeloid leukemia (except for acute promyelocytic leukemia, n=350), lymphoma (n=199), acute promyelocytic leukemia (n=172), acute lymphoblastic leukemia (n=156), myelodysplastic syndromes (n=61), and other (n=94). The incidence rates of bleeding-related adverse events and adverse drug reactions were 17.8% and 4.6%, respectively. In subjects with bleeding symptoms at baseline, 55.0% were assessed as disappeared or improved based on symptoms after TM-α treatment. The DIC resolution and survival rates were 55.9% and 70.7%, respectively. The DIC score and coagulation tests including thrombin-antithrombin complex (TAT) were significantly improved. Coagulation tests were significantly improved after TM-α treatment even in subjects whose clinical course of underlying disease was assessed as unchanged or exacerbated.
This surveillance confirmed the safety and efficacy of TM-α in clinical practice, thus TM-α may be an ideal treatment for patients with DIC based upon hematologic malignancy.
The antithrombotic activity of tecarfarin, a novel orally active vitamin K epoxide reductase inhibitor, was assessed in canine and rabbit thrombosis models. In dogs, once-daily oral doses of 0.5mg/kg tecarfarin selectively reduced the levels of the vitamin K-dependent coagulation factors (factors II, VII, IX, and X) and prolonged the prothrombin time (PT). A 4 to 7day course of oral tecarfarin (0.05 - 0.5mg/kg) prolonged the PT by 3 to 5-fold and reduced thrombus formation in arterial and venous segments subjected to a combination of electrical injury and flow-limiting constriction. To compare the effects of tecarfarin with those of warfarin, rabbits were given once-daily oral doses of 1mg/kg tecarfarin, 1.5mg/kg warfarin, or saline for 2days. After verifying increases in the PT with tecarfarin and warfarin, blood loss from standardized ear incisions was measured to assess hemorrhagic potential. Then, after intravenous injection of (125)I-labeled rabbit fibrinogen, thrombosis was induced in an isolated jugular vein segment by a combination of balloon catheter-induced endothelial denudation and venous occlusion. Compared with the saline control, both tecarfarin and warfarin prolonged the PT, increased blood loss from the ear incisions, and attenuated thrombus formation. Thus, like warfarin, tecarfarin attenuates venous and arterial thrombus formation in animal models by reducing the levels of the vitamin K-dependent coagulation factors.
The new quinazolinone derivative, 2-(4-[1-(2-chlorophenyl)piperazinyl]) methyl-2,3-dihydroimidazo[1,2-c]quinazolin-5(6H)-one(CK53 ), inhibited platelet aggregation and ATP release induced by arachidonic acid, collagen, PAF and U46619 in washed rabbit platelets. In human platelet-rich plasma CK53 also significantly suppressed the platelet aggregation and ATP release challenged by epinephrine and ADP. The thromboxane B2 formation of rabbit washed platelets caused by collagen and thrombin was reduced by CK53 but that induced by arachidonic acid. CK53 inhibited the intracellular calcium increase stimulated by collagen and thrombin in quin-2/AM-loaded rabbit platelets. Phosphoinositides breakdown caused by collagen, U46619, PAF and thrombin was inhibited by CK53. CK53 also suppressed the aggregation of elastase-treated human platelets induced by fibrinogen but no alteration in platelet cyclic-AMP level. In conclusion, these data indicate that antiplatelet effect of CK53 may be mainly due to the direct inhibition of phosphoinositides breakdown.
Tetrahydroacridine (THA), or Cognex, is currently awaiting FDA approval for the treatment of Alzheimer's disease. In addition to reports indicating that THA improves the symptoms of patients with Alzheimer's disease, we have found that THA possesses potent antiplatelet activity. THA produced dose-dependent inhibition of human platelet aggregation induced by collagen, ADP, A23187, and phorbol ester. THA, when added to activated platelets, dispersed the platelet aggregates. We have also examined the effects of THA on intracellular Ca++ mobilization, ATP release, and production of cyclic AMP.
1,25 Dihydroxyvitamin D3 is a differentiation inducer for monocytic cell. It can induce a monoblastic cell line U937 to differentiate. In this paper, we report that by inducing the differentiation of U937, 1,25-dihydroxyvitamin D3 increased urokinase activity expression on U937 cell surfaces. After incubation of the cell with various concentrations of 1,25-dihydroxyvitamin D3, the cell line showed a remarkable progressively increasing membrane-associated urokinase activity in a dose dependent manner. On the contrary, plasminogen activator inhibitor activity which was found in the culture medium is not modified by the 1,25-dihydroxyvitamin D3 induction. This results suggests another role of 1,25-hydroxyvitamin D3 in the treatment of myelofibrosis, since enhanced plasmin generation can accelerate the activation of procollagenase. The induced plasmin and collagenase activities surrounding the monocytic cells may participate in the physiological and pathological events, especially in the connective tissue degradation.
The effects of 1,3-dihydro-7,8-dimethyl-2H-imidazo[4,5-b]quinolin-2-one (BMY-20844) on platelet function and experimental thrombosis were evaluated in a series of in vitro, ex vivo and in vivo experiments. The compound inhibited platelet aggregation in vitro in platelet rich plasma obtained from humans, rats and rabbits with EC50s of less than 1 microgram/ml when aggregation was induced by ADP, collagen or thrombin. Supra-additive interaction against ADP aggregation was also observed when BMY-20844 was combined with prostacyclin. BMY-20844 was orally active with an ex vivo ED50 in the rat of 3.2 mg/kg vs ADP. Significant antithrombotic activity was observed in two animal models (laser induced thrombosis in the microcirculation of the rabbit ear and coronary artery thrombosis in the dog). Inhibitions of 52% at 3 mg/kg p.o. in the laser model and 100% at 1 mg/kg i.d. in the coronary artery thrombosis model were obtained. Modest inotropic and hemodynamic effects were observed in ferrets and dogs. BMY-20844 was found to be a potent, specific inhibitor of platelet low Km cyclic AMP phosphodiesterase.
Sulfation of the natural polysaccharide curdlan results in anticoagulantly active beta-1,3-glucan sulfates whose activity depends on various structural parameters. In this study the anticoagulant and antithrombotic effects of one of these beta-1,3-glucan sulfates (GS) were compared with those of a porcine mucosal heparin. GS produced a concentration dependent anticoagulant effect in all the global coagulation assays with the exception of the anti-Xa assay. The best activity was found in the APTT and the thrombin time assays indicating that protease generation and the direct inhibition of thrombin may be sites of actions of this agent. Whereas the anticoagulant activity of GS was approximately 5 fold lower compared to heparin, a 32 fold higher concentration (ED50 = 550 micrograms/kg) was needed for an antithrombotic effect similar to heparin (ED50 = 17.2 micrograms/kg) in a rabbit model of stasis thrombosis. In contrast to this, when a rat model of clamping induced jugular vein occlusion was used to produce vascular obstruction, GS produced similar antithrombotic actions to heparin. At a 250 micrograms/kg dosage, both agents doubled the number of clampings required for complete vascular obstruction. Since the mechanical injury to the blood vessel is the primary determinant of the thrombogenic response, GS may inhibit some of the pathophysiologic mechanisms responsible for the occlusion of the blood vessel. The current study also points to the fact that the global anticoagulant effects may not reflect the antithrombotic potential of newer sulfated carbohydrate derived drugs.
The effects of four 1,4-naphthoquinone derivatives on the aggregation of rabbit platelets were examined. All the four 1,4-naphthoquinone derivatives inhibited the platelet aggregation of washed rabbit platelets induced by thrombin (0.1 U/ml) and the IC50 is: 2-chloro-3-methyl-1,4-naphthoquinone (CMN), 5 micrograms/ml; 3-methyl-5,8-dihydroxy-1,4-naphthoquinone, 13 micrograms/ml; 5,8-dihydroxy-1,4-naphthoquinone, 18 micrograms/ml; 3-methyl-1,4-naphthoquinone (vitamin K3), 53 micrograms/ml. CMN was the most potent in inhibiting the aggregation and release reaction induced by ADP, arachidonic acid, PAF, ionophore A23187, collagen and thrombin in a dose-dependent manner in washed platelets, platelet-rich-plasma and whole blood. The thromboxane B2 formation caused by collagen and ionophore A23187 was inhibited by CMN. However, the thromboxane B2 formation by arachidonic acid was markedly increased. The platelet inhibitory effect of CMN could not be antagonized either by raising the concentrations of extracellular Ca++ or by wash out. The phosphoinositides breakdown induced by thrombin was inhibited by CMN. Phospholipids (PE, PC, PI) could slightly antagonize the antiplatelet effect of CMN. It is concluded that the inhibitory effect of CMN on rabbit platelet aggregation may be due to the inhibition of phosphoinositides breakdown caused by the inducers.
The mechanism of the antiplatelet functions of SM-10906, the active form of the 3-oxa-methano-prostaglandin (PG) I1 analog SM-10902, was examined in rat platelets. SM-10906 activated adenylate cyclase in crude membrane fractions, and inhibited platelet aggregation and release of adenine nucleotides stimulated by thrombin. SM-10906 also inhibited malondialdehyde production induced by thrombin, but not that induced by arachidonic acid. This may account for its inhibitory effects on phospholipase A2. SM-10906 prevented thrombin-induced inositol 1,4,5-trisphosphate production, Ca++ mobilization from intracellular Ca storage and 45Ca++ influx into platelets, which were all reversed by pretreatment with the adenylate cyclase inhibitor 2',5'-dideoxyadenosine. PGI2 and PGE1 have the same antiplatelet profiles in the order of PGI2 > or = SM-10906 > PGE1. These results indicate that SM-10906 as well as PGI2 and PGE1 may exert antiplatelet activities by stimulating adenylate cyclase to prevent thrombin-induced phospholipase C and A2 activations and increase in cytosolic Ca++ level.
Guanosine 5′-triphosphate (GTP) and its nonhydrolyzable analogs, such as guanosine 5′-0-(3-thiotriphosphate) (GTPγS), induce several responses in platelets including secretion, production of inositol 1,4,5-triphosphate (IP3) and mobilization of Ca2+ from intracellular sites. Because IP3 is well established as a second messenger in mobilizing Ca2+ from intracellular stores it has been generally assumed that Ca2+ release by GTP/GTPγS in platelets is mediated by IP3. However, studies in neuronal, hepatic and smooth muscle cells have suggested that IP3 and GTP/GTPγS activate Ca2+ release by distinct mechanisms and that IP3-independent mechanisms mediate GTP/GTPγS-induced Ca2+ release. In several tissues heparin inhibits binding of IP3 and blocks IP3-stimulated Ca2+ release in a competitive and specific manner. In the present studies, IP3 and GTPγS induced Ca2+ release and their relationship was examined in human platelets using heparin as a probe. In saponin permeabilized platelets, IP3 (0.05-5 μM) induced a prompt, dose-dependent release of Ca2+ (EC50 0.5 μM). GTPγS (1-50 μM) released Ca2+ in a dose-dependant manner with EC50 of 2 μM but with a time lag of 30-90 seconds. Exposure of platelets to 1 μM IP3 following a submaximal response with GTPγS (1 μM) resulted in a further increase in Ca2+ release but no further increase was noted on adding 1 μM IP3 following a maximal response with GTPγS (10 μM); similar findings were noted on reversing the order of addition of GTPγS and IP3 suggesting that these effectors release Ca2+ from the same source. IP3 (0.5 μM) induced Ca2+ release was blocked by low molecular weight (4000-6000) heparin (IC50 30 μg/ml). More importantly, heparin abolished GTPγS (2.5 μM) induced Ca2+ release (IC50 10 μg/ml). These results indicate that, in contrast to the findings in some other cells, in human platelets GTPγS-induced Ca2+ release is mediated largely by a mechanism involving IP3.
In this study we investigated the influence of acetylsalicylic acid (ASA) 1.0 g/day on 111-In-platelet survival time (PST) and on plasma levels of beta-thromboglobulin (beta-TG) and platelet factor 4 (PF 4) in 37 patients (median age: 63.4 years) with arteriographically proven peripheral arterial occlusive disease (PAOD) in a chronic stable phase. We found a slight but significant increase of PST during therapy with ASA (weighted mean (WM): 184.3----193.2 [median] hours, p less than 0.05; multiple hit (MH): 182.4----192.8 hours, p less than 0.005) for the total group of patients. Concerning the influence of risk factors of PAOD on PST during ASA-therapy, there was a significant increase of PST only in the nondiabetics (WM: 180.3----204.6 hours, p less than 0.01; MH: 176.8----195.3 hours, p less than 0.01). There was a negative correlation between the baseline values of PST and their increase following ASA therapy (WM: r = -0.63; p less than 0.0001; MH: r = -0.61, p less than 0.0001). The pretreatment levels of beta-TG--but not PF 4--were significantly (p less than 0.001) elevated compared to healthy controls. Therapy with ASA caused a significant decrease in the plasma levels of beta-TG (median: 30.4----26.6 ng/ml, p less than 0.001) and PF 4 (2.95----2.2 ng/ml, p less than 0.01).
Despite high plasma levels of heparin during cardiopulmonary bypass surgery, activation of the coagulation system has been reported. We hypothesize that the coagulation system activity most appropriately could be assessed by molecular markers of thrombin generation. The aim of the present study was to describe the changes in thrombin generation during CPB, using prothrombin fragment F1 + 2 (F1.2) as an indicator and evaluate different blood sampling regimens for interpretation of the F1.2 measurements. Twenty patients, operated under extracorporeal circulation with coronary artery bypass grafting (CABG), comprised the study material. The heparin levels were maintained above 2.5 IU/ml throughout the bypass procedure and the functional AT-III level was kept above 0.5 U/ml. Despite of this anticipated inactivation of the coagulation system, the concentrations of F1.2 and FpA increased throughout CPB, particularly after release of the aortic crossclamp. F1.2 and FpA correlated significantly (R = 0.69). No statistically significant correlation was found between F1.2 formation rate and age, bodyweight, baseline ACT, ACT after 200 IU heparin/kg, average heparin concentration during CPB or average AT-III level during CPB.
Thrombin formation seems to be a continuous process during CPB despite adequate heparinization. The pattern of thrombin generation can be assessed most appropriately in terms of F1.2 generation rate. Extraordinary high levels of F1.2 were seen after release of the aortic crossclamp, indicating that the periods before and after aortic crossclamping should be evaluated separately.
In this paper we describe the effects of the activation peptides prothrombin fragment 1 and fragment 1.2 on factor Xa-catalyzed prothrombin activation. Prothrombin activation in free solution by either factor Xa or factor Xa together with factor Va is unaffected by the activation fragments. When negatively charged phospholipids are present we observed considerable inhibition of prothrombin activation by both fragment 1 and fragment 1.2. For the activation of 0.25 microM prothrombin by factor Xa in the presence of 50 microM phospholipid (phosphatidylserine/phosphatidylcholine, 25/75; mol/mol) and 5 mM CaCl2 50% inhibition was obtained at 0.28 microM fragment 1 or fragment 1.2. Much higher fragment concentrations were required for 50% inhibition of a prothrombinase complex consisting of factor Xa, factor Va, Ca2+ and phospholipid. This shows that factor Va protects prothrombin activation against inhibition by its own activation peptides. Less inhibition by activation fragments was also observed at higher phospholipid and prothrombin concentrations or when the mole fraction phosphatidylserine in the phospholipid vesicles was decreased. The effects of fragment 1 and fragment 1.2 on prothrombin activation were identical throughout all experiments, indicating that the inhibition is due to the gamma-carboxyglutamic acid containing region of the activation peptides. Our observations suggest that the activation fragments inhibit prothrombin activation by competing with prothrombin and factor Xa for binding sites at the phospholipid surface. In such a model factor Va will protect against the inhibition since it is known to promote the assembly of the prothrombinase complex through interactions with factor Xa and prothrombin that are independent of the gla-residues. The kinetic properties of fragment inhibition also suggest that in vivo prothrombin activation will not be affected by the generation of activation peptides.
We have previously described a laboratory technique for the cryopreservation of human platelets with 1.4 molar glycerol. For the present study we adapted that method for use in clinical blood banks, and we describe the results of in vitro assays of platelets preserved in PVC packs, with storage at -75 degrees C for 1 month. The results suggested that substitution of the PVC pack for standard, 4 ml polypropylene freezing vials had little effect, but substitution of processing (addition and subsequent removal of glycerol) in PVC packs for processing in polystyrene containers resulted in a marked reduction in recovery. The final results, where the entire process was carried out in PVC packs was not satisfactory; only approximately 50% of the platelets were recovered and they exhibited only approximately 30% hypotonic stress response and approximately 3% aggregation response to ADP. We conclude that -75 degrees C may be too high a storage temperature, or that the specific blood packs that we used may be unsuitable for this process, or both.
The aim of this study was to develop a method for the cryopreservation of human platelets that would be more effective than previous methods using glycerol. The problem of defining the concentration of glycerol that would be required and of introducing and removing that concentration without serious osmotic disturbance was approached fundamentally by proposing, on the basis of previously published evidence, the limiting salt concentration that should not be exceeded during the freezing process, and the limits of platelet volume that should not be transgressed during addition and removal of the cryoprotectant. A method was developed to satisfy these requirements and its effectiveness was assessed by measuring the numerical recovery of cryopreserved platelets, their ability to osmoregulate in the hypotonic stress test and their aggregation response to ADP. The physical manipulations of dilution, centrifugation and resuspension etc, and the addition and removal of 1.4 molar glycerol without freezing had, respectively, a moderate effect on the aggregation response and a lesser effect on the hypotonic stress response. Although freezing and thawing produced additional decrements in all the assays, the hypotonic stress response was better by a factor of 3.5 than that previously obtained in a cryopreservation method using 0.5 molar glycerol. The method is technically straightforward and should be adaptable to the requirements of blood banks.
10,10-Difluoro-13-dehydroprostacyclin (DF2-PGI2) is a chemically stable analog of prostacyclin (PGI2). DF2-PGI2 was 6 times more potent than prostaglandin E1 (PGE1), and 1/10 as potent as PGI2 as an inhibitor of arachidonic acid (AA)-induced platelet aggregation. DF2-PGI2 also inhibited platelet aggregation induced by collagen, ADP, epinephrine and two thromboxane agonists, 9,11-azoPGH2 and SQ 24,810 (9,11-epoxy-9α-homo-5(Z), 13(E)-15β-hydroxyprostadienoic acid, racemic mixture). The antiaggregatory effects by DF2-PGI2 and PGI2 on AA-induced platelet aggregation were potentiated by etazolate (SQ 20,009), a potent inhibitor of cyclic AMP phosphodiesterase (PDE), and were blocked by SQ 22,536 (9-(tetrahydro-2-furyl) adenine), an inhibitor of adenylate cyclase (AC). DF2-PGI2 was also more potent than PGE1, and less potent than PGI2 as a stimulator of AC activity in platelet homogenates. DF2-PGI2- and PGI2-stimulated AC activity was inhibited by a series of AC inhibitors, SQ 22,536, SQ 4,647 (9-furfuryl adenine) and 2′,5′-dideoxyadenosine. Furthermore, SQ 22,536 inhibited DF2-PGI2- and PGI2-stimulated AC activity in a concentration-related manner, with 150 values of 150 and 300 μM, respectively. Finally, PGE1, DF2-PGI2 and PGI2, at 0.35 μM induced 2-, 10- and 17-fold increases, respectively, in cyclic AMP levels of intact platelets in platelet rich plasma (PRP). The increase in cyclic AMP levels by PGI2 and DF2-PGI2 in PRP was also blocked by SQ 22,536. We conclude that DF2-PGI2, like PGI2 and PGE1, inhibits platelet aggregation by elevating platelet cyclic AMP levels.
A determination of coagulation system and platelet function was performed on 1000 patients suffering from hemorrhagic diathesis. Typical patterns of abnormal findings could be outlined in Werlhof's disease, allergic reactions, leukaemia and myelopathy resp., in vinyl-chloride disease, and partly in drug induced platelet disorders. Although in many cases platelet function tests cannot govern the basic diagnosis in acquired bleeding disorders without plasmatic defect, they represent a useful additional diagnostic criterion which should be improved through further subtle techniques.
Conversion of fibrinogen to fibrin plays an essential role in hemostasis and results in stabilization of the fibrin clot. Fibrinogen consists of three pairs of non-identical polypeptide chains, encoded by different genes (fibrinogen alpha [FGA], fibrinogen beta [FGB] and fibrinogen gamma [FGG]). A functional single nucleotide polymorphism (SNP) in the 3' untranslated region of the FGG gene (FGG 10034C>T, rs2066865) has been associated with deep venous thrombosis and myocardial infarction. Aim of the present study was to analyze the role of this polymorphism in peripheral arterial disease (PAD). The study was designed as case-control study including 891 patients with documented PAD and 777 control subjects. FGG genotypes were determined by exonuclease (TaqMan) assays. FGG genotype frequencies were not significantly different between PAD patients (CC: 57.3%, CT: 36.7%, TT: 5.8%) and control subjects (CC: 60.9%, CT: 33.5%, TT 5.6%; p=0.35). In a multivariate logistic regression analysis including age, sex, smoking, diabetes, arterial hypertension and hypercholesterolemia, the FGG 10034 T variant was not significantly associated with the presence of PAD (Odds ratio 1.07, 95% confidence interval 0.84 - 1.37; p = 0.60). The FGG 10034C>T polymorphism was furthermore not associated with age at onset of PAD. We conclude that the thrombophilic FGG 10034 T gene variant does not contribute to the genetic susceptibility to PAD.
Thrombin-induced conversion of fibrinogen to fibrin plays an essential role in hemostasis and results in the stabilization of thrombi. Elevated plasma fibrinogen levels have been associated with both increased plasma viscosity and platelet aggregability. Recently, a haplotype-tagging single nucleotide polymorphism characterized by a C to T substitution at nucleotide 10034 of the fibrinogen gamma gene (FGG 10034C>T, rs2066865), has been proposed as a novel risk factor for deep venous thrombosis (DVT). Aim of the present study was to provide further data on the role of the FGG 10034C>T polymorphism for DVT.
FGG genotypes were determined by 5'-exonuclease assay (TaqMan) in 358 patients with documented DVT and a total of 783 control subjects.
In a multivariate analysis adjusting for age, sex, presence of factor V Leiden and carriage of prothrombin 20210A, homozygosity for the FGG 10034 TT genotype yielded an odds ratio of 2.01 (95% CI 1.23-3.31; p=0.006) for DVT.
Our data confirm the primary finding that the FGG 10034C>T polymorphism is associated with DVT risk.
The synthetic polyanion LW 10082 prolonged thrombin clotting times when human or bovine thrombin were used to induce clotting. In the clotting time prolongation LW 10082 was 15 times more potent in the presence of human thrombin than of bovine thrombin. In an amidolytic thrombin inhibition assay, LW 10082 inhibited bovine and human thrombin when plasma was present. Here, too, thrombin inhibition was much more pronounced when human thrombin was used. When purified antithrombin III was used, neither human nor bovine thrombin were inhibited by LW 10082. LW 10082 proved to be a potent inhibitor of human thrombin in the presence of heparin cofactor II in an amidolytic assay. The time course of the inhibition was slow and at least 10 minutes of incubation were required to obtain complete inhibition of thrombin by an excess of HC II and LW 10082. The anticoagulant activity of LW 10082 in the APTT was unchanged in the presence of anti-antithrombin III antibodies while the potency of heparin was clearly reduced. This indicates that the overall anticoagulant effect of LW 10082 was as well independent of antithrombin III.
The depolymerized heparin fragment PK 10169 was compared with conventional mucosal sodium heparin. The inhibition of factors Xa and IXa by heparin and by PK 10169 was similar on a weight base whilst the inhibition of thrombin by PK 10169 was at least 5 times weaker than by heparin. Subcutaneous injection of PK 10169 was not followed by prolongation of the thrombin time. The APTT was considerably less prolonged after PK than after heparin. Platelet reaction was increased by heparin but was not influenced by PK 10169. In vitro the euglobulin lysis time (ELT) was shortened after addition of heparin to plasma but not after addition of PK 10169. After injection, however, there was an equal shortening of the ELT by both substances. Advantages of PK 10169 over heparin are therefore a weaker anticoagulant effect and the missing influence on platelet functions.
Addition of heparin or heparin derivatives to citrate anticoagulated platelet-rich plasma caused platelet aggregation in a dose-dependent manner. Utilizing heparin, a low molecular weight heparin derivative (PK 10169) and its various subfractions, we determined dose/response relationships for platelet aggregation and found that the ability of these agents to cause platelet aggregation was dependent upon the molecular weight of the individual subfraction used. In comparison to unmodified porcine mucosal heparin, the lower molecular weight derivative (PK 10169) yielded a dose/response curve that was shifted down and to the right, and indicated that this agent was less potent in causing platelet aggregation. In addition, as the molecular weight of PK 10169 subfractions decreased, their dose/response curves were progressively shifted down and to the right. The lowest molecular weight subfraction was essentially without platelet aggregating activity. We also measured the anti IIa and anti Xa activities of these agents and concluded that these activities did not appear to correlate with platelet aggregating activity. Platelet aggregation studies with PK 10169 subfractions of high and low affinity for antithrombin III (AT III) indicated that the platelet aggregating activity of these compounds may not be related to their affinity for AT III, but results were not definitive.
The comparative properties of heparin and PK 10169, a low molecular weight fraction, were studied using an antithrombotic test in anaesthetized dogs. The antithrombotic properties of the two compounds were evaluated by measuring inhibition of thrombus formation following transluminar stimulation of coronary artery with anodal current and by measuring anticoagulant properties, anti Xa and anti IIa activities. The results show that PK 10169 displayed significant antithrombotic activities above 0.625 mg/kg and was equipotent at 2.5 mg/kg s.c. with heparin 10 mg/kg s.c. No correlation could be observed between antithrombotic/anti Xa ratio of both compounds. Moreover it was shown that, unlike heparin, PK 10169 s.c. was devoid of obvious anticoagulant properties and induced a negligible anti IIa activity contrasting with a high anti Xa level. A similar dissociation between anti Xa and anti IIa activities was observed following i.v. administration of 2.5 mg/kg of PK 10169 but not with heparin. This low molecular weight heparin fraction might thus be regarded as a potential arterial antithrombotic agent devoid of appreciable anticoagulant effect.
We have measured the effects of Org 10172 (a mixture of naturally occurring glycosaminoglycans derived from hog intestinal mucosa) on blood loss after transurethral prostatectomy (TURP), using doses which are likely to prevent postoperative venous thrombosis (VT). 48 patients entered a double-blind randomised pilot study: 18 were given subcutaneous (sc) injections of a placebo and 30 received sc Org 10172 (750 anti-Xa units/day, 500 units twice daily (bid), or 750 units bid, starting just before TURP and continued until discharge; 10 patients per group). No Org 10172 regimen increased peroperative blood loss but all caused a similar trend towards increased urinary bleeding after surgery. Since there was no apparent dose effect gradient, it was decided to pool the data from all three dosing blocks: this analysis showed that Org 10172 increased geometric mean blood loss during the first 2 days after surgery from 10.4 gm hemoglobin (Hgb; range = 3.2-71) to 20.5 gm Hgb (range = 1.9-147) (p = .005), an effect which retained its significance after allowing for two other major determinants of postoperative bleeding, the weight of prostate resected and the length of surgery, and also when pooling was restricted to the twice daily Org 10172 injection groups and their corresponding controls. Bleeding was not severe, but our results indicate a need for caution when considering the use of Org 10172 in this setting.
A pregnant woman treated with unfractionated heparin for pelvic vein thrombosis in the 26th week of her first pregnancy developed heparin-associated thrombocytopenia. Diagnosis was verified by the heparin induced platelet activation (HIPA) assay, which revealed cross reactivity to various LMW heparins, but not to the LMW heparinoid Org 10172. Upon intravenous (i.v.) anticoagulation with the heparinoid Org 10172 the platelet count returned to normal within 6 days and remained stable throughout the entire treatment period. After 3 weeks i.v. treatment with Org 10172, administration was changed to the subcutaneous route. At term a healthy boy was delivered spontaneously. No Org 10172 was detected in the cord blood, while therapeutic levels were measured in the maternal blood. The infant's platelet count was normal, but serum from the cord blood induced platelet activation in the presence of heparin, indicating the transplacental passage of heparin-dependent maternal antibodies.
Org 10172, a low MW heparinoid derived from animal intestinal mucosal tissue, has a mean molecular weight of 6500 D and a specific activity of 8.0 anti-Xa U/mg. Its elimination half-life after i.v. administration is 18 hours. Six human volunteers received repeated single i.v. injections of 800 and 3200 anti-Xa units of Org 10172, 5000 IU heparin or placebo. Bleeding time, platelet count and plasma beta thromboglobulin were not affected by Org 10172 or heparin. Heparin stimulated ADP-induced platelet aggregation (0.2 uM; p less than 0.05) and inhibited thrombin induced aggregation (0.3 U/ml; p less than 0.05), while the heparinoid lacked these effects. Heparin increased plasma platelet factor 4, whereas Org 10172 had no effect. In contrast to heparin Org 10172 had only a minor effect on the activated partial thromboplastin time and thrombin time, while both compounds induced anti-Xa activity in plasma. In a crossover study in six haemodialysis patients, both heparin and Org 10172 (34.4 and 22.4 anti-Xa units/kg/body weight) successfully prevented clotting of the extracorporeal circuit. Microscopical analysis of the artificial kidney membranes showed that the 34.4 unit Org 10172 dosage was as effective as heparin in preventing fibrin deposition. The haemostatic and coagulation effects were as expected from those observed in the volunteers except that there was a slower elimination of the plasma anti-Xa response. In addition heparin and Org 10172 (34.4 anti-Xa units/kg) inhibited the Xa-induced platelet aggregation (0.5 U/ml; p less than 0.01 and p less than 0.001 respectively).