ABSTRACT
INTRODUCTION: Recurrent venous thromboembolism (VTE) despite curative anticoagulation is frequent in patients with cancer. Identifying patients with a high risk of recurrence could have therapeutic implications. A prospective study was designed to validate the Ottawa risk score of recurrent VTE in cancer patients. METHODS: In a prospective multicenter observational cohort, adult cancer patients with a recent diagnosis of symptomatic or incidental lower limb deep vein thrombosis or pulmonary embolism (PE) were treated with tinzaparin for 6 months. The primary endpoint was the recurrence of symptomatic or asymptomatic VTE within the first 6 months of treatment. All clinical events were centrally reviewed and adjudicated. Time-to-event outcomes were estimated by the Kalbfleisch and Prentice method to take into account the competing risk of death. A C-statistic value of > 0.70 was needed to validate the Ottawa score. RESULTS: A total of 409 patients were included and analyzed on an intention-to-treat basis. Median age was 68 years, 60.4% of patients had PE, and VTE was symptomatic in 271 patients (66.3%). The main primary sites were lung (31.3%), lower digestive tract (14.4%), and breast (13.9%) cancers. The Ottawa score was high (≥ 1) in 58% of patients. The 6-month cumulative incidence of recurrent VTE was 7.3% (95% confidence interval [CI]: 4.9-11.1) overall, and 5.0% (95% CI: 2.3-10.8) versus 9.1% (95%CI: 6.1-13.6) in the Ottawa low versus high risk groups, respectively. The C-statistic value was 0.60 (95% CI: 0.55-0.65). CONCLUSION: In this prospective cohort of patients with cancer receiving tinzaparin for VTE, the Ottawa score failed to accurately predict recurrent VTE.
Subject(s)
Neoplasms/complications , Risk Assessment/standards , Venous Thromboembolism/diagnosis , Adult , Aged , Anticoagulants/pharmacology , Anticoagulants/therapeutic use , Cohort Studies , Female , Follow-Up Studies , France/epidemiology , Humans , Male , Middle Aged , Neoplasms/epidemiology , Prospective Studies , Risk Assessment/methods , Risk Assessment/statistics & numerical data , Tinzaparin/pharmacology , Tinzaparin/therapeutic use , Venous Thromboembolism/epidemiologyABSTRACT
Tinzaparin is an anticoagulant and antiangiogenic drug with inhibitory properties against tumor growth. VEGF stimulates angiogenesis, while an association between reactive oxygen species (ROS) and angiogenesis is involved in tumor progression. The present study aimed to investigate the effect of tinzaparin on VL30 retrotranspositionpositive mouse HC11 mammary stemlike epithelial cells, previously reported to be associated with induced mammosphere/cancer stem cell (CSC) generation and tumorigenesis. Under 24 h serum starvation, 15.2% nominal retrotransposition frequency was increased to 29%. Additionally, while treatment with 312 ng/ml VEGF further induced retrotransposition frequency in a dosedependent manner (up to 40.3%), preincubation with tinzaparin (2 IU/ml) for 0.54 h reduced this frequency to 18.3% in a timedependent manner, confirmed by analogous results in NIH3T3 fibroblasts. Treatment with 1040 pg/ml glucose oxidase (GO) for 24 h induced HC11 cell retrotransposition in a dosedependent manner (up to 82.5%), while a 3 h preincubation with tinzaparin (1 or 2 IU/ml) elicited a 13.5 or 25.5% reduction in retrotransposition, respectively. Regarding tumorigenic VL30 retrotranspositionpositive HC11 cells, treatment with 2 IU/ml tinzaparin for 5 days reduced proliferation rate in a timedependent manner (up to ~55%), and after 3 weeks, disaggregated soft agarformed foci, as well as lowadherent mammospheres, producing single mesenchymallike cells with a ~50% reduced retrotransposition. With respect to the VL30 retrotransposition mechanism: While 12 ng/ml VEGF increased the level of VL30 and endogenous reverse transcriptase (enRT) transcripts ~1.41 and ~1.16fold, respectively, subsequent tinzaparin treatment reduced both endogenous/ROS and VEGFinduced levels 1.15 and 0.40fold (VL30) and 0.60 and 0.52fold (enRT), respectively. To the best of our knowledge, these data demonstrate for the first time, the novel inhibition activity of tinzaparin against ROS and VEGFinduced VL30 retrotransposition, and the proliferation and/or aggregation of mouse HC11 mammosphere/tumorinitiating CSCs, thus contributing to the inhibition of VL30 retrotranspositioninduced primary tumor growth.
Subject(s)
Neoplastic Stem Cells/drug effects , Oxidative Stress/drug effects , Tinzaparin/pharmacology , Vascular Endothelial Growth Factor A/drug effects , Animals , Anticoagulants/pharmacology , Cell Proliferation , Cells, Cultured , Female , Mice , Mice, Inbred BALB C , NIH 3T3 CellsABSTRACT
Pancreatic Cancer (PC) is recognized as a highly thrombogenic tumor; thus, low-molecular-weight heparin (LMWH) such as tinzaparin is routinely used for PC patients. On the basis of combinatorial therapy approaches to treat highly malignant and refractory cancers such as PC, we hypothesized that tinzaparin can augment the effectiveness of traditional chemotherapeutic drugs and induce efficient antitumor activity. PANC-1 and MIAPaCa-2 were incubated alone or in combination with tinzaparin, nab-paclitaxel and gemcitabine. In vivo evaluation of these compounds was performed in a NOD/SCID mouse using a model injected with PANC-1. Tinzaparin enhances the anti-tumor effects of nab-paclitaxel and gemcitabine in mtKRAS PC cell lines via apoptosis in in vitro experiments. The triple combination power acts through the induction of apoptosis, reduction of the proliferative potential and angiogenesis; hence, contributing to a decrease in tumor volume observed in vivo. The triple regimen provided an extra 24.3% tumor reduction compared to the double combination (gemcitabine plus nab-paclitaxel). Combinatorial strategies can create novel therapeutic approaches for the treatment of patients with PC, achieving a better clinical outcome and prolonged survival. Further prospective randomized research is needed and the investigation of various concentrations of tinzaparin above 150 UI/Kg, would potentially provide a valuable synergistic effect to the conventional therapeutic compounds.
Subject(s)
Albumins/administration & dosage , Antineoplastic Combined Chemotherapy Protocols/administration & dosage , Deoxycytidine/analogs & derivatives , Paclitaxel/administration & dosage , Pancreatic Neoplasms/drug therapy , Tinzaparin/administration & dosage , Albumins/pharmacology , Animals , Antineoplastic Combined Chemotherapy Protocols/pharmacology , Caspase 3/metabolism , Cell Line, Tumor , Cell Proliferation/drug effects , Cell Survival/drug effects , Deoxycytidine/administration & dosage , Deoxycytidine/pharmacology , Dose-Response Relationship, Drug , Gene Expression Regulation, Neoplastic/drug effects , Humans , Mice , Mice, Inbred NOD , Mice, SCID , Paclitaxel/pharmacology , Pancreatic Neoplasms/metabolism , Tinzaparin/pharmacology , Xenograft Model Antitumor Assays , GemcitabineABSTRACT
BACKGROUND: The safety and efficacy of low-molecular-weight heparin in the prevention of extracorporeal dialysis circuit clotting among in-center extended duration nocturnal hemodialysis (INHD) patients are unknown. The aim of this study was to determine the safety and efficacy of 2 doses of tinzaparin, among INHD patients receiving 6-8 h hemodialysis, 3 times per week. METHODS: We conducted a retrospective cohort study to examine antifactor Xa levels at time 0, 2 h, 4 h mid-hemodialysis (mid-HD), 6 h, and at end of each INHD session for 4 weeks and to determine extracorporeal dialysis circuit clotting and bleeding events after switching from unfractionated heparin to tinzaparin, using a standard protocol of tinzaparin delivery at the initiation and midpoint of HD. RESULTS: All 16 patients in The Ottawa Hospital INHD program were converted to tinzaparin and followed for 177 INHD sessions. Mean antifactor Xa level at 2 h of HD was 0.41 ± 0.21 (SD) IU/mL, at 4 h (mid-HD) 0.19 ± 0.17 IU/mL, at 6 h 0.44 ± 0.21 IU/mL, and at dialysis end 0.26 ± 0.14 IU/mL. Antifactor Xa levels were undetectable at the start of INHD, suggesting no tinzaparin accumulation. Five patients required an increase in tinzaparin due to extracorporeal dialysis circuit clotting. There were no bleeding events. One patient required a switch to fondaparinux due to an adverse reaction. CONCLUSION: Tinzaparin was safe and efficacious for most INHD patients without accumulation or bleeding. The conversion from unfractionated heparin to tinzaparin required an increased tinzaparin dose for 31% of INHD patients.
Subject(s)
Anticoagulants/pharmacology , Renal Dialysis/methods , Tinzaparin/pharmacology , Adult , Aged , Blood Coagulation , Circadian Rhythm , Factor Xa/analysis , Female , Hemorrhage , Heparin , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Male , Middle Aged , Patient Safety , Retrospective Studies , Treatment OutcomeSubject(s)
Autoantibodies/metabolism , Complement Activation/drug effects , Complement C5a/metabolism , Pemphigoid, Bullous/immunology , Tinzaparin/pharmacology , Autoantibodies/blood , Autoantibodies/immunology , Autoantigens/immunology , Complement Activation/immunology , Complement C5a/immunology , Complement Fixation Tests , Dystonin/immunology , Humans , Non-Fibrillar Collagens/immunology , Off-Label Use , Pemphigoid, Bullous/blood , Pemphigoid, Bullous/drug therapy , Skin/immunology , Skin/pathology , Tinzaparin/therapeutic use , Collagen Type XVIIABSTRACT
An intimate interplay with platelets is an initial key issue for tumor cells in terms of hematogenous metastasis. Tumor cells activate platelets by different pathways and receive, upon forming a platelet cloak, protection from immune surveillance and support in metastatic niche creation. Therapeutic intervention with this early interaction is promising to antagonize the whole metastatic cascade. Here we aimed to investigate the capability of low molecular weight heparin (LMWH), unfractionated heparin (UFH), and a non-anticoagulant heparin derivative or FXa inhibitor fondaparinux to interfere with platelet activation by tumor cells. Coagulation-dependent and independent pathways of platelet activation by three tumor cell lines, and interference therewith were analyzed by fluorigenic thrombin formation assay, platelet aggregometry, ATP and VEGF release and endothelial tube formation assay. LMWH and UFH were found to repress various routes of platelet activation, reflected by attenuated endothelial tube formation. This confirms the duality of anti-coagulative and anti-adhesive properties of heparin. While non-anticoagulative heparin (RO-heparin) depressed platelets' ATP and VEGF release by contact inhibition sufficiently, fondaparinux just attenuated tissue factor mediated thrombin generation. Concluding, these data suggest that LMWH as a guideline-based drug for anticoagulative strategies in oncology is promising to provide additional benefit for interference with metastatic activities.
Subject(s)
Blood Coagulation/drug effects , Heparin, Low-Molecular-Weight/pharmacology , Platelet Activation/drug effects , Signal Transduction/drug effects , Tinzaparin/pharmacology , Blood Platelets/drug effects , Blood Platelets/metabolism , Cell Line, Tumor , Heparin, Low-Molecular-Weight/chemistry , Humans , Platelet Aggregation/drug effects , Thrombin/biosynthesis , Tinzaparin/chemistry , Vascular Endothelial Growth Factor A/biosynthesisABSTRACT
OBJECTIVE: Foetal growth retardation (FGR) is a leading cause of perinatal death and long-term harms at survivors. Placental infarction plays a role in FGR, yet, no trials have evaluated whether low molecular weight heparins increase birth weight in ongoing FGR pregnancies. METHODS: An open-labelled randomized trial in Denmark during 2011-2016, including singleton pregnant women with FGR (estimated foetal weightâ¯<â¯2.3 percentile) diagnosed before gestational weeks 32. Participants were randomly assigned using sealed, blinded envelopes 1:1 to tinzaparin (4500â¯IU daily until 37 gestational weeks) or no tinzaparin. The primary outcomes were the observed birthweight relative to the expected for gestational age and gender, and foetal growth rates in the two trial groups evaluated by an intention to treat analysis. RESULTS: We enrolled 53 women. The mean gestational age was 261â¯days in the tinzaparin group and 246â¯days in the no treatment group. The mean birth weight was 2229â¯g in the tinzaparin group compared to 1968â¯g in the no treatment group. However, the birth weight relative to the expected from gestational age and gender was only 2.5 percentage points higher in the tinzaparin group [-5.1 to 10.0] (pâ¯=â¯0.51). The foetal growth rate during follow-up was 124â¯g/week in the tinzaparin group and 119â¯g/week in the no treatment group, a difference of 5â¯g/week [-19 to 29] (pâ¯=â¯0.67). Two perinatal deaths both occurred in the no treatment group. CONCLUSION: We found no evidence of a tinzaparin effect on the foetal growth rate or the birth weight after adjustment for gestational age.