Anti-IIa activity and antitumor properties of a hybrid heparin/heparan sulfate-like compound from Litopenaeus vannamei shrimp.

In this present study, the anti-IIa activity and the antitumor properties of a hybrid heparin/heparan sulfate-like compound (sH/HS) from Litopenaeus vannamei shrimp heads are related. In addition to inhibiting 90.7% of thrombin activity at the lowest tested concentration (0.5 µg/mL), sH/HS compound stimulated the synthesis of antithrombotic heparan sulfate by endothelial cells in a dose-dependent manner. In vitro experiments demonstrated that the molecule from shrimp displayed a potent anti-angiogenic effect, reducing over 80% of the tubular structures formation at 50 and 100 µg/mL. In addition, sH/HS compound was able to inhibit the migration of B16F10 cells at all tested concentrations without affecting the cell viability. Although the studied compound had no effect on the proliferation of such cells during a period of 24 h, it had a significant long-term anti-proliferative effect, reducing about 80% of colony formation and anchorage-independent growth at 50 and 100 µg/mL concentrations. When its effectiveness was tested in vivo, it was demonstrated that sH/HS promoted a reduction of more than 90% of tumor growth. In the context of thromboembolic disorders associated with cancer, such findings make the sH/HS compound an excellent target for studies on inhibiting of development and tumor progression, and the prevention of coagulopathies.

Design, synthesis, and evaluation of heparan sulfate mimicking glycopolymers for inhibiting heparanase activity.

Heparanase is an enzyme which cleaves heparan sulfate (HS) polysaccharides of the extracellular matrix. It is a regulator of tumor behavior, plays a key role in kidney related diseases and autoimmune diabetes. We report herein the use of computational studies to extract the natural HS-heparanase interactions as a template for the design of HS mimicking glycopolymers. Upon evaluation, a glycopolymer with 12 repeating units was determined to be the most potent inhibitor and to have tight-binding characteristics. This glycopolymer also lacks anticoagulant activity.

[PROCURING OF ІNTRAOPERATIVE HEMOSTASIS IN REVASCULARIZATION INTERVENTIONS].

Results of the hemostasis conduction in conditions of revascularization in 106 patients, оperated on for atherosclerotic affection of aorta and the main arteries of the lower extremities, were adduced. Syndrome of hypercoagulation of traumatic stage of surgical intervention in early postoperative period is developing due to thrombinemia on background of a fibrinolytic system depression. There was proved a necessity to impact on thrombin-fibrinous factor (factor ІІа) of hemocoagulant cascade by application of nonfractionized heparins immediately after conclusion of operative intervention with thromboprophylaxis prolongation, using low-molecular heparins (impact on Ха factor) in accordance to the branch standards.

The Antithrombotic Potential of Tinzaparin and Enoxaparin Upon Thrombin Generation Triggered In Vitro by Human Ovarian Cancer Cells IGROV1.

BACKGROUND: A documented relationship between ovarian cancer and thrombosis does exist. Low-molecular-weight heparins (LMWHs) are cornerstone drugs in the primary prevention and treatment of venous thromboembolic events in patients with cancer. However, cancer cells may alter the efficiency of these antithrombotic agents. OBJECTIVE: We aimed to characterize the procoagulant phenotype of human epithelial ovarian adenocarcinoma cells, IGROV1, and to compare the capacity of tinzaparin and enoxaparin to inhibit thrombin generation triggered by these cells. METHODS: Thrombin generation induced by different concentrations of IGROV1 cells on platelet poor plasma (PPP) was assessed by the calibrated automated thrombogram assay. Tissue factor (TF) expression was studied using Western blot analysis. Then, the experimental model of thrombin generation was used to compare the inhibitory effect of clinically relevant concentrations of both tinzaparin and enoxaparin. The inhibitory concentration 50 (IC50) of the mean rate index and the endogenous thrombin potential and the 2-fold increase in lag time were analyzed on the basis of the anti-Xa and anti-IIa activities of the LMWHs. RESULTS: IGROV1 cells suspended into PPP resulted in a significant increase in thrombin generation in the absence of any exogenous source of TF and phospholipids. Tissue factor was expressed by IGROV1 cells. Tinzaparin was a more potent inhibitor of thrombin generation than enoxaparin. The inhibition of thrombin generation induced by IGROV1 cancer cells depended mainly on the anti-Xa activity of the LMWHs. CONCLUSION: This experimental study in ovarian cancer cells demonstrates that the antithrombotic activity of LMWHs is not completely predicted by the anti-Xa or anti-IIa activities measured in PPP.

Inhibition of coagulation proteases Xa and IIa decreases ischemia-reperfusion injuries in a preclinical renal transplantation model.

Coagulation is an important pathway in the pathophysiology of ischemia-reperfusion injuries. In particular, deceased after circulatory death (DCD) donors undergo a no-flow period, a strong activator of coagulation. Hence, therapies influencing the coagulation cascade must be developed. We evaluated the effect of a new highly specific and effective anti-Xa/IIa molecule, with an integrated innovative antidote site (EP217609), in a porcine preclinical model mimicking injuries observed in DCD donor kidney transplantation. Kidneys were clamped for 60 minutes (warm ischemia), then flushed and preserved for 24 hours at 4°C in University of Wisconsin (UW) solution (supplemented or not). EP217609-supplemented UW solution (UW-EP), compared with unfractionated heparin-supplemented UW solution (UW-UFH) or UW alone (UW). A mechanistic investigation was conducted in vitro: addition of EP217609 to endothelial cells during hypoxia at 4°C in the UW solution inhibited thrombin generation during reoxygenation at 37°C in human plasma and reduced tumor necrosis factor alpha, intercellular adhesion molecule 1, and vascular cell adhesion molecule 1 messenger RNA cell expressions. In vivo, function recovery was markedly improved in the UW-EP group. Interestingly, levels of thrombin-antithrombin complexes (reflecting thrombin generation) were reduced 60 minutes after reperfusion in the UW-EP group. In addition, 3 months after transplantation, lower fibrosis, epithelial-mesenchymal transition, inflammation, and leukocyte infiltration were observed. Using this new dual anticoagulant, anti-Xa/IIa activity during kidney flush and preservation is protected by reducing thrombin generation at revascularization, improving early function recovery, and decreasing chronic lesions. Such an easy-to-deploy clinical strategy could improve marginal graft outcome.

Regulation of expression of venom toxins: silencing of prothrombin activator trocarin D by AG-rich motifs.

Trocarin D (TroD), a venom prothrombin activator from Tropidechis carinatus, shares similar structure and function with blood coagulation factor Xa [Tropidechis carinatus FX (TrFX) a]. Their distinct physiologic roles are due to their distinct expression patterns. The genes of TroD and TrFX are highly similar, except for promoter and intron 1, indicating that TroD has probably evolved by duplication of FX, the plasma counterpart. The promoter insertion in TroD accounts for the elevated but not venom gland-specific expression. Here we examined the roles of 3 insertions and 2 deletions in intron 1 of TroD in the regulation of expression using luciferase as a reporter. By systematic deletions, we showed that a 209 bp region within the second insertion silences expression in mammalian and unmilked venom gland cells. Through bioinformatics analysis, we identified 5 AG-rich motifs in this region. All except the 5th motif are important for silencing function. YY1, Sp3 and HMGB2 were identified to bind these AG-rich motifs and silence gene expression in mammalian cells. Similar AG-rich motif clusters are also found in other toxin genes but not in their physiologic counterparts. Thus, AG-rich motifs contribute to regulation of expression of TroD, and probably other toxin genes.-Han, S. X., Kwong, S., Ge, R., Kolatkar, P. R., Woods, A. E., Blanchet, G., Kini, R. M. Regulation of expression of venom toxins: silencing of prothrombin activator trocarin D by AG-rich motifs.

The treatment of cancer-associated venous thromboembolism in the era of the novel oral anticoagulants.

INTRODUCTION: The initial and long-term administration of low-molecular-weight heparin (LMWH) is now regarded as the treatment of choice for the therapy of patients with cancer-associated venous thromboembolism (CAT). However, LMWH requires daily subcutaneous injections and can induce thrombocytopenia. In recent years, novel direct oral anticoagulants (DOAC) have emerged to potentially replace conventional treatments. AREAS COVERED: The advantages and limitations of conventional approaches for the treatment of CAT are presented and analyzed based on available findings and on recommendations from international guidelines, as is the potential for the DOAC. EXPERT OPINION: LMWH still remains the mainstay of initial and long-term treatment of CAT. Vitamin K antagonists may have a role in patients with inactive cancer and in those with severe renal failure. Whether there is a potential for the DOAC is uncertain. Indeed, most patients with advanced cancer were excluded from the trials addressing their value. Although available findings are encouraging, before implementing them in the routine clinical practice there is the need for dedicated studies in which cancer patients, whichever their severity and prognosis, are allocated to either DOAC or LMWH, which represent the standard of treatment for patients with CAT.

Genetic diminution of circulating prothrombin ameliorates multiorgan pathologies in sickle cell disease mice.

Sickle cell disease (SCD) results in vascular occlusions, chronic hemolytic anemia, and cumulative organ damage. A conspicuous feature of SCD is chronic inflammation and coagulation system activation. Thrombin (factor IIa [FIIa]) is both a central protease in hemostasis and a key modifier of inflammatory processes. To explore the hypothesis that reduced prothrombin (factor II [FII]) levels in SCD will limit vaso-occlusion, vasculopathy, and inflammation, we used 2 strategies to suppress FII in SCD mice. Weekly administration of FII antisense oligonucleotide "gapmer" to Berkeley SCD mice to selectively reduce circulating FII levels to ∼10% of normal for 15 weeks significantly diminished early mortality. More comprehensive, long-term comparative studies were done using mice with genetic diminution of circulating FII. Here, cohorts of FII(lox/-) mice (constitutively carrying ∼10% normal FII) and FII(WT) mice were tracked in parallel for a year following the imposition of SCD via hematopoietic stem cell transplantation. This genetically imposed suppression of FII levels resulted in an impressive reduction in inflammation (reduction in leukocytosis, thrombocytosis, and circulating interleukin-6 levels), reduced endothelial cell dysfunction (reduced endothelial activation and circulating soluble vascular cell adhesion molecule), and a significant improvement in SCD-associated end-organ damage (nephropathy, pulmonary hypertension, pulmonary inflammation, liver function, inflammatory infiltration, and microinfarctions). Notably, all of these benefits were achieved with a relatively modest 1.25-fold increase in prothrombin times, and in the absence of hemorrhagic complications. Taken together, these data establish that prothrombin is a powerful modifier of SCD-induced end-organ damage, and present a novel therapeutic target to ameliorate SCD pathologies.

Effective management of acute deep vein thrombosis: direct oral anticoagulants.

Deep vein thrombosis (DVT) is a manifestation of venous thromboembolism (VTE) and accounts for most venous thromboembolic events. Although DVT is not directly life-threatening, thrombi in the proximal veins of the leg can embolize to the lungs to form a pulmonary embolism, which may prove rapidly fatal. If untreated, DVT can also lead to significant morbidity, including development of post-thrombotic syndrome. Among many risk factors, surgery, hospitalization, older age and active cancer increase the risk of VTE, and a previous event increases the risk of recurrence. Early detection and effective clot resolution are vital in managing DVT. Conventional approaches to acute treatment of VTE involve initial fast-acting parenteral heparin overlapping with and followed by vitamin K antagonist therapy. However, vitamin K antagonists have a narrow therapeutic window, require regular monitoring, and have multiple food and drug interactions. Results from phase III clinical studies involving direct Factor Xa and IIa inhibitors suggest that these agents provide an alternative therapeutic option that overcomes some of the complications associated with conventional treatment with predictable pharmacological properties and convenient dosing schedules. Analysis of data from the rivaroxaban EINSTEIN studies also suggests that these agents have the potential to improve patient-reported treatment satisfaction and reduce the length of hospital stay compared with conventional therapy. This review considers these treatment options, suitable treatment durations to prevent recurrence, and the management of DVT treatment in challenging patient groups.

Antithrombotic activities of aspalathin and nothofagin via inhibiting platelet aggregation and FIIa/FXa.

Aspalathin (Asp) and nothofagin (Not) are two major active dihydrochalcones found in green rooibos tea (Aspalathus linearis; family, Fabaceae; tribe, Crotalarieae), which have been reported for their anti-oxidant activity. Here, the anticoagulant activities of Asp and Not were examined by monitoring activated partial thromboplastin time (aPTT), prothrombin time (PT), and the activities of thrombin (Factor IIa, FIIa) and activated factor X (FXa). And, the effects of Asp and Not on expression of plasminogen activator inhibitor type 1 (PAI-1) and tissue-type plasminogen activator (t-PA) were evaluated in tumor necrosis factor (TNF)-α activated human umbilical vein endothelial cells (HUVECs). Treatment with Asp and Not resulted in prolonged aPTT and PT and inhibition of the activities of thrombin and FXa, as well as inhibited production of thrombin and FXa in HUVECs. In addition, Asp and Not inhibited thrombin-catalyzed fibrin polymerization and platelet aggregation. Asp and Not also elicited anticoagulant effects in mice. In addition, treatment with Asp and Not resulted in significant reduction of the PAI-1 to t-PA ratio. Collectively, Asp and Not possesses antithrombotic activities and offers a basis for development of a novel anticoagulant.

Probing the coagulation pathway with aptamers identifies combinations that synergistically inhibit blood clot formation.

Coordinated enzymatic reactions regulate blood clot generation. To explore the contributions of various coagulation enzymes in this process, we utilized a panel of aptamers against factors VIIa, IXa, Xa, and prothrombin. Each aptamer dose-dependently inhibited clot formation, yet none was able to completely impede this process in highly procoagulant settings. However, several combinations of two aptamers synergistically impaired clot formation. One extremely potent aptamer combination was able to maintain human blood fluidity even during extracorporeal circulation, a highly procoagulant setting encountered during cardiopulmonary bypass surgery. Moreover, this aptamer cocktail could be rapidly reversed with antidotes to restore normal hemostasis, indicating that even highly potent aptamer combinations can be rapidly controlled. These studies highlight the potential utility of using sets of aptamers to probe the functions of proteins in molecular pathways for research and therapeutic ends.

Antithrombotic activities of sulforaphane via inhibiting platelet aggregation and FIIa/FXa.

Sulforaphane (SFN), a natural isothiocyanate that is present in cruciferous vegetables such as broccoli and cabbage, is effective in preventing carcinogenesis, diabetes and inflammatory responses. Here, the anticoagulant activities of SFN were examined by monitoring activated partial thromboplastin time (aPTT), prothrombin time, and the activities of thrombin (Factor IIa, FIIa) and activated factor X (FXa). And, the effects of SFN on expression of plasminogen activator inhibitor type 1 (PAI-1) and tissue-type plasminogen activator (t-PA) were evaluated in tumor necrosis factor-α activated human umbilical vein endothelial cells (HUVECs). Treatment with SFN resulted in prolonged aPTT and PT and inhibition of the activities of thrombin and FXa, as well as inhibited production of thrombin and FXa in HUVECs. In addition, SFN inhibited thrombin-catalyzed fibrin polymerization and platelet aggregation. SFN also elicited anticoagulant effects in mice. In addition, treatment with SFN resulted in significant reduction of the PAI-1 to t-PA ratio. Collectively, SFN possesses antithrombotic activities and offers a basis for development of a novel anticoagulant.

Rituximab therapy for factor II inhibitor in a patient with antiphospholipid antibody syndrome.

Factor II inhibitors have been associated with an increased risk of bleeding. The management of patients with factor II inhibitors has not been adequately described. We describe a patient with an increased bleeding tendency due to factor II inhibitor who was unable to undergo surgery due to her bleeding tendency. The patient was successfully treated with a course of rituximab, which markedly reduced her factor II inhibitor: the factor II level rose from 12 to 61%; prothrombin time decreased from 20 to 14.7 s; and partial thromboplastin time (PTT) decreased from 148 to 38.8 s. She was able to undergo abdominal surgery without any hemorrhagic complications. This case exemplifies the possibility of treating patients with factor II inhibitors with rituximab therapy.

In vitro comparison of the novel, dual-acting FIIa/FXa-inhibitor EP217609C101, unfractionated heparin, enoxaparin, and fondaparinux in preventing cardiac catheter thrombosis.

Efficient and safe anticoagulation is crucial in patients requiring percutaneous coronary intervention (PCI) or extracorporeal circulation during cardiac surgery. Although new anticoagulant strategies have emerged for PCI as alternatives to the established treatment with heparins, the development of new anticoagulants with an improved efficacy/safety ratio is still necessary. Our study compared the efficacy of the novel, dual-acting, neutralizable FIIa/FXa-inhibitor EP217609C101 (EP) at 2, 1.2, 0.9, and 0.6 µg/ml to unfractionated heparin (UFH), enoxaparin, and fondaparinux in preventing cardiac catheter thrombosis under in vitro conditions. Blood drawn by venepunction from healthy male volunteers (n = 10) pretreated with 500 mg aspirin orally was treated with the anticoagulant to test and continuously circulated through a cardiac catheter for 60 min or until the catheter became blocked by thrombotic debris. Anticoagulant efficacy was assessed by thrombus weight, electron microscopic features of the developing thrombi, and laboratory parameters. Whereas UFH, enoxaparin, EP 2, and EP 1.2 µg/ml secured maximum circulation times, statistically significant premature catheter occlusions were observed for EP 0.9, EP 0.6 µg/ml, and fondaparinux. The UFH group and both high-dose concentrations of EP showed significantly lower thrombus weights than the low-dose concentrations of EP and fondaparinux, (p ≤ 0.05). On electron microscopic analysis of the thrombotic debris no differences were observed in erythrocyte deposition between UFH, enoxaparin, and all EP concentrations tested. A significant reduction in fibrin deposition was achieved by UFH and EP 2 µg/ml but no significant differences in platelet deposition were found, except for a significant reduction for EP 0.6 µg/ml. Our in vitro study showed that EP217609C101 is a promising new drug that is dose-dependently superior to classical (UFH, enoxaparin) and newer (fondaparinux) drugs in preventing heart catheter thrombosis.

Tissue factor-mediated activation of the prothrombin complex concentrate (PCC) is differently inhibited by dabigatran, rivaroxaban, and apixaban: potential clinical implication.

Currently, several newer oral anticoagulants namely dabigatran (anti-IIa), rivaroxaban (anti-Xa), and apixaban are available for various clinical implications. Another oral anti-Xa edoxaban is under development. A parenteral anti-Xa drug namely otamixaban is also under development for cardiovascular interventions. Bleeding complications have been reported in the new oral anticoagulants and have been managed by conventional approaches with limited success. Prothrombin complex concentrates (PCCs) are reported to neutralize the anticoagulant activity of these agents. The PCCs are also able to generate endogenous factor Xa and IIa along with other proteases that are capable of neutralizing the circulating anti-Xa or anti-IIa activities of the newer anticoagulants. The generation of Xa and IIa is also dependent on the type of tissue factor available for their activation. These reported studies suggest that different tissue factors differentially activate a PCC namely Profilnine SD. Furthermore, dabigatran differs from rivaroxaban and other factor Xa inhibitors in its inhibitory profile.

[New anticoagulants--are we prepared?]. / Nowe leki przeciwkrzepliwe--czy jestesmy na nie przygotowani?

Rivaroxaban and dabigatran are the new anticoagulant drugs--factor Xa and IIa inhibitors. Recently registered in atrial fibrillation and venous thromboembolic disease became the serious competition to other anticoagulants. Blood coagulation parameters do not need to be monitored which can be seen as a huge advantage. At the same time their effectiveness in thromboembolic incidents prevention is comparable and the risk of serious hemorrhage is even lower comparing to therapy with vitamin K antagonists. Concerns arose around the fact that for the time being there is no effective antidote in case of intoxication and no possibility of quick reversal in case of hemorrhage or surgery. The purpose of this paper is to summarize current knowledge regarding the safety of new anticoagulants, and to answer the question--are we really prepared for them?

Implementing the new oral anticoagulants into the hospital formulary.

The new oral anticoagulants may prove to be one of most significant innovations in clinical practice in the past 60 years. Apixaban and rivaroxaban are direct inhibitors of Factor Xa, while dabigatran inhibits Factor IIa. The predictable pharmacological profile of these new agents allows physicians to prescribe these drugs without the need for routine coagulation monitoring, which is the mainstay of warfarin therapy. In addition, these new agents have not been shown to have any food interactions and minimal drug-drug interactions, interactions are limited to the p-glycoprotein (p-Gp) transporter or cytochrome P450 (CYP450) system, each drug is unique in its drug interaction profile, as will be discussed below. These unique pharmacokinetics profiles may usher in for clinicians a new era of managing thromboembolic disorders. In this article, the pharmacology of these new oral anticoagulants will be reviewed along with the major clinical trials evaluating the use of these agents for thromboembolic prophylaxis in patients undergoing total hip and knee arthroplastic surgery, the treatment of venous thromboembolic disorders and stroke prevention in atrial fibrillation. Am. J. Hematol., 2012. © 2012 Wiley Periodicals, Inc.

Novel oral anticoagulants and their role in clinical practice.

The complexities of oral anticoagulation with warfarin have led to the search for more practical alternative agents. Novel direct factor IIa inhibitors and direct factor Xa inhibitors currently in development can be administered at a fixed dose and do not require routine coagulation monitoring and ongoing dosage adjustment to ensure their effectiveness and safety. A number of phase III trials of these agents for the prevention of venous thromboembolism associated with orthopedic surgery and acute medical illness, for the treatment of venous thromboembolism, and for stroke prevention in patients with atrial fibrillation have been completed, with almost universally positive results. If these novel agents are approved for use in the United States, the future of oral anticoagulant therapy will allow a more nuanced approach to drug selection than has been available in the past. Attention to drug interactions and renal function will be required, as methods to measure the presence of these agents are not precise, cannot quantify the degree of anticoagulant present, and are influenced by the changes in serum drug concentrations during the dosing interval. In the future, patient preferences and the pharmacokinetic and pharmacodynamic characteristics of individual drugs will be able to be matched to optimize therapy. These new agents represent a new paradigm for anticoagulation that promises to improve patient care in the long term.

[New antithrombotic drugs for the treatment of venous thromboembolism]. / Les nouveaux anticoagulants dans la maladie thrombo-embolique veineuse.

Numerous newer anticoagulants are under advanced clinical development for the treatment of venous thromboembolism. These new drugs specifically inhibit activated factors II or X, with predictable effects and no need for dose modification and laboratory monitoring. The main direct activated factor X (FXa) inhibitors are rivaroxaban, apixaban and edoxaban. They are taken orally once or twice per day. Dabigatran is the main inhibitor of activated factor II (IIa) and is administered orally once daily. Dabigatran and rivaroxaban are already licensed for the prevention of thromboembolic events following major orthopedic surgery such as total hip and knee replacement. They will probably soon be authorized for the treatment of venous thromboembolism, if they both confirm their efficacy and safety, and can demonstrate their cost-effectiveness. However, only rivaroxaban has been tested as a stand-alone treatment, whereas dabigatran was compared to vitamin K antagonism after a standard treatment regimen based on heparin or its derivates.