Combination of aptamer and drug for reversible anticoagulation in cardiopulmonary bypass.

Unfractionated heparin (UFH), the standard anticoagulant for cardiopulmonary bypass (CPB) surgery, carries a risk of post-operative bleeding and is potentially harmful in patients with heparin-induced thrombocytopenia-associated antibodies. To improve the activity of an alternative anticoagulant, the RNA aptamer 11F7t, we solved X-ray crystal structures of the aptamer bound to factor Xa (FXa). The finding that 11F7t did not bind the catalytic site suggested that it could complement small-molecule FXa inhibitors. We demonstrate that combinations of 11F7t and catalytic-site FXa inhibitors enhance anticoagulation in purified reaction mixtures and plasma. Aptamer-drug combinations prevented clot formation as effectively as UFH in human blood circulated in an extracorporeal oxygenator circuit that mimicked CPB, while avoiding side effects of UFH. An antidote could promptly neutralize the anticoagulant effects of both FXa inhibitors. Our results suggest that drugs and aptamers with shared targets can be combined to exert more specific and potent effects than either agent alone.

Rendering factor Xa zymogen-like as a therapeutic strategy to treat bleeding.

PURPOSE OF REVIEW: New therapies are needed to control bleeding in a range of clinical conditions. This review will discuss the biochemical properties of zymogen-like factor Xa, its preclinical assessment in different model systems, and future development prospects. RECENT FINDINGS: Underlying many procoagulant therapeutic approaches is the rapid generation of thrombin to promote robust clot formation. Clinically tested prohemostatic agents (e.g., factor VIIa) can provide effective hemostasis to mitigate bleeding in hemophilia and other clinical situations. Over the past decade, we explored the possibility of using zymogen-like factor Xa variants to rapidly improve clot formation for the treatment of bleeding conditions. Compared to the wild-type enzyme, these variants adopt an altered, low activity, conformation which enables them to resist plasma protease inhibitors. However, zymogen-like factor Xa variants are conformationally dynamic and ligands such as its cofactor, factor Va, stabilize the molecule rescuing procoagulant activity. At the site of vascular injury, the variants in the presence of factor Va serve as effective prohemostatic agents. Preclinical data support their use to stop bleeding in a variety of clinical settings. Phase 1 studies suggest that zymogen-like factor Xa is safe and well tolerated, and a phase 1b is ongoing to assess safety in patients with intracerebral hemorrhage. SUMMARY: Zymogen-like factor Xa is a unique prohemostatic agent for the treatment of a range of bleeding conditions.

A rapid pro-hemostatic approach to overcome direct oral anticoagulants.

Direct inhibitors of coagulation factor Xa (FXa) or thrombin are promising oral anticoagulants that are becoming widely adopted. The ability to reverse their anticoagulant effects is important when serious bleeding occurs or urgent medical procedures are needed. Here, using experimental mouse models of hemostasis, we show that a variant coagulation factor, FXa(I16L), rapidly restores hemostasis in the presence of the anticoagulant effects of these inhibitors. The ability of FXa(I16L) to reverse the anticoagulant effects of FXa inhibitor depends, at least in part, on the ability of the active site inhibitor to hinder antithrombin-dependent FXa inactivation, paradoxically allowing uninhibited FXa to persist in plasma. Because of its inherent catalytic activity, FXa(I16L) is more potent (by >50-fold) in the hemostasis models tested than a noncatalytic antidote that is currently in clinical development. FXa(I16L) also reduces the anticoagulant-associated bleeding in vivo that is induced by the thrombin inhibitor dabigatran. FXa(I16L) may be able to fill an important unmet clinical need for a rapid, pro-hemostatic agent to reverse the effects of several new anticoagulants.

Enzymatic dissolution of calcium and struvite crystals: in vitro evaluation of biochemical requirements.

OBJECTIVE: To evaluate the factors that affect the enzymatic dissolution rate of calcium oxalate monohydrate (COM), calcium phosphate (brushite), and magnesium ammonium phosphate (struvite) crystals as enzymatic digestion of kidney stones could enhance lithotripsy or provide alternatives to surgical removal. METHODS: At pH 4.2, pelleted COM crystals were combined with oxalate decarboxylase (ODC from Bacillus subtilis), oxalate oxidase (from Hordeum vulgare), or control. Crystal dissolution was followed by measuring increases in solution calcium ion concentration. For phosphate-based crystals, the rates of phosphorolysis by the enzyme purine nucleoside phosphorylase (PNP, assay form) were compared to the control solution using spectrophotometry. RESULTS: The addition of ODC to COM crystals resulted in production of highly soluble calcium formate and a 15-fold increase in COM solubility. By adding a formate-catabolizing enzyme (formate dehydrogenase), dissolution increased 47-fold compared with controls with nearly one half of the mineral dissolved. Oxalate oxidase showed much lower activity than ODC in COM dissolution. Using inorganic phosphate as a substrate, PNP was able to dissolve both brushite and struvite minerals in water at concentrations near saturation. Measuring dissolution by adding more PNP was not possible because of equilibrium and assay detection restraints. CONCLUSION: Stone dissolution using enzymes appears to be viable, particularly for oxalate-based minerals. In a closed system, product inhibition by calcium formate appeared to limit the extent of COM crystal dissolution using ODC. Although phosphate-containing minerals appear to be suitable phosphate sources for PNP, the reversibility of the reaction limits the use of this enzyme.

Kinetic mechanism and structural requirements of the amine-catalyzed decarboxylation of oxaloacetic acid.

The kinetic and chemical mechanism of amine-catalyzed decarboxylation of oxaloacetic acid at pH 8.0 has been reevaluated using a new and versatile assay. Amine-catalyzed decarboxylation of oxaloacetic acid proceeds via the formation of an imine intermediate, followed by decarboxylation of the intermediate and hydrolysis to yield pyruvate. The decrease in oxaloacetic acid was coupled to NADH formation by malate dehydrogenase, which allowed the rates of both initial carbinolamine formation (as part of the imination step) and decarboxylation to be determined. By comparing the rates observed for a variety of amines and, in particular, diamines, the structural and electronic requirements for diamine-catalyzed decarboxylation at pH 8.0 were identified. At pH 8.0, monoamines were found to be very poor catalysts, whereas some diamines, most notably ethylenediamine, were excellent catalysts. The results indicate that the second amino group of diamines enhances the rate of imine formation by acting as a proton shuttle during the carbinolamine formation step, which enables diamines to overcome high levels of solvation that would otherwise inhibit carbinolamine, and thus imine, formation. The presence of the second amino group may also enhance the rate of the carbinolamine dehydration step. In contrast to the findings of previous reports, the second amino group participates in the reaction by enhancing the rate of decarboxylation via hydrogen-bonding to the imine nitrogen to either stabilize the negative charge that develops on the imine during decarboxylation or preferentially stabilize the reactive imine over the unreactive enamine tautomer. These results provide insight into the precise catalytic mechanism of several enzymes whose reactions are known to proceed via an imine intermediate.