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Home , Anticoagulant, Heparin, Heparinoid

Some side effects of , , and their antagonists

Effects of heparin, heparinoids, and their antagonists, other than actions on and lipemia clearing, are described. Many, if not all, of these properties are probably related to the unusual structure and high-charge density of these macromolecules. Some may have therapeutic utility.

William W. Coon, M.D., and Park W. Willis, III, M.D. Ann Arbor, Mich. Departments of Surgery and Medicine, University of Michigan

Since its discovery fifty years ago, and Astrup56 demonstrated that these salts heparin has been extensively used as an partially dissociate according to mass law and, in recent years, as an as long as the product remains in solution; agent to facilitate more rapid clearing of this has been confirmed by Jaques.100 Com• lipemic plasma. These functions of heparin plexing with heparin has been observed have been adequately reviewed in the re• not only with proteins and peptides (silk cent past. This monograph lists some of peptone, gelatin, clupein, salmine, his tones the side effects of heparin which are not from thymus and blood, hemoglobin, egg so well known. Some may ultimately be albumin, casein, serum proteins, pro• shown to be directly related to the anti• teins, thromboplastins, enzymes, and so coagulant effect of heparin but, if so, this forth) but also with organic bases (benzi• association has not yet been proved. dine, , brucine, and piperidine) and Several of these effects have been observed basic dyes (thionine, toluidine blue, and only in vitro, and to our knowledge studies others). Although optimal combination of to document whether or not they persist in heparin with protein occurs near the iso• vivo have not yet been carried out. A few electric point, it is possible for heparin to may have therapeutic applications. Knowl• combine with proteins on the alkaline side edge of others may aid in the correct inter• of their isoelectric point. Dissociation of pretation of extraneous effects which might these compounds is markedly affected by occur during heparin . pH and ionic strength.10o Jaques has made reference to the difficulty of confirmation Formation of "complexes" of reports by others regarding the inhibi• One of the earlier known side effects tory effect of heparin on certain proteins of heparin was demonstration of its ability because reproduction of relative concen• to form stable salts with many pro• trations of heparin, the protein under teins.31 , 54, 172 Over thirty years ago, Fischer study, of other proteins, pH, ionic strength, and so forth is often difficult. The early Supported in part by the Parke-Davis Surgical Research Fund and the Michigan Association. work on complex formation by heparin 106 Received for publication Jan. 25, 1966. has been summarized by Jorpes. Studies 379 380 Coon and Willis Clinical and Therapeutics

of charged polyglucose derivatives add to of affinity between heparin and other our understanding of the mechanism of anionic have been attrib• effect of heparin and heparinoids. Macro• uted to differences in structure of these cationic substances with enzymatic activity several molecules. Their association with (hyaluronidase, ribonuclease, and lyso• cations in solution is thought to be of elec• zyme) are reversibly inhibited by synthetic trostatic rather than covalent type. The sulfated polysaccharides; these enzymes affinity of acid mucopolysaccharides for can be reactivated by addition of other decreases in the order: heparin, cationic agents such as or pro• sulfate B, tamine. Highly substituted sulfates are the A, and .24 most effective enzyme inhibitors, while The effect of heparin upon cellular cal• sulfates of similar molecular size but lower cium has been studied in vitro in Ehrlich charge density have less inhibitory activity. ascites tumor cells labeled in vivo with 4li The product with highest branching and isotopic Ca ; no change in calcium content charge density is about five times as active of cells was observed when cells were in• as heparin in inhibiting ribonuclease. These cubated in solutions containing up to 0.6 derivatives also precipitate other basic pro• mg. heparin per milliliter.205 Heparin does teins (, an ACTH preparation, increase Rb86 outflow from the diaphrag• cytochrome C, and serum albumin) from matic muscle of rats, an effect similar to aqueous solution at low pH and salt con• that produced by reduction in concentra• centration.15l tion of calcium . 28 Potassium exchange The electric charges of heparin prepara• is affected in a similar manner.86 tions are proportional to their content of Heparin is a potent inhibitor in vitro of ester sulfate; cataphoric mobility is of the fumarase,57 ,115 and tissue ribonu• order of 17 to 19 x 10-5 cm.2 V-I sec-1 at cleases and desoxyribonucleases.128, 178, 207 pH 2 to 8; heparin apparently has the Significant inhibition of acid and alkaline strongest electric charge of any organic ribonucleases of hepatic origin has been compound normally found in the obtained one hour after heparin body.219 in vivo in white mice.129 Heparin, but not Macroglobulins isolated from patients hyaluronic acid or polyglutamic acid, in• with macroglobulinemia are precipitable hibits adenylic deaminase in vitro; no by heparin but not by chondroitin sul• inhibition of phosphoenolpyruvic kinase, fate. 149 Heparin and heparinoids precipitate hexokinase, phosphoglyceric mutase, or , particularly at low tempera• enolase has been observed!' Heparin is a tures.9. 174. 194. 204 A stoichiometric relation• nonspecific and apparently competitive ship exists between heparin and fibrino• inhibitor of hyaluronidases of diverse gen65 during the process of precipitation, origins.77,95 Both inhibitor and substrate as it does for other heparin-protein com• compete for the same energy sites; an in• plexes.56 Beta liproproteins are also pre• crease in ionic strength decreases the cipitated by heparin.25 inhibitory effect of heparin and chondroitin Heparin, along with other anionic poly• sulfate B.95 Serum beta-glucuronidase saccharides, acts as an ion exchanger.51 . activity is decreased 43 to 64 per cent in 182, 183, 211 The order of increasing cation human postheparin sera.14 Beta-glucuroni• affinity, when acid mucopolysaccharides dase shows a two thousand fold greater are treated as ion exchangers, varies affinity for heparin than for • for heparin, heparin monosulfate, and phthalein .beta-glucuronide. 27 Nonspecific chondroitin sulfate.45 The order of increas• stimulation of tyrosine-alpha ketoglutarate ing cation affinity for heparin is: sodium, activity in vivo by heparin, potassium, magnesium, strontium, barium, chondroitin sulfate, and a number of other and calcium; the differences in order agents has been observed. This stimulation Volume 7 Side effects of heparin 381 Nllmber3

is dependent upon intact adrenal glands to molecular size.32 Heparin has been or upon the presence of hydrocortisone.138 shown to dissociate the insulin complex in Heparin is thought to function in an ion• vitro, freeing insulin from its basic pro• exchange capacity in its complexing with tein. 76 Heparin also complexes with histamine. In vitro, heparin binds hista• kallidin; the complex may be split with mine4, 12, 167 and also apparently inhibits compound 48/80. 217 Heparin and release of histamine from cells to plasma.44 sulfate accelerate plasma kinin formation Histamine is selectively bound by heparin in vitro, as reHected by increased oxytocic in the presence of equivalent amounts of activity, pOSSibly by blocking the effect of cadaverine, serotonin, or epinephrine but an inhibitor; and hexadi• is displaced by multivalent ions in prefer• methrine bromide but not toluidine blue ence to univalent ions,119 One mole of block kinin formation both in the presence heparin will bind 21.5 to 22.0 moles of his• and absence of heparin but do not inter• tamine.119,2l6 However, heparin, even in fere with uterine response to preformed high doses, has little effect on the actions kinin. G Hexadimethrine apparently inhibits 26 of histamine in vivo. , 132 kinin formation by an inhibition of Hage• Heparin inhibits gastric secretion from man factor which normally plays a role Heidenhain pouches in dogs after stimula• in kinin formation by activating a kinin• tion by food or by exogenously adminis• forming enzymeY tered histamineY' However, whether this Heparin also complexes with trypsin; the suppression of gastric secretion is secon• heparin-trypsin complex may be disso• dary to complexing with histamine in vivo ciated by acidification to pH 3 for 30 is not yet known. Heparin, chondroitin minutes with complete recovery of tryptic sulfate, and sodium polyhydromannuronic activity. Heparin does not inhibit chymo• acid sulfate, but not hyaluronic acid, in• trypsin.94 Although heparin completely pro• hibit pepsin in vitro. Chondroitin sulfate, tects rats against LD99 doses of trypsin which markedly reduces the number of intravenously, this effect may be related gastric ulcers in Shay rats, has been shown to the anticoagulant action of heparin, to inhibit pepsin in vivo as well.135 blocking the coagulant properties of The nonspecific complexing of heparin trypsin. 43 with cationic macromolecules has been used In the past few years, the relationship experimentally to protect mice from a lethal of heparin to the -enzyme system dose of polymyxin; intraperitoneal admin• has received a great deal of interest and istration of heparin is more effective than attention. The current consensus of opinion an intravenous dose.90 Sulfate and carboxyl is that, while large amounts of heparin in• derivatives of polyglucose have a similar hibit plasmin in vitro and in vivo, smaller protective effect against polymyxin and, to amounts stimulate fibrinolytic activity if a lesser degree, neomycin and strepto• a factor from the albumin fraction of mycin.152 Heparin apparently counteracts plasma is also present.8 , 33, 78, 111, 112, 122, 199 the acute toxic effects of neomycin with• Heparin 74 and a (Ateroid) 121 out producing an equivalent loss in anti• increase fibrinolytic activity which has de• biotic activity. 89 creased in the presence of alimentary In recent years, further data on "com• lipemia; Ateroid does not affect the plas• plexing" by heparin in vitro have been re• min-enzyme system in the absence of ported. This complexing might have con• alimentary lipemia. Fibrinolytic activity in siderable physiologic significance if it were guinea serum is increased in vitro by shown to occur in vivo as well. The anti• heparin, hyaluronic acid and chondroitin curariform action of heparin and many sulfate, dextran sulfate, and several other heparinoids has been related both to synthetic sulfated polysaccharides; neutral magnitude of electronegative charge and polysaccharides have no effect. Total activ- 382 Coon and Willis Clinical Pharmacology and Therapeutics

ity is dependent upon pH and concentra• tensity of ocular inflammation produced tion of acid . Some of the by horse serum or tuberculin hypersensi• most potent stimulators of fibrinolytic activ• tivity.IS, 19, 210, 223, 224 ity have no anticoagulant activity. In higher Heparin, heparinoids, and salts of a concentrations, acid polysaccharides ap• rare earth (neodymium) inhibit in vitro'97 parently precipitate inhibitors of fibrinol• and in vivo'9s hemolysis produced by anti• ysis. Olesen'62 has suggested that the erythrocyte antibodies in rabbits. This mechanism of action of these acid poly• effect is not related to anticoagulant activ• saccharides is polyanionic in character, and ity since germanin and Treburon (a sul• that they interact with an inactive complex fonated pectin) which are weak anticoagu• in serum to release a plasminogen activa• lants have higher anticomplementary tor. The effects of these acid polysaccha• activity than heparin. Hemolysis induced rides can be reversed by addition of by cobra is also inhibited, presum• cationic agents. ably by suppression of lysolecithinase. None Addition of heparin in low concentration of these agents has an effect on adsorption to , serum, or oxalated plasma of amboceptor on the erythrocyte, on increases the rate of hydrolysis of benzoyl• agglutination, or on hemolysis by simple I-arginine ethyl ester.59 Since this ester lysins (saponin and digitonin).197 Heparin is a substrate for plasmin and since larger has a beneficial effect in vitro and in vivo amounts of heparin inhibit hydrolysis, this in acquired hemolytic anemia in man; the increase in enzymatic activity may be direct Coombs reaction decreases in titer mediated through the effect of heparin and becomes negative, and plasma hemo• in stimulating fibrinolytic (plasmin) activ• globin, serum bilirubin, and osmotic fra• ity. In vitro, in high concentration, heparin gility decrease. SS, 164, 179, lSI Similar inhibi- inhibits plasminogen activation by strepto• tion of hemolysis has been reported in kinase or but not the fibrinolytic patients with paroxysmal nocturnal hemo• s 6o effect of Aspergillus protease. , 92 globinuria. Heparin has not been shown to have a In the light of modern knowledge, the demonstrable effect upon fibrinolytic activ• anticomplementary effect of heparin is not ity in vivo. Heparin injections in healthy a convincing explanation for the beneficial male volunteers previously given a bac• effect of heparin in acquired hemolytic terial pyrogen did not alter fibrinolytic anemia.'so Fifteen thousand units of activity.93 heparin injected subcutaneously in normal subjects will depress complement activity Anticomplementary effect; treatment of about 40 per cent for less than 2 hours. hyperimmune Since 5,000 to 10,000 units per 24 hours In vitro, in a sheep red-cell system, 0.04 will achieve a beneficial effect in the treat• to 0.06 mg. of heparin will inhibit one unit ment of hemolytic anemia, and protamine of complement from guinea pig serum; this which is a more potent anticomplementary inhibitory effect is considered to be on agent has no effect, this cannot be the the third component of complement.46 The mechanism of action. Studies in vitro of anticomplementary effect of heparin and the effect of heparin on autoantibodies and several heparinoids (dextran sulfate, chlo• sensitized red cells from patients with ac• razol pink, and polyanethol sulfonate) quired hemolytic anemia have shown that does not correlate with relative anticoagu• heparin acts on red blood cells and auto• lant potency.127 Heparin treatment of antibodies directly, and that complement guinea has no effect upon syntheSis plays no part.'SO of antibody induced by immunization with Pretreatment with heparin protects human serum.96 Local or parenteral guinea pigs and rabbits from anaphylactic injection of heparin reduces the in- shock.102, 103, 124, 220 Heparin pretreatment Volume 7 Side effects of heparin 383 Number 3

also suppresses anaphylactic shock in sensi• heparin inhibitors (protamine, toluidine tized pigeons124 and the Arthus phenom• blue, , fuchsin, and methyl enon in sensitized rabbits.133 In anaphylac• violet) stimulate motor activity of the iso• tic shock, heparin prevents a decrease in lated guinea pig uterus; heparin has no and an increase in 5-hydroxy• direct effect on spontaneous motor activity tryptamine in whole blood.102, 103 Heparin of the uterus but inhibits the effect of may act by inhibiting the ability of plate• these other agents.17 lets to absorb or release 5-hydroxy• The inhibitory effect of heparin on cer• tryptamine. Heparin also prevents the de• tain physiologic responses to ACTH may crease in count accompanying be valid. Heparin does not alter the mag• allergic reactions to a specific antigen and nitude of depletion of adrenal ascorbic prevents most of the local response to acid produced by various stress-producing intradermal injection of a specific antigen agents154 but actually potentiates the de• in man; this antiallergic effect of heparin crease in thymic weight produced by has also been explained on the basis of ACTH.37 Protamine sulfate, however, has inhibition of release of 5-hydroxytrypt• been reported to suppress the effect of amine.104 Heparin does not block histamine ACTH on depletion of adrenal ascorbic shock in the mouse, nor is the contracture acid.52 Heparin pretreatment prevents the of isolated ileal segments from sensitized decrease in total leukocyte and eosinophil animals elicited by antigen or histamine in counts in rats given sodium salicylate, vitro inhibited.110 epinephrine, or ACTH but, in moderate Heparin has also been shown to prevent doses, has no effect on cortisone-treated or partially suppress the manifestations of animals.82 Other investigators have shown experimental nephrosis in rats,r 77 nephritis an inhibitory effect of larger doses of in rabbits79 , 80, 118 and guinea pigs191 pro• heparin on cortisone-induced leukopenia duced by antikidney serum, and cortisone as well. 81 Guinea pigs injected with hepa• nephropathy in the rabbit.176 Experimental rin daily for 5 days develop a rise in nephrosis in dogs and rats is not affected eosinophil counts to several times basal by heparin treatment.214 valuesY Heparin may mobilize eosinophils Reversal of the L.E. (lupus erythema• from the intestinal wall since perfusion of tosus) test in vivo in several patients re• isolated dog intestine with heparinized ceiving injections of heparin has been blood results in a decrease of eosinophils reported; inhibition in vitro is also demon• in intestinal wall and an increase of these strable and may be related to binding of cells in the perfusate.66 Heparin does not complement.85 inhibit the de granulating effect of ACTH on gastric mucosal mast cells or its destruc• Effect upon ACTH and lymphocytic and tive effect on tissue eosinophilia.169 A single granulocytic response intravenous injection of 20,000 I.U. of hepa• The possible antagonistic effects of rin produces in normal man an increase heparin and ACTH have not been clearly in eosinophils which lasts for more than defined. The inhibitory effect of ACTH on 4 hours.21 An intravenous injection of heparin appears to be spurious. Not all heparin in rabbits brings about a re• preparations of ACTH have an inhibitory duction in the number of circulating effect.16 The influence of ACTH on throm• .168, 206 This phenomenon could bin clotting time of heparinized plasma not be reproduced in normal human may be due to phenolic contaminants or males.23,206 additives in ACTH preparations which Intravenous heparin produces definite produce partial inactivation of heparin co• lymphocytosis in the calf; mobilization of factor. 50 Heparin-neutralizing substances lymphocytes from lymph nodes, rather than isolated from preparations of ACTH and an actual increase in production, is favored 384 Coon and Willis Clinical Pharmacology and Therapeutics

99 to explain this phenomenon. Heparin in• samine, has the same effect. 39 Protamine jections in rats are followed by not only a sulfate produces an inhibition of cardiac significant increase in lymphocytes but in contraction which is not effectively re• neutrophils as well; the lymphocytosis is versed by calcium.39 predominant, however. When heparin and Large doses of heparin increase myo• hydrocortisone are given simultaneously, cardial contractile force. 73 Preparations of heparin blocks the lymphopenic effect of heparin which have a greater concentra• hydrocortisone, and hydrocortisone in• tion of amino-containing compounds than hibits the effect of heparin on the neutro• that expected on the basis of the content phil count."66 of cause a contraction of guinea pig ileum; this smooth muscle con• Effect on the vascular system, blood tractility, which could have been secondary flow, and oxygen consumption to contamination with conjugated hista• Clinical observations from Germany of mine, was different in type from that in• apparent beneficial effects of heparin in duced by histamine and was not prevented the treatment of hypertension have been by an antihistamine.72 This contraction of followed by several experimental studies. smooth muscle has been explained as prob• Heparin in doses which do not appreciably ably related to contaminating polypeptides affect clotting time lowers the blood pres• which have been shown to be present. sure in DOCA-induced hypertension or Chondroitin sulfate and hyaluronic acid nephrogenic hypertension in rats; the de• have no significant effect as smooth muscle pression in blood pressure persists if hepa• stimulators. 84 rin treatment is continued. , 114, 148 If, Heparin inhibits serotonin-induced activ• however, hypertensive rats are injected ity in an in vitro rat colon preparation and intraperitoneally with water to damage the vascular effects of serotonin mast cells, the hypotensive effect of hepa• in cats.193 However, heparin has no con• rin is very transitory. Similar inhibition of sistent effect on forearm blood How in heparin effect on blood pressure is ob• and does not block the vascular served after pretreatment with large doses effects of serotonin injections.126 These ex• of a histamine liberator (compound 48/ periments do not exclude the possibility 80).114 Although hypertensin is bound to that heparin might prevent the release of heparin in vitro,lOl heparin-treated hyper• serotonin from platelets or other cellular tensive rats respond like normal rats to sources. injections of angiotensin , renin, or ConHicting studies have appeared con• epinephrine.83 cerning the effect of heparin on blood Some controversy exists concerning the viscosity. Heparin in increasing amounts effect of heparin on cardiac activity. Hepa• has been reported to decrease the apparent rin inhibits the contraction of isolated frog viscosity, pseudoviscosity, and yield value , apparently having a primary effect of whole blood, plasma, or serum.35 How• on heart muscle itself since atropine and ever, the magnitude and significance of any epinephrine do not reverse this action. decrease in viscosity is still controversial,70 Since calcium, however, induces recovery, and recent studies do not confirm this this effect may be related to the action of finding. 61 heparin as an ion exchanger in binding Intravenous injections of heparin in calcium. Inhibition of cardiac activity with guinea pigs in doses comparable to or a high concentration of calcium is reversed higher than those utilized in man have no when heparin is added.39 Heparin inhibits effect on vasodilatation or per• cardiac contractility even when desul• meability. Vasodilatation is observed after furated. 28 , but not gluco- intra-arterial heparin but not after the Volume 7 Side effects of heparin 385 Number 3

intra-arterial injection of several hepa• added to a culture of Staphylococcus rinoidsYs Heparin has no significant effect au reus containing heparin.196 Warren and 2l on cerebral blood flow, cerebral oxygen Graham " have postulated that these find• utilization, or cerebral vascular resistance ings support the premise that heparin con• in man.20~ In controlled studies of subjects tains more than one bacteriostatically active with intermittent claudication of the lower component, one not requiring a cofactor extremities, heparin has brought about no but rendered inactive by possible com• improvement other than an anticipated plexing with basic proteins, and the other "placebo effect" observed in controls as requiring a cofactor but active in the pres• well.158. 1 "2 ence of other proteins. Although heparin does have an im• Protamine sulfate also has a bacterio• mediate effect on increasing coronary blood static but not a bacteriocidal effect against flow in dogs, intravenous injection of bis• many bacteria in neutral or acid media.189, hydroxycoumarin has a similar prompt 215 Since added ribonucleic acid has been effect. The mechanism of action of either shown to block this bacteriostatic effect, of these agents has not been clarified; no Wolff and Brignon221 have proposed that change in blood viscosity was detected.02 the effect of protamine may be to combine An increase in survival time has been with ribonucleic acid, thus blocking cellu• observed in heparinized rats maintained in lar division. an environment of pure nitrogen; no change Heparin and certain other sulfated muco• in total oxygen consumption was noted.109 polysaccharides inhibit multiplication of Following heparin administration the some viruses in culture.1, 156. 200. 201 Chon- blood, brain, cerebrospinal fluid, and droitin sulfate has no effect on virus replica• vitreous humor barriers become more per• tion while dextran sulfate, heparin, and a meable to p32 and to penicillin. 1 13 The sulfated agar polysaccharide all produce erythrocyte content of lymph also in• significant inhibition.20o While dextran creases.226 The mechanism of this effect sulfate inhibits multiplication of encephalo• has not been defined. Saxl and associates1S4 myocarditis, Coxsackie A 9, and herpes have shown that many polyelectrolytes viruses, the plaque-forming ability of at• with a negative charge disperse red blood tenuated types 1 and 2 poliovirus is actually cells, while those with a positive charge enhanced.201 Heparin has no effect on induce agglutination. Heparin is adsorbed mumps, Newcastle , measles, vac• on the surface of the erythrocyte, in• cinia, adeno I and II, Coxsackie B 5, and creasing electrostatic repulsion between red ECHO 9 and 13 viruses.209 Heparin de• blood cells and thus increasing suspension creases the titer of the infectious nucleic stability of the blood.,s4 acid prepared from the lactic dehydrogen• ase agent but has no demonstrable effect on Effect upon growth of bacteria, yeasts, the intact virus.160 The growth of fibroma and viruses virus-induced tumors in the rabbit is in• Heparin in a protein-free medium is hibited by heparin and polyanethol sul• bacteriostatic but not bacteriocidal at con• fonate.'" Heparin therapy has also shown centrations of 100 parts per million or some promise in the clinical treatment of greater when tested against Bacillus dermatitis herpetiformis.3 Heparin is stewarti or Micrococcus pyogenes var. thought to inhibit virus multiplication by aureus. Heparin failed to inhibit budding preventing the attachment of virus to in yeasts at concentrations of lO,OOO parts cells;209 dextran sulfate may have a dif• per million.215 Heparin produces bacterio• ferent mechanism of action. 20o Various stasis in an organic medium only if blood polyanions with strong electronegative from the region of an injury or pus is charges produce viral inhibition; molecular 386 Coon and Willis Clinical Pharmacology and Therapeutics

size and the degree of appear to demonstration of granules of ribonucleo• influence the magnitude of the effect.157 protein which accumulate in the cytoplasm of these cells." 65 Heparin in a low concen• Effect upon other cells and tration increases the viscosity of a rat liver The development of the fertilized eggs brei. This increased viscosity is prevented of certain marine organisms is inhibited by by removal of the nuclear fraction from heparin, toluidine blue, and Thrombocid the brei; heparin increases the viscosity (a heparinoid),87. 150 of nuclear suspensions, and DNA can be Several investigators have reported that demonstrated in the centrifugate. Similar heparin has a strong growth-inhibitory ef• experiments with mitochondria have shown fect on both fibroblasts175 and chondro• that heparin causes the release of ribo• blasts55 in tissue culture although this find• nucleic acid from this fraction. Anderson ing could not be duplicated with strain L and Wilbur5 propose, on the basis of these fibroblasts.ll7 No inhibition of growth of experiments, that heparin displaces nucleic three strains of human cells (one from a acids from basic proteins and that this nonneoplastic source), grown directly on may be the mechanism of the inhibitory glass in a fluid medium, was observed after effect of heparin upon cell division. exposure to high concentrations of heparin; Addition of heparin before or after Lisnell and Mellgren137 have proposed that freeze-thaw-induced structural alterations other reports regarding growth-inhibiting of Littre ascites tumor cells brings about action of heparin in vitro may have re• dramatic fading of nuclei. No effect is seen sulted from differing tissue culture tech• after addition of heparin to unfrozen con• niques. Other investigators have grown trol samples. After injury of the plasma cells in a plasma coagulum; the effect of membrane by freezing and thawing, hep• heparin may have been related to the arin is able to enter the cell and produce stimulation by heparin of fibrinolytic de• solubilization of nucleoprotein. Similar ef• struction of the coagulum, causing the fects are seen with fresh nuclei isolated cells to lose support and thus a suitable from chick erythrocytes. The gellike vis• medium for growth. cosity of the medium surrounding frozen• Incubation of rabbit marrow cells thawed preparations of ascites tumor cells in concentrations of heparin from 0.025 to or chicken erythrocytes is immediately 1.0 mg. per milliliter is not followed by a liquefied by desoxyribonuclease. Chon• significant decrease in synthesis of desoxy• droitin sulfate A has no effect in this sys• ribonucleic acid. Phenol in low concentra• tem."90 tion does depress DNA synthesis. Lochte, Heparin is taken up by cells in tissue Ferrebee, and Thomas" 39 speculate that culture, producing various cytologic effects phenol added as a preservative in heparin on hamster sarcoma, depending upon its solutions may be one factor influencing concentration in the culture medium. At prior reports of the inhibitory effects of 100 and 1,000 gamma per milliliter, it heparin. This effect of phenol is only ob• stimulates the appearance of cytoplasmic served, however, when the concentration of microvilli. At 1,000 gamma per milliliter phenol is greater than 0.12 mg. per milli• an alteration in neutral-red staining is meter. Although heparin does not appear observed; at 2,000 gamma per milliliter to have an effect upon synthesis of desoxy• vital staining disappears. Cytoplasmic and ribonucleic acid, there is considerable evi• nucleolar vacuolation and abnormal mitotic dence that it does produce solubilization figures are also observed. 36 These effects of nucleoprotein. Decreases in mitotic ac• may be related to other observations con• tivity in hanging-drop cultures of embry• cerning the effect of heparin upon solubil• onic chick heart after the addition of hep• ization of ribonucleoprotein and desoxy• arin have been related to the histochemical ribonucleoprotein. Volume 7 Side effects of heparin 387 Number 3

Heparin is a potent inhibitor of the up• fibril formation in solutions of acid-soluble take of labeled serum-bound lipids by collagen at pH 7. Chondroitin sulfates A human and animal epithelial cells. This and C accelerate fibril formation. Chon• appears to be due to a physicochemical droitin sulfate B and hyaluronic acid have effect of heparin upon the cell membrane no effect.2"2 since other anions or cations produce sim• ilar or opposite results, depending exclu• Effect upon the growth of transplan• Sively upon their charges.131 This finding table tumors may be of considerable importance in Since heparin is most effective if given pointing to a potential action of heparin prior to and again immediately after tumor and other anionic macromolecules in in• inoculation, it may act to inhibit successful Ruencing mechanisms of cellular transport. implantation of tumor cells. GD This effect Heparin also stimulates pinocytosis in of heparin may be related to its anticoagu• mouse fibroblasts 42 and induces the forma• lant effect in suppressing formation, tion of pseudopodia in Amoeba proteus but documentation of this fact, as far as when a fine pipette containing 3 x 10-5 inhibition of the growth of a primary tumor molar heparin is held near an ameba. Hep• inoculum is concerned, has not yet been arin apparently depolarizes the membrane established. of the ameba; this is thought to be the Preliminary exposure of sections of rat basis for stimulation of pseudopod forma• carcinoma to a solution of heparin for 22 tion.15 hours prior to transplantation has com• ConRicting reports have appeared con• pletely suppressed tumor development.G7 cerning the effect of heparin upon mitotic Zakrzewski,227 studying thousands of ani• activity of cells. Heparin injected intra• mals with rat and mouse sarcoma, has peritoneally in rats reduces the number of shown that heparin injected intravenously, mitoses in gastric epithelium but not in intraperitoneally, or into tumor tissue is duodenal epithelium.170 Intraperitoneal in• effective in reducing the rate of tumor jection of heparin results in marked stimu• growth and in prolonging survival of the lation of mitotic activity and increase in animals. Confirmatory studies have demon• desoxyribonucleic acid synthesis in paren• strated increased longevity in mice with chymal liver cells of normal rats; heparitin Ehrlichll or Krebs69 ascites tumor treated sulfate has a similar effect. Chondroitin with either heparin or a heparinoid. Other sulfate B displays lesser activity while investigators have not been able to repro• chondroitin sulfate A, chitin sulfate, and duce these findings,123, 218 although sig• polystyrene sulfonate have no stimulatory nificant decreases in mitotic index136 or in effect.229 This action of heparin may be percentage of tumor "takes" have been 2 responsible for contradictory reports con• reported. , 105 The subcutaneous adminis• cerning the presumed stimulatory effect of tration of heparin has no effect on the plasma from hepatectomized rats on mitosis primary growth of sarcoma T-241 and sar• of liver cells in normal rats, since this coma DBA49 in mice; metastases are in• effect is not observed when plasma is creased markedly in heparin-treated mice collected in citrate rather than heparin with the former , while solutions.228 formation decreases in mice with sarcoma Collagen fibers are formed immediately DBA49. in vitro by the action of heparin (1: 80,000) Increases in tumor growth have been or Paritol (a heparinoid, 1: 40,000) on solu• reported after treatment with glucuronic tions of collagen. Glucuronic acid, glucos• acid or glucosamine, components of the amine, and N-acetyl glucosamine have no heparin molecule. 105 For this reason hep• effect.153 Other investigators have reported arin inhibitors have been evaluated; partial that low concentrations of heparin retard inhibition of growth of Ehrlich ascites tu- 388 Coon and Willis Clinical Pharmacology and Therapeutics

mor has been reported after treatment with wounds and increasing the incidence of mixtures of toluidine blue and protamine nonunion of fractures.l6l Histologic evi• or toluidine blue, thionine, and ammonium dence of a deleterious effect of either hep• chloride but not after treatment with a arin or oral upon bone re• 38 195 single heparin antagonist. • 40 pair in rabbits and dogs is in support The effect of heparin upon suppression of the premise that inhibition of wound of tumor metastasis is probably secondary healing or bone repair by these agents 2 to the anticoagulant effect of heparin. , 34, may be related to their anticoagulant effect. 58, 120 In a study of the incidence of hepatic Since oral anticoagulants appear to have metastases in rats after intraportal injection an effect similar to that of heparin, com• of Walker carcinoma cells, an appreciable petitive inhibition by heparin of mucopoly• decrease in incidence of metastatic lesions saccharide synthesis seems a less likely was seen only when heparinization pre• explanation than the suppression by anti• ceded tumor injection and when heparin coagulants of the development of the fibrin was continued for 4 to 7 days after in• matrix upon which fibrous tissue or bone jection.58 Heparin has also been reported is laid down. Daily heparin injection pro• to decrease the number of tumor cells duces no demonstrable histologic effect circulating in the blood stream,34 although upon osteogenesis in mice.125 However, this finding has not been confirmed by other rabbits receiving a high fat diet and given investigators.12o, 144 heparin for a prolonged period frequently develop spontaneous fractures.63 Rats on a Effect upon wound healing and bone low calcium, high phosphorus diet and repair D develop rickets, , Conflicting reports have appeared con• and show a marked increase in tissue mast cerning effects of heparin upon wound cells.208 When the calvaria of Swiss mice healing. Daily injections of heparin bring are maintained in tissue culture, the addi• about an increase in the tensile strength of tion of small amounts of heparin or a hep• wounds in rats 5 days after wounding. This arinoid (Treburon) to the medium mark• increase in tensile strength was over 50 edly enhances the amount of bone resorp• per cent in each of four experiments, and tion obtained with suboptimal concentra• the wounds healed more rapidly than in tions of parathyroid extract, vitamin A, control animals. A further increase in ten• or vitamin D 2 , all of which stimulate bone sile strength was achieved when alternating resorption; no effect is seen when any of injections of histamine and heparin were these agents is added singly at the same given.53 Healing of small bums in dogs concentration. Goldhaber68 speculates that has been accelerated by heparin treat• heparin functions as a cofactor in stimu• ment143 although the experimental design lating bone resorption. The collagenolytic was such that the more rapid healing may activity of rat bone cell homogenates is have been due to the influence of secon• increased two- to fourfold in animals re• dary wounds on acceleration of healing ceiving large doses of heparin for 10 or rather than to the effects of heparin per se. more days.7 In well-controlled studies, heparin has in• Several clinical reports have appeared, creased the survival time of dogs with describing spontaneous fractures of verte• lethal bums and no supportive treatment.48 brae and ribs in patients receiving 15,000 Vascular healing is not significantly altered units or more of heparin per day for periods by heparin treatment.10 greater than 6 months.75 , 97 No deleterious Heparin treatment of scorbutic guinea effects have been observed in a large series pigs has been associated with an accelera• of patients receiving 10,000 units or less tion of the scorbutic process, producing a per day for 1 to 15 years. 75 These patients further decrease in the tensile strength of have had no alteration in parathyroid Volume 7 Side effects of heparin 389 Number 3

function, a normal serum calcium, low heparinoids have no effect on aldosterone urinary calcium, and normal secretion from isolated perfused adrenals, of hydroxyproline. Griffith and associates 75 they do suppress secretion when admin• have suggested that, on the basis of istered to the intact anima1. 49, 64, 213 preliminary observations relating heparin A different pattern has been observed effect to a decrease in stability of lyso• in both intact and adrenalectomized dogs some-like bodies in bone ceIls,225 the which, within 15 minutes after intravenous primary effect of heparin may be at this injection of heparin, develop an appreci• locus, and the bone abnormality seen in able increase in urinary potassium without disease may be secondary to in• a comparable change in sodium output; creased systemic levels of heparin. these were short-term experiments lasting for 2 hours or less. '55 A comparable effect Effect upon diuresis is not seen in humans.'87 In longer-term Several isolated clinical observations of studies in dogs, sodium output in urine an apparent effect following hep• is increased significantly,lS" arin injections, the earliest being that of Heparin appears to inhibit the antidi• Raynaud,171 stimulated subsequent docu• uretic effects of when the ef• mentation of this phenomenon. Heparin fects of vasopressin alone and heparin and several heparinoids (N-formyl-chitosan followed by vasopressin are compared in polysulfuric acid and xylan polysulfuric water-loaded human subjects.163 acid) produce diuresis in humans charac• terized by an increase in urinary sodium Miscellaneous effects and a slight decrease in potassium excre• Injection of heparin into normal rats 146 tion. , 185 The heparinoids are less potent produces a decrease in nitrogen excretion as than heparin. The diuretic of a magnitude equivalent to the effect effect of these agents appears only after at of 2.5 units of growth hormone; protamine least 36 hours of therapy and continues produces an increased nitrogen excretion for several days after heparin is discon• and inhibits the action of heparin.71 This tinued. The similarities between this pat• anabolic effect of heparin could not be con• tern of response and that induced by firmed in short-term studies (5 days).116 amphenone or spirolactones has been Heparin activates in the globulin frac• notedY5 Measurement of aldosterone ex• tion of a serum a substance which inhibits cretion in patients receiving a heparinoid the action of human or rat melanocyte• revealed a reduction in aldosterone excre• stimulating hormone on frog skin.lo8 tion (no effect on 17-hydroxycorticoid ex• The color intensity of sulfobromophthal• cretion) in conjunction with an increase ein dye is increased in postheparin serum in sodium output30, 145, 147, 186, 212; addition and the absorption peak shifts from 5,800 of spirolactone to this regimen produces to 5,950 Angstrom units; studies were car• an appreciable further increase in natri• ried out 3 minutes after intravenous in• uresis.3o Several highly sulfonated heparin• jection of 2 to 50 mg. of heparin intra• oids have natriuretic properties but little venously in normal human males.203 anticoagulant activity.,sB Schlatmann and During the induction of hypothermia in associates"86 have speculated that the ef• dogs, administration of heparin lowers fect of heparin on natriuresis and aldoste• "terminal temperature" (the rectal tempera• rone suppression may be mediated by in• ture to which an animal can be cooled hibition of the renin-angiotensin system by surface cooling before the advent of which is thought to stimulate aldosterone ventricular fibrillation or cardiac arrest). 29 secretion. In support of this theory is the This effect may be secondary to an anti• finding that heparin complexes with angio• thrombotic effect, alteration of suspension tensin"o1 and that, although heparin or stability of the blood, or, less likely, to 390 Coon and Willis Clinical Pharmacology and Therapeutics

activity in prevention of has. This, in itself, is of both theoretical fat embolism. The effect and practical interest as a demonstration seems most likely.140 of the many unsuspected side effects which Heparin alone or heparin in combination may be produced by a administered with nicotinic acid raises serum iron levels to achieve a solitary therapeutic objective. in patients with "infectious hyposideremia"; In the 30 years of extensive clinical use this has been explained on the basis of in• of heparin, reports of undesirable side ef• hibition by heparin of the uptake of free fects have been remarkably few. Occa• iron by the reticuloendothelial system. 22 sional hemorrhagic complications related Phagocytosis of colloidal particles and to its anticoagulant action are inevitable. bacteria is also inhibited by heparin and Very rarely, an anaphylactOid response other negatively charged macromole• following repeated injections has been ob• cules.98, 159 served. In recent years, interest has devel• Injection of a heparinoid (Treburon) oped concerning potential deleterious ef• reduces the period of anesthesia from pen• fects upon bone of long-term tobarbital in dogs, is partially effective administration of relatively large doses of (significant reduction in time of return of heparin. The possibility of development of righting reHex) in pigeons, and has no osteoporotic changes after chronic admin• significant effect on anesthesia in rabbits; istration of heparin for 6 months or more it has no demonstrable analeptic effect in seems real. unanesthetized animals.107 Several other pharmacologic effects of Injection of heparin in rabbits is ac• heparin deserve further investigation be• companied by a highly significant rise in cause of their potential therapeutic use• fasting blood sugar which can be prevented fulness in other areas of human disease. by prior injection of tolazoline. Heparin The complexing of heparin with many does not alter hyperglycemic response to cationic macromolecules may be more of glucagon or epinephrine but does decrease theoretical than practical value since most the magnitude of the hypoglycemia in• of the effects described have been observed duced by insulin. The authors postulate only in vitro. The apparent reduction of that heparin stimulates endogenous release toxicity of neomycin in vivo without equiv• of epinephrine.20 Administration of hep• alent loss in activity may have arin to normal males produces a mean rise practical utility. The role of heparin and in blood glucose over that in control sub• heparinoids in reducing experimental peptic jects of 30 mg. per cent with a peak effect ulcers is of considerable interest; whether at 4 hours.142 this effect is related to complexing with Pulmonary edema produced in dogs by pepsin or histamine has not yet been clari• intracarotid infusion of massive amounts fied. of physiologiC saline is prevented by pre• The therapeutic value of heparin in treatment with heparin but not pretreat• certain autoimmune diseases and allergiC ment with oral anticoagulants.H1 states is also receiving current attention. When rats are pretreated with one of a The natriuretic properties of heparin are number of heparinoids, but not heparin, well documented. Since heparin and re• a significant anti-inHammatory effect is lated compounds without appreciable anti• demonstrable as measured by the zymosan• coagulant activity potentiate the effects of edema test.130 other diuretics as well, this action may also have therapeutic value. Comment If heparin's antiviral action is secondary The multitude of ancillary effects of a to an inhibition of attachment of virus to pharmacologic agent has seldom evoked cell membrane, then this function at an the interest or documentation that heparin extracellular locus provides some ground Volume 7 Side effects of heparin 391 Number 3

for hope that it might be effective against 14. Bartalos, M., Cyorkey, F., and Koppanyi, Z.: some viruses in vivo. Its apparent bene• Diminution of B-glucuronidase activity in ficial effect in the treatment of dermatitis post-heparin human sera, 195:181- 182, 1962. herpetiformis would support this premise. 15. Bell, L. C. E., and Jeon, K. W.: Stimulation The effect of heparin and plasmin in in• of cell locomotion and pseudopod formation hibiting tumor implantation and metastasis by heparin, Nature 195:400-401, 196,2. has been under investigation in several 16. Beller, F. K.: Der Einfluss des Regulations• laboratories; this inhibition is most likely systems ACTH-Heparin auf die Gerinnungs• vorange, Arzneimittelforsch. 8:243-249, 1954. secondary to the antithrombotic actions of 17. Beller, F. K., and Krauss, W.: Dber die these agents. Uteruswirksamkeit von Heparin-antidoten, Gynaecologia 140:273-287, 1955. References 18. Bick, M. W., and Wood, R. M.: Heparin and ocular , J. ImmunoI. 64: 1. Agol, V. I., and Chumakova, M. Y.: Effect 357-3,64, 195.0. of polyanions on the multiplication of two 19. Bick, M. W., and Wood, R. M.: Heparin and variants of polio virus, Acta virol. 7:97-106, uveitis. An experimental study, Am. J. Ophth. 1963. 33:1878-1881, 1950. 2. Agostino, D., and Cliffton, E. E.: Anticoagu• 20. Bond, B. D., and Spitzer, J. J.: Effects of lants and the development of pulmonary heparin on metabolism in the metastases, Arch. Surg. 84:449-453, 1962. rabbit, Am. J. Physiol. 180:575-579, 1955. 3. Alexander, J. 0.: The treatment of derma• 21. Braunsteiner, H., Potuzhek, 0., and Thumb, titis herpetiformis with heparin, Brit. J. N.: Dber die Beeinflussung der Eosino• Dermat. 75:289-293, 1963. philenzahl durch heparin, Rev. hemat. 22: 4. Amann, R, and Werle, E.: Ueber Komplexe 153c 157, 1959. von Heparin mit Histamin und anderen Di• 22. Braunsteiner, H., Sailer, S., and Weippl, W.: und Polyaminen, Klin. Wchnschr. 34:207-209, Dber den Einfluss von Nikotinsaure und 1956. Heparin auf den EisenstoffwechseI, Blut 5: 5. Anderson, N. C., and Wilbur, K. M.: The 149"154, 1959. release of nucleic acids from cell components 23. Braunsteiner, H., and Thumb, N.: Dber quan• by heparin, Fed. Proc. 9:254, 195.0. titative Veranderungen der basophilen Leu• 6. Armstrong, D. A. J., and Stewart, J. W.: kozyten und ihre Stoffwechselbedeutung, Anti-heparin agents as inhibitors of plasma Wien. Ztschr. inn. Med. 39:285-288, 1958. kinin formation, Nature 194:689, 1962. 24. Buddecke, E., and Drzeniek, R: Stabilitats• 7. Asher, J. D., and Nichols, C., Jr.: Heparin konstanten der calcium komplexe von sauren stimulation of bone collagenase activity, Fed. mucopolysacchariden, Ztschr. physioI. Chern. Proc. 24:211, 1965. Abst. 327:49-64, 1962. 8. Astrup, T., Crookston, J., and Macintyre, A.: 25. Burstein, M., and SamailIe, J.: Precipitation Proteolytic enzymes in blood, Acta physioI. des lipoproteines par l'heparine et par des scandinav. 21:2.38-249, 1950. heparinoides de synthese, Brussels, 1956, 20th 9. Astrup, T., and Piper, J.: Interaction between Internat. Phys. Congr., p. 149. Abst. fibrinogen and polysaccharide polysulfuric 2B. Butler, S.: Experiments dealing with relation acids, Acta physiol. scandinav. 11:211-220, of blood histamine to coagulation, hemocon• 1946. centration and arterial blood pressure, Quart. 10. Bacigalupo, F., Simandl, E., Bhonslay, S. B., Bull. Northwestern University M. School 29: and Deterling, R A., J r.: The effect of 10.0-105, 1955. heparinization upon vascular healing, Arch. 27. Cajani, F.: Inibizione da parte dell'idrolisi Surg. 74: 153-172, 1957. enzimatica del fenolftalein-B-glucuronide, 11. Balazs, A., and Holmgren, H. J.: Effect of Atti Soc. lomb. sc. med. e bioI. 12:286-290, sulfomucopolysaccharides on growth of tu• 1957. mor tissue, Proc Soc. Exper. BioI. & Med. 28. Capraro, V., Marro, F., and Valzelli, G.: 72:142-145, 1949. Permeabilizing effects of heparin and heparin• 12. Barlow, C. H.: Macromolecular properties like substances, Nature 182:603-604, 1958. and biological activity of heparin. III. Paper 29. Caranna, L., Montgomery, V., and Swan, H.: electrophoretic studies of histamine binding, Effect of intravenous heparin on terminal Biochim. et biophys. acta 83: 120-122, 1964. temperature in the hypothermic dog, Arch. 13. Barr, S. E., Brown, H., and Dyer, R. F.: The Surg. 79:729-733, 1959. influence of heparin on the blood eosinophil, 30. Cejka, V., de Vries, L. A., Smorenberg• J. 31:406-412, 1960. Schoor!, M. E., van Daatselaar, J. J., Borst, 392 Coon and Willis Clinical Pharmacology and Therapeutics

J. G. G., and Majoor, C. L. H.: Effect of tween acid mucopolysaccharides and various heparinoid and spirolactone on the renal ex• cations, Biochem. J. 85:336-351, 1962. cretion of sodium and aldosterone, Lancet 46. Ecker, E. E., and Gross, P.: Anticomplemen• 1:317, 1960. tary power of heparin, J. Infect. Dis. 44: 31. Chargaff, E., and Olsen, K. B.: Studies on 250-253, 1929. the chemistry of blood coagulation. VI. 47. Eisen, V.: Effect of hexadimethrine bromide Studies on the action of heparin and other on plasma kinin formation, hydrolysis of p• anticoagulants. The influence of protamine tosyl-l-arginine methyl ester and , on the anticoagulant effect in vivo, J. BioI. Brit. J. Pharmacol. 22:87-103, 1964. Chern. 122: 153-167, 193'7. 48. Elrod, P. D., McCleery, R. S., and Ball, C. 32. Cheymol, J., Bourillet, F., and Levassort, C.: O. T.: An experimental study of the effect of Action anticurarimimetique de l'heparine et heparin on survival time following lethal d'heparinoides de syntMse chez Ie lapin, J. burns, Surg. Gynec. & Obst. 92:35-42, 1951. Physiol. (Paris) 47:132-136, 1955. 49. Fachet, J., Stark, E., Vallent, K., and Pal• 33. Cliffton, E. E.: Early experience with fibrinol• kovits, M.: Some observations on the func• ysin, Angiology 10:244-252, 1959. tional interrelationship between the thymus 34. Cliffton, E. E., and Agostino, D.: cells and the adrenal cortex, Acta med. Acad. sc. in the blood in simulated colon cancer, Hung. 18:461-466, 1962. resectable and unresectable: Effect of fibrinol• 50. Fantl, P., and Marr, A. G. M.: as ysin and heparin on growth potential, Sur• inhibitors of the heparin co-factor of plasma, gery 50:395-401, 1961. Nature 180:99,0, 1957. 35. Copley, A. L., Krchma, L. C., and Whitney, 51. Farber, S. J., and Schubert, M.: The binding M. E.: Humoral rheology. I. Viscosity studies of cations by chondroitin sulfate, J. Clin. and anomalous flow properties of human Invest. 36:1715-172,2, 1957. blood systems with heparin and other 52. Fekete, G., and Hegyeli, A.: Investigations anticoagulants, J. Gen. Physiol. 26:49-64, on the ACTH-protamine complex, Experi• 1942. entia 12:222-223, 1956. 36. Costachel, 0., Fadei, L., and Nachtigal, M.: 53. Fenton, H., and West, G. B.: Studies on The action of heparin in vitro on Syrian• wound healing, Brit. J. Pharmacol. 20:507- hamster sarcoma-cell cultures, Exper. Cell 515, 1963. Res. 34:542-547, 1964. 54. Fischer, A.: Untersuchungen iiber Muskel• 37. Creutzfeldt, W., Hoffmann, R, and Weiss• koaguline, Biochem. Ztschr. 240:357-364, becker, L.: Beeinflussung der ACTH-Wirk• 1931. ung durch Heparin 1M Thymusinvolutionstest, 55. Fischer, A.: Ueber die Wirkung des Klin. Wchnschr. 32:1003~1O04, 1954. auf das Wachstum von Gewebezellen in 38. Csaba, G., Acs, Th., Horvath, c., and Kapa, vitro, Protoplasma 26:344, 1936. E.: Some new data concerning the biology 56. Fischer, A., and Astrup, T.: Stochiometrische of tumors, Brit. J. Cancer 14:367-375, 1960. Bindungsverhaltnisse zwischen Heparin und 39. Csaba, G., and Horvath, C.: The effect of Gerinnungsstoff, Biochem. Ztschr. 278:3,26- heparin and its components on frog heart, 333, 1935. Biochem. Pharmacol. 12:1075-1080, 1963. 57. Fischer, A., and Herrmann, H.: Ueber die 40. Csaba, G., Horvath, C., and Acs, Th.: Some Hemmung der Fumarasewirkung durch Hep• new data concerning the biology of tumors, arin, Enzymologia 3:180-182,1937. Brit. J. Cancer 14:362-366, 1960. 58. Fisher, B., and Fisher, E. R.: Experimental 41. Dimond, E. G.: Inhibitory effect of heparin studies of factors which influence hepatic upon adenylic deaminase, J. Lab. & Clin. metastases. VIII. Effect of anticoagulants, Med. 46:807-809, 1955. Surgery 50:240-247, 19>61. 42. Dougherty, T. F., and Dolowitz, D. A.: 59. Floch, M. H., and Groisser, V. W.: The Physiologic actions of heparin not related to effect of heparin on the arginine (BAEE) blood clotting, Am. J. Cardiol. 14: 18-24, esterase activity of blood, J. Pharmacol. & 1964. Exper. Therap. 135:256-258, 1962. 43. Dragstedt, C. A., Wells, J. A., and Rocha e 60. Fritzsche, W., and Martin, H.: Properdin Silva, M.: Heparin as an to trypsin Und Hamolyse. Zur Hemmung der Hamolyse in the rat, Fed. Proc. 1: 149, 1942. der Erythrocyten von Kranken mit paroxy• 44. Dragstedt, C. A., Wells, J. A., and Rocha e smaler nachtlichen Hamoglobinurie durch Silva, M.: Inhibitory effect of heparin upon Heparin, Klin. Wchnschr. 35:1166-1168, 1957. histamine release by trypsin, antigen, and 61. Galluzzi, N. J., DeLashmutt, R E., and proteose, Proc. Soc. Exper. BioI. & Med. 51: Connolly, V. J.: Failure of anticoagulants to 191-192, 1942. influence the viscosity of whole blood, J. 45. Dunstone, J. R: Ion-exchange reactions be- Lab. &. Clin. Med. 64:773-777, 1964. Volume 7 Side effects of heparin 393 Number 3

62. Gilbert, N. C., and Nalefski, L. A.: The effect able par l'heparine de la nephropathie hetero• of heparin and Dicumarol in increasing the immune experimentale, Compt. rend. Soc. coronary flow volume, J. Lab. & Clin. Med. bioI. 158:2297-2302, 1964. 34:797-805, 1949. 80. Halpern, B. N., Milliez, P., Lagrue, G., Fray, 63. Gillman, T.: Discussion in Tunbridge, R. E., A., and Morard, J. C.: Protective action of editor: Connective Tissue: A Symposium, heparin in experimental immune nephritis, Oxford, 1957, Blackwell Scientific Publica• Nature 205:257-259, 1965. tions, p. 33. 81. Hamilton, L. H.: Heparin-induced block of 64. Ghiz, K, and Sugar, K: Effect of heparin the leukocyte response to cortisone, En• and heparinoids on the synthesis of aldo• docrinology 61:392-3,97, 1957. sterone and corticosterone by the rat adrenal 82. Hamilton, L. H., and Lowenthal, J.: Effect gland, Endocrinology 74: 159-164, 1964. of heparin pretreatment on stress-induced 65. Godal, H. C.: Precipitation of human fibrin• leukocyte changes in the rat, Endocrinology ogen with heparin, Scandinav. J. Clin. & 58:546-549, 1956. Lab. Invest. 12:56-65, 191610. 83. Hardegg, W., Huhnstock, K, Maass, W., 66. Godlowski, Z. Z.: The fate of eosinophils in and Abel, H.: Zum Mechanismus der blut• hormonally induced eosinopenia and its sig• drucksenkenden Wirkung von Heparin, Klin. nificance, J. Endocrinol 8:102-125, 1952. Wchnschr. 34:763, 1956. 67. Goerner, A.: The influence of anticlotting 84. Hardegg, W., Maass, W., Mayer, G., Abel, agents on transplantation and growth of tu• H., and Huhnstock, K: Ueber die Wirkung mor tissue, J. Lab. & Clin. Med. 16:369-372, von Heparin auf den experimentellen Hoch• 1931. druck bei Ratten, Klin. Wchnschr. 33:811- 68. Goldhaber, P.: Heparin enhancement of fac• 813, 1955. tors stimulating bone resorption in tissue 85. Hartman, M. M.: Reversal of serologic reac• culture, Science 147:407-408, 1965. tions by heparin: Therapeutic implications. 69. Goldie, H., Walker, M., Biscoe, B., Powell, 1. Systemic lupus erythematosus, Ann. Allergy G. J., and Howse, R. J.: Growth character• 22:238-243, 1964. istics of ascitic tumor cells in the heparinized 86. Hashish, S. K K: The effects of low tem• peritoneal cavity of the mouse, Proc. Soc. peratures and heparin on potassium exchange• Exper. BioI. & Med. 107:838-842, 1961. ability in rat diaphragm, Acta physioI. 70. Gousios, A., and Shearn, M. A.: Effect of scandinav. 43:189-199, 1958. intravenous heparin on human blood vis• 87. Heilbrunn, L. Y., and Wilson, W. L.: The cosity, Circulation 20:1063-1066, 1959. effect of heparin on cell division, Proc. Soc. 71. Granitsas, A. N.: Heparin and nitrogen ex• Exper. BioI. & Med. 70: 179-182, 1949. cretion in normal rats, Am. J. PhysioI. 199: 88. Heine, K M., Herrmann, H., and Stobbe, H.: 729-730, 1960. Die Heparinbehandlung bei erworbener 72. Green, J. P., Day, M., and Roberts, M.: On hamolytischer Anamie, Acta haem at. 32:27- the smooth-muscle stimulating activity of 34, 1964. preparations of heparin, J. PharmacoI. & 89. Higginbotham, R D.: Effect of heparin on Exper. Therap. 132:58-64, 1961. neomycin, Texas Rep. BioI. & Med. 18:408- 73. Green, J. P., and Nahum, L. H.: Effects of 417, 1960. liver fractions on myocardial contractility, 90. Higginbotham, R D., and Carter, P. B.: Circulation Res. 5:634-640, 1957. Enhanced tolerance of heparin-treated mice 74. Greig, H. B. W.: Inhibition of fibrinolysis for polymyxin B, 7:527-531, 1957. by alimentary lipemia, Lancet 2:16-18, 1956. 91. Higginbotham, R D., and Murillo, George J.: 75. Griffith, G. c., Nichols, G., Jr., Asher, J. D., Influence of heparin on resistance of rabbits and Flanagan, B.: Heparin osteoporosis, to with fibroma virus, J. ImmunoI. J. A. M. A. 193:91-94, 1965. 94:228-233, 1965. 76. Gundersen, K., and Lin, B. J.: Effect of 92. Holemans, R, Adamis, D., and Horace, J. F.: heparin on insulin complexes, Tufts Folio Heparine et fibrinolyse, Experientia 18:377- Med. 8:17~19, 1962. 378, 1962. 77. Hadidian, Z., Murphy, M. M., and Mahler, 1. 93. Hiirder, M. H., Kickhiifen, B., and Wendt, R: Studies of inhibitors of bacterial and other F.: Aktivierung der Fibrinolyse beim Men• hyaluronidases. II. Heparin and other non• schen durch ein bakterielles Pyrogen, Klin. specific inhibitors, J. Bact. 73:491-493, 1957. Wchnschr. 36: 164-166, 1958. 78. Hajjar, G. c., and Moser, K M.: Heparin• 94. Horwitt, M. K: The anti-tryptic properties fibrinolytic synergism in vivo, Clin. Res. 10: of heparin, Science 92:89-9(), 1940. 26, W62. 95. Houck, J. C.: The competitive inhibition of 79. Halpern, B. N., Lagrue, G., Milliez, P., Mor• hyaluronidase, Arch. Biochem. 71:336-341, ard, J. C., and Fray, A.: Inhibition remarqu- 1957. 394 Coon and Willis Clinical Pharmacology and Therapeutics

96. Hummel, K., Kohler, R., and Behringer, F.: 112. von Kaulla, K. N., McDonald, S. T., and Zur Frage des Einflusses von Heparin• Taylor, G. H.: The effect of heparin on praparaten (Liquemin-Roche und Thrombo• fibrinolYSiS, J. Lab. & Clin. Med. 48:952, cid-Benend) auf die Bildung von Anti• 1956. korpem, Ztschr. klin. Med. 148:597-602, 1951. 113. Kelentey, B., Foldes, I., Lipak, J., and 97. Jaffe, M. D., and Willis, P. W., III: Multiple Csongor, J.: Effect of heparin on the blood, fractures associated with long-term sodium brain, cerebrospinal fluid, and vitreous humor heparin therapy, J. A. M. A. 193:158-160, barriers, Arch. intemat. pharmacodyn. 150: 1965. 363-371, 1964. 98. von J ancso, N.: Pharmakologische Beein• 114. Keller, R.: Experimentelle Untersuchungen flussung des Reticuloendothels. Zugleichein zur Blutdrucksenkenden, Arch. intemat. phar• Beitrag zu den Beziehungen zwischen Blut• macodyn. 110:300-308, 1957. gerinnung and Speicherung, Klin. Wchnschr. 115. Kerby, G. P., and Eadie, G. S.: Inhibition 10:537-540, 1931. of lysozyme by heparin, Proc. Soc. Exper. 99. Jansen, C. R., Cronkite, E. P., Mather, G. C., Bio!. & Med. 83:111-113, 1953. Nielsen, N. 0., Rai, K., Adamik, E. R., and 116. Kim, K. S.: Anabolic agents and histamine Sipe, C. R.: Studies on lymphocytes. II. The metabolism, Nature 191:1368-1370, 1961. production of lymphocytosis by intravenous ll7. King, D. W., Bensch, K. G., and Simbonis, heparin in calves, Blood 20:443-45,1, 1962. S.: The lack of effect of heparin on mitosis in 100. Jaques, L. B.: The reaction of heparin with strain L cells, Cancer Res. 18:382-384, 1958. proteins and complex bases, Biochem. J. 37: 118. Kleinerman, J.: Effects of heparin on experi• 189-195, 1943. mental nephritis in rabbits, Lab. Invest. 3: 101. Jaques, R., Kuttner, K., Bein, H. J., and 495-508, 1954. Meier, R.: "Bindung" eines synthetischen 119. Kobayashi, Y.: Histamine binding by heparin, Polypeptides (Hypertensin) an Heparin und Arch. Biochem. 96:20-27, 1962. Freisetzung des Peptides durch Compound 120. Koike, A.: Mechanism of blood-borne metas• 48/80 in vitro, Experientia 16: 147, 1960. tases. I. Some factors affecting lodgment and 102. Johansson, S.: Inhibition of growth of tumor cells in the lungs, Cancer and 5-hydroxytryptamine release in anaphy• 17 :450-460, 1964. lactic shock by heparin, Acta physio!. scand• 121. Konttinen, Y.: On the effect of alimentary inav. 50:95-104, 1960. lipemia and a natural heparinoid on the 103. Johansson, S. A.: Studies on platelets and fibrinolytic system of man, Scandinav. J. heparin during sensitization and anaphylaxis, Clin. & Lab. Invest. 14:87-99, 1962. Acta allergo!. 19: 142-162, 1964. 122. Konttinen, Y.: The effect of heparin on the 104. Johansson, S. A., Lundberg, A. and Sjoberg, fibrinolytic activity of -activated H. E.: Influence of Heparin on thrombocyto• human plasma, Scandinav. J. Clin. & Lab. penia in allergic reactions, Acta med. scand• Invest. 14:15-18, 1962. inav. 168:165-168, 1960. 123. Kreisler, L.: Effect of heparin on the growth 105. Jolles, B., and Greening, S. G.: Effect of of a transplantable lymphosarcoma in mice, heparin upon tumour growth, Acta Unio Science 115: 145-146, 1952. intemat. contra Cancrum 16:682-685, 1960. 124. Kyes, P., and Strauser, E. R.: Heparin in• 106. J orpes, J. E.: Heparin in the treatment of hibition of anaphylactic shock, J. Immuno!. , ed. 2, London, 1946, Oxford 12:419-422, 1926. University Press, pp. 53-56. 125. Lagier, R., and Pollman, G.: Contribution 107. Joseph, A. D., Jindal, M. N., and Patel, M. a I'etude de I'os oestrogenique chez la souris. A.: Treburon as a barbiturate antagonist? Administration d'heparine au cause de son Lancet 1:815-816, 1959. developpement, Arch. Sc. (Gem'we) 8:441- 108. Kadas, L.: Experimentelle Untersuchung des 449, 1955. im Normalserum auf Einwirkung von Heparin 126. Lambert, H. P.: Vascular effects of heparin, entstehenden die Melanophorennaktivitat hem• dextran sulphate, and 5-hydroxytryptamine, menden Faktors, Acta physrio!. Budapest 6: Clin. Sc. 17:621-628, 1958. 485-493, 1954. 127. Lambert, H. P., and Richley, J.: The action 109. Karasek, F., and Mourek, J.: L'influence de of mucin in promoting : The anti• l'heparine sur la resistance contre I'anoxemie, complementary effect of mucus extracts and J. Physio!. Paris 51:496-497, 1959. certain other substances, Brit. J. Exper. Path. 1l0. Katsh, S.: Heparin and anaphylaxis, Arch. 33:327-339, 19152. intern at. pharmacodyn. 137:272-277, 1962. 128. de Lamirande, G., Allard, C., da Costa, H., lll. von Kaulla, K. N., and McDonald, S. T.: and Cantero, A.: Intracellular distribution of The effect of heparin on components of the acid and alkaline ribonuclease in normal rat human fibrinolytiC system, Blood 13:811-821, liver, Science 119:351-353, 1954. 1958. 129. de Lamirande, C., Weber, G., and Cantero, Volume 7 Side effects of heparin 395 Number 3

A.: In vivo effect of heparin on acid and 145. Majoor, C. L. H., Jansen, A. P., Schlatmann, alkaline ribonuclease activities of mousp liver, R. J. A. F. M., van der Korst, J., and Prenen, Am. J. Physiol. 184:415-417, 1956. H.: Heparin and related polysaccharides as 1.'3,0. Lauenstein, K., Friedrich, H., and Haberland, diuretic and aldosterone suppressing G. L.: On the antiphlogistic effect of in man and dog, Acta cardio!. 17:657-671, heparin and heparinoids, Med. exper. 6:200- 1962. 204, 1962. 146. Majoor, C. L. H., Prenen, H., Van Munster, 131. Lazzarini-Robertson, A., Jr.: Effects of hep• P. J. J., and Schlatmann, R. J. A. F. M.: Het arin on the uptake of lipids by isolated hu• diuretische effect van heparine, in het bij• man and animal arterial endothelial type zonder bijpatienten met het nefrotische syn• cells, Angiology 12:525-534, 1961. drome, Nederl. tijdschr. v. geneesk. 101: 1301- 132. Lecomte, J.: Sur r action antiallergique de 13,07, 1957. l'heparine, Arch. internat. pharmacodyn. 109: 147. Majoor, C. L. H., Schlatrnann, R. J. A. F. 25-38, 1957. M., Jansen, A. P., and Prenen, H.: Excretion 133. Lecomte, J., and Hugues, J.: Action in• pattern and mechanism of diuresis induced hibitrice de l'heparine sur Ie pMnomtme by heparin, CHn. chim. acta 5:591-606, 1960. d'Arthus, Intemat. Arch. Allergy 5:367-373, 148. Mayer, G.: Ueber die Wirkung von Heparin 1954. auf den nephrogenen Hochdruck der Ratte, 134. Lerner, H. J., and Thompson, J. c.: Heparin Ztschr. ges. exper. Med. 128:27-35, 1956. suppression of gastric acid secretion, Proc. 149. Miller, D.: Heparin precipitability of the Soc. Exper. BioI. & Med. 112:730-732, 1963. macroglobulin in a patient with Walden• 135. Levey, S., and Sheinfeld, S.: The inhibition strom's macroglobulinemia, Blood 16:1313- of the proteolytic action of pepsin by sulfate• 1317, 1960. containing polysaccharides, Gastroenterology 150. Molho, D., Molho-Lacroix, L., and Cordier, 27:625-628, 1954. D.: Action de quelques anticoagulants sur 136. Lippman, M.: The growth-inhibitory action Ie developpement de la membrane de fertil• of heparin on the Ehrlich ascites tumor in isation de l'oeuf d' Oursin, Compt. rend. mice, Cancer Res. 17:11-14, 1957. Soc. bioI. 148:1824-1829, 1954. 137. Lisnell, A., and Mellgren, J.: Effect of 151. Mora, P. T., and Young, B. C.: Reversible heparin, protamine, , streptokinase, inhibition of enzymes by interaction with and epsilon-amino-N-caproic acid on the synthetic polysaccharide macroanions, Arch. growth of human cells in vitro, Acta path. Biochem. 82:6-20, 1959. et microbiol. scandinav. 57:145-153, 1963. 152. Mora, P. T., Young, B. C., and Shear, M. 138. Litwack, G., and Diamondstone, T. I.: Non• J.: Reduction of toxicity of cationic macro• specific stimulation of tyrosine-a-ketoglutarate molecules by complexing with anionic deriva• transaminase activity in vivo, J. BioI. Chern. tives of synthetic polyglucoses, Nature 184: 237:469-472, 1962. 431-435, 1959. 139. Lochte, H. L., Jr., Ferrebee, J. W., and 153. Morrione, T. G.: Formation of collagen fibers Thomas, E. D.: The effect of heparin and by action of heparin on soluble collagen: EDTA on DNA synthesis by marrow in Electron microscopic study, J. Exper. Med. vitro, J. Lab. & Clin. Med. 55:435-438, 96:107-114,1952. WOO. 154. Morris, F. R., Lowenthal, J., and Hamilton, 140. Lofstrom, B., and Zederfeldt, B.: Effect of L. H.: Effect of heparin pretreatment on heparin on intravascular aggregation in in• stress-induced adrenal ascorbic acid changes duced hypothermia, Acta chir. scandinav. in the rat, Experientia 12:156, 1956. 116:163-166, 1959. 155. Muldowney, F. P., and Banks, P.: Kaluretic 141. Luisada, A. A., and Contro, S.: Experi• effect of heparin, Lancet 1:548-549, 1960. mental pulmonary edema following rapid 156. Nahmias, A. J., and Kibrick, S.: Inhibitory carotid infusion: Mechanism and therapy, effect of heparin on certain viruses, Bact. Circulation Res. 1:179-183, 1953. Proc. 66:145, 1963. Abst. 142. Lusztig, G., SibaHn, E., and Lusztig, G.: 157. Nahmias, A. J., Kibrick, S., and Bernfeld, P.: Die antilipamische und hyperglykamie ver• Effect of synthetic and biological polyanions ursachende Wirkung des Heparins, Ztschr. on herpes Simplex virus, Proc. Soc. Exper. ges. inn. Med. 14:498-5,03, 1959. BioI. & Med. 115:993-996, 1964. 143. McCleery, R. S., Schaffarzick, W. R., and 158. Newman, H. c., and Barnett, A. J.: A com• Light, R. A.: An experimental study of the parison of placebo and heparin treatment in effect of heparin on the local pathology of intermittent claudication, Australian Ann. burns, Surgery 26:548-564, 1949. Moo. 4:195-199, 1955. 144. Madden, R. E., and Malmgren, R. A.: Quan• 159. Northover, B. J.: Influence of the charge on titative studies on circulating cancer cells in a serum protein molecule and its ability to the mouse, Cancer Res. 22:62-66, 1962. stimulate or inhibit the phagocytosiS of bac- 396 Coon and Willis Clinical Pharmacology and Therapeutics

teria by leucocytes, Nature 189:574-576, vestigations into the roles of heparin in pro• 1961. liferative tissue reactions, Surgery 34:470- 160. Notkins, A. L., and Cosmides, M.: The effect 481, 1953. of heparin on the titer of the infectious 176. Rosen, D. A., Becker, B., Maengwyn-Davies, nucleic acid from the lactic dehydrogenase G. D., and Friedenwald, J. S.: The influence agent, Biochim. et biophys. acta 91:536-538, of heparin on the cortisone nephropathy of 1964. the rabbit, Bull. Johns Hopkins Hosp. 95: 161. Ohlwiler, D. A., Jurkiewicz, M. J., Butcher, 144-146, 1954. H. R., Jr., and Brown, J. B.: The effect of 177. Rosenman, R. H., Solomon, B., Byer, S., and heparin and ascorbic acid upon the formation Friedman, M.: Arresting effect upon experi• of collagen, S. Forum 10:301-303, 1960. mental nephrosis in rats, Proc. Soc. Exper. 162. Olesen, E. S.: Effect of acid polysaccharides Bio!. & Med. 86:599-603, 1954. on the fibrinolytic system in guinea-pig serum, 178. Roth, J. S.: Inhibitors and activators for Acta pharmacol. et toxico!. 15:307-318, 1959. ribonuclease and desoxyribonuclease, Fed. 163. Orosz, L., and Hankiss, J.: Heparin and the Proc. 11:277-278, 1952. water metabolism with special reference to 179. Roth, K. L.: Interaction of heparin with the ADH, Tohoku J. Exper. Med. 79:152-157, auto-agglutinins in idiopathic acquired hemo• 1963. lytic anemia, Proc. Soc. Exper. BioI. & Med. 164. Owren, P. A.: Acquired hemolytic jaundice, 86:352-356, 1954. Scandinav. J. Clin. & Lab. Invest. 1:41-48, 180. Roth, K. L.: Notes on the relationship be• 1949. tween the therapeutic and anticomplementary 165. Paff, G. H., Sugiura, H. T., Bocher, C. A., effects of heparin in acquired hemolytic and Roth, J. S.: The probable mecha• anemia, Ann. Allergy 23:83-912, 1965. nism of heparin inhibition of mitosis, Anat. 181. Roth, K. L., and Frumin, A. M.: Effect of Rec. 114:499,-503, 1952. intramuscular heparin on antibodies in 166. Paluska, D. J., and Hamilton, L. H.: Effect idopathic acquired hemolytic anemia, Am. J. of heparin on leukocyte response to hydro• Med. 20:968-970, 1956. cortisone injections, Am. J. Physio!' 204: 182. Salminen, S.: Studies on the ultrafiltrability 1103-1106, 1963. of serum sodium and potassium, Ann. med. 167. Parrot, J. L., and Laborde, C.: Captation de exper. et bioI. Fenniae. 39: Suppi. 4, 1961. l'histamine par l'heparine, Compt. rend. Soc. 183. Salminen, S., and Luomanmaki, K.: The bio!. 145:1047-1051, 1951. binding of sodium and potassium ions by 168. Piette, M., and Piette, C.: Studies on the heparin, Biochim. et biophys. acta 69:533- basophilic of the blood. II. In• 537, 1963. travenous injection of heparin in the rabbit, 184. Saxl, H., Marikovsky, Y., Danon, D., and Ann. Pharmaco!. 17:344-352, 1959. Katchalsky, A.: The effect of heparin and of 169. Rasanen, T.: Effects of heparin and asbestos treatment by the El faction of the elastase with corticotrophin on the mucosal mast cells complex on the agglutinability of erythrocytes and tissue eosinophils of rat stomach, Acta by polybases, Med. exper. 6:54-62, 1962. endocrino!. 41:437-440, 1962. 185. Schlatmann, R. J. A. F. M., Jansen, A. P., 170. Rasanen, T.: Fluctuations in the mitotic fre• Prenen, H., and Majoor, C. L. H.: The quency of the glandular stomach and intestine natriuretic action of heparin and some re• of rat under the influence of ACTH, gluco• lated substances, Lancet 1:314-317, 1960. corticoids, stress and heparin, Acta physiol. 186. Schlatmann, R. J. A. F. M., Jansen, A. P., scandinav. 58:201-210, 1963. Prenen, H., van der Korst, J. K., and Majoor, 171. Raynaud, R., D'Eshougues, J. R., Pasquet, C. L. H.: The natriuretic and aldosterone• P., and Karoubi, E.: Effets remarquables de suppressive action of heparin and some re• l'heparine dans deux cas d'asystolie, Algerie• lated polysulfated polysaccharides, J. Clin. med. 56: 135-143, 1952. Endocrino!. 24:35-47, 1964. 172. Reiner, L., and Kopp, H.: Zur Frage der 187. Schlatmann, R. J. A. F. M., Prenen, H., Jan• Isolierung und Bestimmung des Serum• sen, A. P., and Majoor, C. L. H.: Effect of globulins mittels Elektrodialyse, Kolloid• heparin and ROl-8307 on kaluresis, Lancet Ztschr. 46:99-107, 1928. 1:880, 1960. 173. Retik, A. B., Arons, M. S., Ketcham, A. S., 188. Schmidt, H. W.: Tierexperimentelle Unter• and Mantel, N.: The effect of heparin on suchungen zur Gefabwirksamkeit der ver• primary tumors and metastases, J. S. Res. 2: schiedenen Antikoagulantien, Ztschr. Kreisl• 49~53, 1962. aufforsch. 47:782-791, 1958. 174. Ricketts, C. R.: Interaction of dextran and 189. Schoog, M.: Die Beeinflussung des Bakterien• fibrinogen, Nature 169:970, 1952,. wachstums durch Protamin sulfat, Klin. 175. Robinson, D. W., and Hamilton, T. R.: In- Wchnschr. 32:224-225, 1954. Volume 7 Side effects of heparin 397 Nttmber3

190. Sherman, J. K.: Unusual action of heparin 205. Thomason, D., and Schofield, R.: Heparin on ascites tumour cells during freezing and and cellular calcium, Nature 184: 1712-1713, thawing, Nature 204:100-101, 1964. 1959. 191. SiHversklold, B. P.: Heparin und experi• 206. Thonnard-Neumann, E.: Studies of baso• mentelle Glomerulonephritis, Scandinav. Arch. phils. The effects of exogenous heparin upon Physiol. 83:175-180, 1940. the number and morphology of basophils, 192. Simon, E. P., and Wright, I. S.: Controlled Acta haemat. 31:24-35, 1964. ergometric studies of effect of heparin on 207. Ukita, T., Terao, T., and Irie, M.: Inhibition intermittent claudication, J.A.M.A. 153:98- of pancreatic ribonudease-I activity by 102, 1962. heparin, J. Biochem. 52:455-457, 1962. 193. Smith, G., and Smith, A. N.: The role of 208. Urist, M. R, and McLean, F. C.: Accumula• serotonin in experimental pulmonary em• tion of mast cells in endosteum of of bolism, Surg. Gynec. & Obst. 101:691-700, calcium-deficient rats, Arch. Path. 63:239- 1955. 251,1957. 194. Smith, R T., and Von Korff, R. W.: A 209. Vaheri, A., and Cantell, K.: The effect of heparin-precipitable fraction of human plasma. heparin on herpes simplex virus, Virology 21: I. Isolation and characterization of the frac• 661-662, 1963. tion, J. Clin. Invest. 36:596-604, 1957. 210. Vannas, S.: Experimental and clinical investi• 195. Stinchfield, F. E., Sankaran, B., and Samil• gations into the effect of locally administered son, R: The effect of anticoagulant therapy heparin on the eye, Acta ophth. (Suppl. 40): on bone repair, J. Bone & Surg. 38: 1-102, 1952. 270-282, 1956. 211. Veis, A.: The interaction of the alkali ions 196. Stoker, S. B.: Bacteriostatic action of heparin, with some linear polyelectrolytes, J. Phys. J. Physiol. 1l0:26P, 1949. Chern. 57:189-194, 1953. 197. Storti, E., and Vaccari, F.: Studies on the 212. Veyrat, R, Fabre, J., and Muller, A. F.: In• relationship between anticoagulants and hibition selective de la secretion de l'aldo• hemolysis. I. Effect of anticoagulants on sterone par un heparinoide semi-synthetique hemolysis and on the agglutination of red (ROI-8307), Helvet. med. acta 29:543-549, blood cells by anti-erythrocyte serum, Acta 1962. haemat. 15:12-22, 1956. 213. Veyrat, R, Manning, E. L., Fabre, J., and 198. Storti, E., Vaccari, F., and Baldini, E.: Muller, A. F.: Mesure de la secretion de Studies on the relationships between anti• l'aldosterone sous administration d'un adreno• coagulants and hemolysis. II. The effect of statique semi-synthetic, l'heparinoide ROl- anticoagulants on the hemolysis caused by 8307, Rev. fram;. etud. din. bioI. 8:667-673, antibodies in vivo, Acta haem at. 15:106-117, 1963. 1956. 214. Wakim, K. G., McKenzie, B. F., McGuckin, 199. Stiittgen, G., Hofmann, N., and Simmich, W.: W. F., Brown, A. L., Jr., and Baggenstoss, A. Die Aktivierung der Proteolyse des mensch• H.: The effect of heparin, nicotinic acid and lichen Serums und der Haut durch Heparine, ACTH on experimental nephrosis, Am. J. M. Klin. Wchnschr. 35: 1168-1171, 1957. Sc. 245:259-276, 1963. 2I(){}. Takemoto, K. K., and Fabisch, P.: Inhibition 215. Warren, J. R, and Graham, F.: The effect of of herpes virus by natural and synthetic acid heparin on the growth of bacteria and yeasts, polysaccharides, Proc. Soc. Exper. BioI. & J. Bact. 60:171-174, 1950. Med. 116:140-144, 1964. 216. Werle, E., and Amann, R: Zur Physiologie 201. Takemoto, K. K., and Liebhaber, H.: Virus• der Mastzellen als Trager des Heparins und polysaccharide interactions. II. Enhancement Histamins, Klin. Wchnschr. 34:624-630, 1956. of plaque formation and the detection of 217. Werle, E., Trautschold, I., and Leysath, G.: variants of poliOVirus with dextran sulfate, Ueber die Bindung von Kallidin an Heparin, Virology 17:499-501, 1962. Experientia 17:85-86, 1961. 202. Talley, R W.: The effect of heparin on the 218. Wheatley, D. N.: Influence of various sub• cerebral blood flow of elderly state hospital stances on production of ascites tumour, patients, Am. J. M. Sc. 230:61-64, 1955. Nature 202:1348-1349, 1964. 203. Therkelsen, A. J.: Effect of serum on spec• 219. \Vilander, 0.: Complete blood analysis of tral absorption of Bromsulphalein after intra• heparinized blood, Acta med. scandinav. 94: venous injection of heparin, Scandinav. J. 258-266, 1938. Clin. & Lab. Invest. 9:156-159, 1957. 220. Williams, O. B., and Van DeCarr, F. R: The 204. Thomas, L., Smith, R T., and Von Korff, R: effect of heparin on anaphylactic shock in Cold-precipitation by heparin of a protein guinea pigs, Proc. Soc. Exper. BioI. & Med. in rabbit and human plasma, Proc. Soc. 24:798-800, 1927. Exper. BioI. & Med. 86:813-818, 1954. 221. Wolff, R., and Brignon, J.: Influence et mode 398 C Don and Willis Clinical Pharmacolog!f and Therapeutics

d'action du sulfate de protamine sur la 226. Yoshimura, H., and Djerassi, I.: Blood croissance microbienne, Bull. Soc. chim. bioI. coagulation and vascular integrity: Effects 36:1125-1136, 1954. of heparin, Blood 20:602-608, 1962. 222. Wood, C. C.: The formation of fibrils from 227. Zakrzewski, Z.: Untersuchungen iiber den collagen solutions. Effect of chondroitin Einfluss von Heparin auf das Wachstum von sulphate and some other naturally occuring transplantablen Sarkomen, Bull. intern at. poly anions on the rate of formation, Biochem. Acad. polon. sc. de Cracovie, CI. med., J. 75:605-612, 1960. pp. 239-259, 1932. 223. Wood, R. M., and Bick, M. W.: A compari• 228. Zimmerman, M., and Celozzi, E.: Stimulation son of the influence of parenteral trypsin, of cell division in normal rat liver by a cortisone, and heparin on acute inflammation, factor in serum from hepatectomized rats, Arch. Ophth. 62:112-116, 1959. Fed. Proc. 19:139, 1960. 2Q4. Wood, R. M., and Bick, M. W.: The effect 229. Zimmerman, M., and Celozzi, E.: Stimulation of heparin on the ocular tuberculin reaction, by heparin of parenchymal liver cell prolifera• Arch. Ophth. 61:709-711, 1959. tion in normal adult rats, Nature 191:1014- 225. Woods, J. F., and Nichols, C., Jr.: The 1015, 1961. intracelluiar location of bone "coll~genase," Fed. Proc. 23:550, Abst. 2690, 1964.