Fibrinolysis and Anticoagulant Potential of a Metallo Protease Produced by Bacillus Subtilis K42
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Urokinase, a Promising Candidate for Fibrinolytic Therapy for Intracerebral Hemorrhage
LABORATORY INVESTIGATION J Neurosurg 126:548–557, 2017 Urokinase, a promising candidate for fibrinolytic therapy for intracerebral hemorrhage *Qiang Tan, MD,1 Qianwei Chen, MD1 Yin Niu, MD,1 Zhou Feng, MD,1 Lin Li, MD,1 Yihao Tao, MD,1 Jun Tang, MD,1 Liming Yang, MD,1 Jing Guo, MD,2 Hua Feng, MD, PhD,1 Gang Zhu, MD, PhD,1 and Zhi Chen, MD, PhD1 1Department of Neurosurgery, Southwest Hospital, Third Military Medical University, Chongqing; and 2Department of Neurosurgery, 211st Hospital of PLA, Harbin, People’s Republic of China OBJECTIVE Intracerebral hemorrhage (ICH) is associated with a high rate of mortality and severe disability, while fi- brinolysis for ICH evacuation is a possible treatment. However, reported adverse effects can counteract the benefits of fibrinolysis and limit the use of tissue-type plasminogen activator (tPA). Identifying appropriate fibrinolytics is still needed. Therefore, the authors here compared the use of urokinase-type plasminogen activator (uPA), an alternate thrombolytic, with that of tPA in a preclinical study. METHODS Intracerebral hemorrhage was induced in adult male Sprague-Dawley rats by injecting autologous blood into the caudate, followed by intraclot fibrinolysis without drainage. Rats were randomized to receive uPA, tPA, or saline within the clot. Hematoma and perihematomal edema, brain water content, Evans blue fluorescence and neurological scores, matrix metalloproteinases (MMPs), MMP mRNA, blood-brain barrier (BBB) tight junction proteins, and nuclear factor–κB (NF-κB) activation were measured to evaluate the effects of these 2 drugs in ICH. RESULTS In comparison with tPA, uPA better ameliorated brain edema and promoted an improved outcome after ICH. -
The Central Role of Fibrinolytic Response in COVID-19—A Hematologist’S Perspective
International Journal of Molecular Sciences Review The Central Role of Fibrinolytic Response in COVID-19—A Hematologist’s Perspective Hau C. Kwaan 1,* and Paul F. Lindholm 2 1 Division of Hematology/Oncology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA 2 Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA; [email protected] * Correspondence: [email protected] Abstract: The novel coronavirus disease (COVID-19) has many characteristics common to those in two other coronavirus acute respiratory diseases, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS). They are all highly contagious and have severe pulmonary complications. Clinically, patients with COVID-19 run a rapidly progressive course of an acute respiratory tract infection with fever, sore throat, cough, headache and fatigue, complicated by severe pneumonia often leading to acute respiratory distress syndrome (ARDS). The infection also involves other organs throughout the body. In all three viral illnesses, the fibrinolytic system plays an active role in each phase of the pathogenesis. During transmission, the renin-aldosterone- angiotensin-system (RAAS) is involved with the spike protein of SARS-CoV-2, attaching to its natural receptor angiotensin-converting enzyme 2 (ACE 2) in host cells. Both tissue plasminogen activator (tPA) and plasminogen activator inhibitor 1 (PAI-1) are closely linked to the RAAS. In lesions in the lung, kidney and other organs, the two plasminogen activators urokinase-type plasminogen activator (uPA) and tissue plasminogen activator (tPA), along with their inhibitor, plasminogen activator 1 (PAI-1), are involved. The altered fibrinolytic balance enables the development of a hypercoagulable Citation: Kwaan, H.C.; Lindholm, state. -
ACTIVASE (Alteplase) for Injection, for Intravenous Use Initial U.S
Application 103172 This document contains: Label for ACTIVASE [Supplement 5203, Action Date 02/13/2015] Also available: Label for CATHFLO ACTIVASE [Supplement 5071, Action Date 01/04/2005] HIGHLIGHTS OF PRESCRIBING INFORMATION Acute Ischemic Stroke These highlights do not include all the information needed to use • Current intracranial hemorrhage. (4.1) ACTIVASE safely and effectively. See full prescribing information for • Subarachnoid hemorrhage. (4.1) ACTIVASE. Acute Myocardial Infarction or Pulmonary Embolism • History of recent stroke. (4.2) ACTIVASE (alteplase) for injection, for intravenous use Initial U.S. Approval: 1987 -----------------------WARNINGS AND PRECAUTIONS----------------------- • Increases the risk of bleeding. Avoid intramuscular injections. Monitor for ---------------------------INDICATIONS AND USAGE-------------------------- bleeding. If serious bleeding occurs, discontinue Activase. (5.1) Activase is a tissue plasminogen activator (tPA) indicated for the treatment of • Monitor patients during and for several hours after infusion for orolingual • Acute Ischemic Stroke (AIS). (1.1) angioedema. If angioedema develops, discontinue Activase. (5.2) • Acute Myocardial Infarction (AMI) to reduce mortality and incidence of • Cholesterol embolism has been reported rarely in patients treated with heart failure. (1.2) thrombolytic agents. (5.3) Limitation of Use in AMI: the risk of stroke may be greater than the benefit • Consider the risk of reembolization from the lysis of underlying deep in patients at low risk of death -
A First in Class Treatment for Thrombosis Prevention. a Phase I
Journal of Cardiology and Vascular Medicine Research Open Access A First in Class Treatment for Thrombosis Prevention. A Phase I study with CS1, a New Controlled Release Formulation of Sodium Valproate 1,2* 2 3 2 1,2 Niklas Bergh , Jan-Peter Idström , Henri Hansson , Jonas Faijerson-Säljö , Björn Dahlöf 1Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 2 Cereno Scientific AB, Gothenburg, Sweden 3 Galenica AB, Malmö, Sweden *Corresponding author: Niklas Bergh, The Wallenberg Laboratory for Cardiovascular Research Sahlgrenska University Hospi- tal Bruna Stråket 16, 413 45 Göteborg, Tel: +46 31 3421000; E-Mail: [email protected] Received Date: June 11, 2019 Accepted Date: July 25, 2019 Published Date: July 27, 2019 Citation: Niklas Bergh (2019) A First in Class Treatment for Thrombosis Prevention? A Phase I Study With Cs1, a New Con- trolled Release Formulation of Sodium Valproate. J Cardio Vasc Med 5: 1-12. Abstract Several lines of evidence indicate that improving fibrinolysis by valproic acid may be a fruitful strategy for throm- bosis prevention. This study investigated the safety, pharmacokinetics, and effect on biomarkers for thrombosis of CS1, a new advanced controlled release formulation of sodium valproate designed to produce optimum valproic acid concen- trations during the early morning hours, when concentrations of plasminogen activator inhibitor (PAI)-1 and the risk of thrombotic events is highest. Healthy volunteers (n=17) aged 40-65 years were randomized to receive single doses of one of three formulations of CS1 (FI, FII, and FIII). The CS1 FII formulation showed the most favorable pharmacokinetics and was chosen for multiple dosing. -
(Tpa) As a Novel Treatment for Refractory COVID
Journal of Trauma and Acute Care Surgery, Publish Ahead of Print DOI: 10.1097/TA.0000000000002694 Is There a Role for Tissue Plasminogen Activator (tPA) as a Novel Treatment for Refractory COVID-19 Associated Acute Respiratory Distress Syndrome (ARDS)? Hunter B. Moore1, Christopher D. Barrett2,3, Ernest E. Moore1,4, Robert C. McIntyre1, Peter K. Moore5, Daniel S. Talmor6, Frederick A. Moore7, and Michael B. Yaffe2,3,8 1 Department of Surgery, University of Colorado Denver, Denver, CO USA 2 Koch Institute for Integrative Cancer Research, Center for Precision Cancer Medicine, Departments of Biological Engineering and Biology, Massachusetts Institute of Technology, Cambridge MA, USA 3 Division of Acute Care Surgery, Trauma and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA USA 4 Ernest E Moore Shock Trauma Center at Denver Health, Department of Surgery, Denver, CO USA 5 Department of Medicine, University of Colorado Denver, Denver CO USA 6 Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA USA 7 Department of Surgery, University of Florida, Gainesville, FL USA 8 ACCEPTED To whom correspondence should be addressed: E-mail: [email protected], Ph: 617- 452-2103, Fax: 617-452-2978 1 This work was supported by NIH Grants UM1-HL120877 (EEM, MBY), F32-HL134244 (CDB), and L30-GM120751 (CDB); and DoD Peer Reviewed Medical Research Program, Contract Number W81XWH-16-1-0464 (MBY). Keywords: COVID-19; Acute Respiratory Distress Syndrome (ARDS); Tissue Plasminogen Activator (tPA); Pulmonary Failure; Fibrinolysis This is an open-access article distributed under the terms of the Creative Commons Attribution- Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. -
Therapeutic Fibrinolysis How Efficacy and Safety Can Be Improved
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL.68,NO.19,2016 ª 2016 PUBLISHED BY ELSEVIER ON BEHALF OF THE ISSN 0735-1097/$36.00 AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION http://dx.doi.org/10.1016/j.jacc.2016.07.780 THE PRESENT AND FUTURE REVIEW TOPIC OF THE WEEK Therapeutic Fibrinolysis How Efficacy and Safety Can Be Improved Victor Gurewich, MD ABSTRACT Therapeutic fibrinolysis has been dominated by the experience with tissue-type plasminogen activator (t-PA), which proved little better than streptokinase in acute myocardial infarction. In contrast, endogenous fibrinolysis, using one-thousandth of the t-PA concentration, is regularly lysing fibrin and induced Thrombolysis In Myocardial Infarction flow grade 3 patency in 15% of patients with acute myocardial infarction. This efficacy is due to the effects of t-PA and urokinase plasminogen activator (uPA). They are complementary in fibrinolysis so that in combination, their effect is synergistic. Lysis of intact fibrin is initiated by t-PA, and uPA activates the remaining plasminogens. Knockout of the uPA gene, but not the t-PA gene, inhibited fibrinolysis. In the clinic, a minibolus of t-PA followed by an infusion of uPA was administered to 101 patients with acute myocardial infarction; superior infarct artery patency, no reocclusions, and 1% mortality resulted. Endogenous fibrinolysis may provide a paradigm that is relevant for therapeutic fibrinolysis. (J Am Coll Cardiol 2016;68:2099–106) © 2016 Published by Elsevier on behalf of the American College of Cardiology Foundation. n occlusive intravascular thrombus triggers fibrinolysis, as shown by it frequently not being A the cardiovascular diseases that are the lead- identified specifically in publications on clinical ing causes of death and disability worldwide. -
Intrapleural Fibrinolytics (Tpa + Dnase) for Pleural Infection
Treatment Guideline Intrapleural Fibrinolytics (tPA + DNase) for Pleural Infection Summary Patients with pleural infection should be managed with antibiotics and drainage of the pleural cavity If medical management fails or is not possible, referral for surgical management should be considered Intrapleural fibrinolytic treatment with alteplase (tPA) and dornase alfa (DNase) may be considered as an adjunct to medical management in selected patients at the discretion of the Respiratory Consultant This guideline details the rationale, indications, contraindications and protocol for administering intrapleural fibrinolytic treatment Scope This guidance relates to adult inpatients with non-resolving pleural infection. Such patients should be under the care of the Respiratory physicians. Decisions related to this treatment must be made by a Respiratory Consultant. Introduction Pleural infection has a significant mortality of up to 20%. Standard medical management with antimicrobials and chest tube drainage fails in approximately 30% of patients. Such patients are often referred for thoracic surgery, but many patients are not suitable for surgery due to co-morbidities or frailty, and the surgery itself is not without morbidity and is associated with long hospital stays. Intrapleural fibrinolysis with a combination of alteplase (tPA) and dornase alfa (DNase) has been shown in a randomised controlled trial (MIST2) to reduce rate of referral for surgery and the duration of hospital stay for patients with pleural infection treated with antibiotics and chest drain insertion. This combination treatment reduces length of stay by a mean of 6.7 days and reduces referral for thoracic surgery by 77% (Rahman et al. 2011). It is currently unclear how the use of intrapleural fibrinolytic therapy should be used in the context of thoracic surgery, however if a patient fails to improve after 24-48 hours of treatment with chest tube drainage and antimicrobials, intrapleural tPA/DNase can be used at the discretion of a Respiratory Consultant. -
Mechanism of Ancrod Anticoagulation: a Direct Proteolytic Effect on Fibrin
Mechanism of ancrod anticoagulation: A direct proteolytic effect on fibrin Salvatore V. Pizzo, … , Robert L. Hill, Patrick A. McKee J Clin Invest. 1972;51(11):2841-2850. https://doi.org/10.1172/JCI107107. Fibrin formed in response to ancrod, reptilase, or thrombin was reduced by β-mercaptoethanol and examined by sodium dodecyl sulfate polyacrylamide gel electrophoresis. It was found that ancrod progressively and totally digested the α- chains of fibrin monomers at sites different than plasmin; however, further digestion of fibrin monomers by either reptilase or thrombin was not observed. Highly purified ancrod did not activate fibrin-stabilizing factor (FSF); however, the reptilase preparation used in these experiments, like thrombin, activated FSF and thereby promoted cross-link formation. Fibrin, formed by clotting purified human fibrinogen with ancrod, reptilase, or thrombin for increasing periods of time in the presence of plasminogen, was incubated with urokinase and observed for complete lysis. Fibrin formed by ancrod was strikingly more vulnerable to plasmin digestion than was fibrin formed by reptilase or thrombin. The lysis times for fibrin formed for 2 hr by ancrod, reptilase, or thrombin were 18, 89, and 120 min, respectively. Evidence was also obtained that neither ancrod nor reptilase activated human plasminogen. These results indicate that fibrin formed by ancrod is not cross-linked and has significantly degraded α-chains: as expected, ancrod-formed fibrin is markedly susceptible to digestion by plasmin. Find the latest version: https://jci.me/107107/pdf Mechanism of Ancrod Anticoagulation A DIRECT PROTEOLYTIC EFFECT ON FIBRIN SALVATORE V. PIZZO, MARTIN L. SCHWARTZ, ROBERT L. HILL, and PATRICK A. -
The Efficacy and Safety of Combination Glycoprotein Iibiiia Inhibitors And
Interventional Cardiology The efficacy and safety of combination glycoprotein IIbIIIa inhibitors and reduced-dose thrombolytic therapy–facilitated percutaneous coronary intervention for ST-elevation myocardial infarction: A meta-analysis of randomized clinical trials Mohamad C.N. Sinno, MD, Sanjaya Khanal, MD, FACC, Mouaz H. Al-Mallah, MD, Muhammad Arida, MD, and W. Douglas Weaver, MD Detroit, MI Objective We reviewed the literature and performed a meta-analysis comparing the safety and efficacy of adjunctive use of reduced-dose thrombolytics and glycoprotein (Gp) IIbIIIa inhibitors to the sole use of Gp IIbIIIa inhibitors before percutaneous coronary intervention (PCI) in patients presenting with acute ST-segment elevation myocardial infarction (STEMI). Background Early reperfusion in STEMI is associated with improved outcomes. The use of reduced-dose thrombolytic and Gp IIbIIIa inhibitors combination before PCI in the setting of acute STEMI remains controversial. Methods We performed a literature search and identified randomized trials comparing the use of combination therapy–facilitated PCI versus PCI done with Gp IIbIIIa inhibitor alone. Included studies were reviewed to determine Thrombolysis in Myocardial Infarction (TIMI)-3 flow at baseline, major bleeding, 30-day mortality, TIMI-3 flow after PCI,and 30-day reinfarction. We performed a random-effect model meta-analysis. We quantified heterogeneity between studies with I2. A value N50% represents substantial heterogeneity. Results We identified 4 clinical trials randomizing 725 patients; 424 patients were pretreated with combination therapy before PCI, and 301 patients had Gp IIbIIIa inhibitor alone during PCI. Combination therapy–facilitated PCI was associated with a 2-fold increase in TIMI-3 flow upon arrival to the catheterization laboratory compared with the sole use of upstream Gp IIbIIIa inhibitors (192/390 patients [49%] versus 60/284 [21%]; relative risk [RR], 2.2; P b .00001). -
Streptokinase Resistance: When Might Streptokinase Administration Be Ineffective?
Br Heart J 1992;68:449-53 449 Streptokinase resistance: when might streptokinase administration be ineffective? Maurice B Buchalter, Ganesh Suntharalingam, Ian Jennings, Catherine Hart, Roger J Luddington, Ronjon Chakraverty, S Kim Jacobson, Peter L Weissberg, Trevor P Baglin Abstract patients after 24 months. Retreatment Objective-(a) To develop an assay for with streptokinase is likely to be sub- streptokinase resistance. (b) To deter- optimal even after 24 months. The fibrin mine the prevalence of streptokinase plate lysis assay detects resistance in resistance in patients presenting with patients with normal concentrations of acute myocardial infarction for the first streptokinase antibodies. Streptococcal time. (c) To determine the prevalence of infection is associated with a high streptokinase resistance in patients after incidence of streptokinase resistance. exposure to streptokinase or strepto- coccal infection. (Br Heart J 1992;68:449-53) Design-Open, prospective. Patients-30 healthy volunteers. 40 Thrombolysis has become an essential com- patients admitted to the coronary care ponent of the management of an acute unit at Addenbrooke's Hospital with sus- myocardial infarction. Large controlled trials pected acute myocardial infarction, 12 have shown that streptokinase compares patients 12 months after streptokinase favourably with other fibrinolytic agents in treatment, eight patients 24 months terms of efficacy, side effects, and cost.'-5 It is after streptokinase treatment, and sera therefore likely to remain the thrombolytic from 12 patients with raised anti- agent of choice in the United Kingdom for the streptolysin 0 (ASO) titres. foreseeable future. Because of its antigenic Methods-Three assays were used; a nature, however, the presence of neutralising dilution neutralisation a,ssay, an enzyme antibodies in some patients may reduce its linked immunosorbent assay (ELISA) effectiveness. -
Fibrinolytic Drugs
FIBRINOLYTIC DRUGS Margaret Holland, PA-C, Director of Education Originally published in the July/August 2017 Sutureline, Volume 37, No. 4 In the last issue of Sutureline, we addressed antiplatelet and anticoagulant drugs in the Student Corner. In this article, we will finish investigating fibrinolytic drugs! Recall that antithrombotic drugs are commonly used for a host of medical conditions in which thrombi have or are likely to form including atrial fibrillation, coronary artery disease, deep vein thrombosis, and pulmonary embolism. We know that there are important categories of antithrombotic drugs that differ in their mechanism of action. Antiplatelet: inhibit platelet activation or aggregation Anticoagulant: affect fibrin formation Fibrinolytic: degrade fibrin The rest of this article will look at the fibrinolytic drugs and give you key points about the most common drugs and how they work. Fibrinolysis As their name implies, fibrinolytic drugs all break down fibrin, through enzymatic and biochemical reactions. Dissolution of a clot is the process called fibrinolysis, a process in which fibrin is de- graded and the foundation of the clot is disrupted. Thus fibrinolytic drugs are used to dissolve an already formed clot. This is an important point. Fibrinolytic drugs are not intended to be used to prevent clots from forming! Fibrinolytics are used to disrupt clots that have formed in situations such as acute myocardial infarction, acute ischemic stroke, and massive pulmonary embolism. In all of these cases, rapid clot dissolution is the main goal with the hope of restoring perfusion to the heart, preventing neuronal death in the brain, or restoring pulmonary artery function. -
An Observational Cohort Study Sini Saarinen1*†, Jyrki Puolakka1†, James Boyd1†, Taneli Väyrynen2†, Harri Luurila3† and Markku Kuisma1†
Saarinen et al. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:21 http://www.sjtrem.com/content/19/1/21 ORIGINALRESEARCH Open Access Warfarin and fibrinolysis - a challenging combination: an observational cohort study Sini Saarinen1*†, Jyrki Puolakka1†, James Boyd1†, Taneli Väyrynen2†, Harri Luurila3† and Markku Kuisma1† Abstract Background: Patients presenting with ST-segment elevation myocardial infarction (STEMI) frequently use warfarin. Fibrinolytic agents and warfarin both increase bleeding risk, but only a few studies have been published concerning the bleeding risk of warfarin-prescribed patients receiving fibrinolysis. The objective of this study was to define the prevalence for intracranial haemorrhage (ICH) or major bleeding in patients on warfarin treatment receiving pre-hospital fibrinolysis. Methods: This was an observational cohort study. Data for this retrospective case series were collected in Helsinki Emergency Medical Service catchment area from 1.1.1997 to 30.6.2010. All warfarin patients with suspected ST- segment elevation myocardial infarction (STEMI), who received pre-hospital fibrinolysis, were included. Bleeding complications were detected from Medical Records and classified as ICH, major or minor bleeding. Results: Thirty-six warfarin patients received fibrinolysis during the study period. Fourteen patients had bleeding complications. One (3%, 95% CI 0-15%) patient had ICH, six (17%, 95% CI 7-32%) had major and seven (19%, 95% CI 9-35%) had minor bleeding. The only fatal bleeding occurred in a patient with ICH. Patients’ age, fibrinolytic agent used or aspirin use did not predispose to bleeding complications. High International Normalized Ratio (INR) seemed to predispose to bleedings with values over 3, but no statistically significant difference was found.