The effect of rofecoxib on the pharmacodynamics and pharmcokinetics of warfarin.

OBJECTIVE: The objective of this study was to examine the effect of 3 doses of rofecoxib (12.5, 25, and 50 mg) on the pharmacodynamics and pharmacokinetics of warfarin. METHODS: Two single-dose (12.5 or 50 mg of rofecoxib with 25 mg or 30 mg of oral warfarin, respectively, on day 7 of each period) trials (N = 12 men) and 1 steady-state warfarin trial (25 mg rofecoxib; N = 15, 13 men and 2 women) were completed as two-period, randomized, balanced, crossover, double-blind designs. The prothrombin time international normalized ratio (INR) and S(-) and R(+) warfarin enantiomers were assessed during 144 hours after the single warfarin doses. In the steady-state warfarin trial, after the attainment of a stable INR (1.4-1.7), the stable warfarin dose was co-administered with rofecoxib (25 mg) and placebo over two 21-day periods. After the dose of warfarin on day 21, INR and S(-) and R(+) warfarin were assessed during 24 hours. RESULTS: Compared with placebo, rofecoxib slightly increased the INR by approximately 5% (90% confidence interval on the geometric ratio, 1.03, 1.08) and 11% (1.04, 1.19) for the two single-dose warfarin trials with 12.5 and 50 mg of rofecoxib, respectively. In the steady-state warfarin study with 25 mg of rofecoxib, the INR was increased by 8% (1.02, 1.15). Rofecoxib had no significant effect (versus placebo) on the pharmacokinetics of S(-) warfarin. However, in the 3 studies, treatment with 12.5, 25, and 50 mg of rofecoxib was associated with a 27%, 38%, and 40% increase in the area under the plasma concentration-time curve of the biologically less active R(+) warfarin. CONCLUSIONS: Rofecoxib increased plasma concentrations of the biologically less active R(+) warfarin, which accounted for a small increase in INR. The approximately 8% increase in INR at steady state with warfarin co-administered with 25 mg of rofecoxib is not likely to be clinically important in most patients taking warfarin. However, standard monitoring of INR values should be conducted when therapy with rofecoxib is initiated or changed, particularly in the first few days, for patients receiving warfarin.

A new manifestation and treatment alternative for heparin-induced thrombosis.

We treated a coronary artery bypass patient whose postoperative course was complicated by heparin-induced thrombocytopenia and resultant pulmonary artery and saphenous vein graft thromboses. The pulmonary thromboemboli were found first, and pulmonary blood flow was restored with intravenously administered tissue plasminogen activator (tPA). A short time later, the vein grafts were found to be occluded, and we subsequently performed multivessel percutaneous transluminal coronary angioplasty (PTCA) using tPA as an adjuvant to oral warfarin sodium therapy with excellent results. We conclude that heparin-induced thromboses in the pulmonary arteries are amenable to thrombolytic therapy, including tPA, whereas this regimen appears to have little effect on saphenous vein grafts. We also found that a combination of warfarin and thrombolytic therapy is an alternative regimen for heparin-intolerant patients who require PTCA.

Indications for thrombolytic therapy in acute pulmonary embolism.

Pulmonary thromboembolism is commonly misdiagnosed and is associated with significant morbidity and mortality both in the early and late stages. A major cause of late morbidity is chronic pulmonary hypertension. Although the incidence of chronic thromboembolic pulmonary hypertension is unknown, there is anatomic and physiologic evidence that it is responsible for a significant degree of the late morbidity and mortality following acute pulmonary embolism. In the absence of underlying cardiopulmonary disease, pulmonary artery pressure is a useful indicator of the severity of acute pulmonary embolism and of the patient's prognosis. Thrombolytic agents accelerate the lysis of the thromboemboli, offer an excellent alternative to emergency embolectomy, and are likely to decrease the incidence of chronic pulmonary hypertension. All currently available agents have been shown to be effective and have similar bleeding-complication profiles. In this review, we discuss the natural history and pathophysiology of pulmonary thromboembolic disease, as well as applications of thrombolytic therapy in the treatment of acute pulmonary embolism.

High-dose thrombolytic therapy and angioplasty for thrombosis in a subacute femoropopliteal bypass graft.

The rate of success in reoperation for thrombosed infrainguinal grafts is unimpressive, particularly in patients with disease of distal vessels. In certain cases, combining high-dose urokinase and angioplasty appears to offer a safe and effective alternative. We describe the successful use of this combined treatment in a patient with a recently occluded femoropopliteal bypass graft.

Molecular basis of S100 proteins interacting with the p53 homologs p63 and p73.

S100 proteins modulate p53 activity by interacting with its tetramerization (p53TET, residues 325-355) and transactivation (residues 1-57) domains. In this study, we characterized biophysically the binding of S100A1, S100A2, S100A4, S100A6 and S100B to homologous domains of p63 and p73 in vitro by fluorescence anisotropy, analytical ultracentrifugation and analytical gel filtration. We found that S100A1, S100A2, S100A4, S100A6 and S100B proteins bound different p63 and p73 tetramerization domain variants and naturally occurring isoforms with varying affinities in a calcium-dependent manner. Additional interactions were observed with peptides derived from the p63 and p73 N-terminal transactivation domains. Importantly, S100 proteins bound p63 and p73 with different affinities in their different oligomeric states, similarly to the differential modes of binding to p53. On the basis of our data, we hypothesize that S100 proteins regulate the oligomerization state of all three p53 family members and their isoforms, with a potential physiological relevance in developmental and disease-related processes. The regulation of the p53 family by S100 is complicated and depends on the target preference of each individual S100 protein, the concentration of the proteins and calcium, as well as the splicing variation of p63 or p73. Our results outlining the complexity of the interaction should be considered when studying the functional effects of S100 proteins in their biological context.