Anticoagulants and Thrombolytics

Anil Sharma MCC

Objectives
To learn how Blood Clots are formed.  How the blood clots are broken down ?  What drugs can be used to regulate clotting ?  How to rectify clotting deficiencies


 Blood

clots - Thrombus  Thrombus dislodge from arteries and veins and become an embolus.  Venous emboli can block arterioles in the lung and pulmonary circulation


Thromboembolism

Classes of Drugs
Prevent coagulation  Dissolve clots  Prevent bleeding and hemorrhage Hemostatic  Overcome clotting deficiencies ( replacement therapies)


Blood Clotting
Vascular Phase  Platelet Phase  Coagulation Phase  Fibrinolytic Phase


Vascular Phase
Vasoconstriction  Exposure to tissues activate Tissue factor and initiate coagulation


Tissue Factor

Platelet phase
Non-nucleated - arise from magakaryocytes  blood vessel wall (endothelial cells) prevent platelet adhesion and aggregation  platelets contain receptors for fibrinogen and von Willebrand factor  after vessel injury Platelets adhere and aggregate.  Release permeability increasing factors (e.g. vascular permeability factor, VPF)  Loose their membrane and form a viscous plug


Platelets and Thromboemolism

Arteries : White Thrombus  Platelets adhere  Release ADP  More adhesion/ aggregation  Reduced blood flow (stasis)  Fibrin clot


Veins low pressure : Red thrombus is formed Especially in valve pockets Contains a long tail of fibrin Can detach and form emboli

Coagulation Phase


Two major pathways

 

Intrinsic pathway Extrinsic pathway

  

  

Both converge at a common point 13 soluble factors are involved in clotting Biosynthesis of these factors are dependent on Vitamin K1 and K2 Most of these factors are proteases Normally inactive and sequentially activated Hereditary lack of clotting factors lead to hemophilia -A

Intrinsic Pathway  All clotting factors are within the blood vessels  Clotting slower  Activated partial thromboplastin test (aPTT)

Extrinsic Pathway Initiating factor is outside the blood vessels - tissue factor Clotting - faster - in Seconds Prothrombin test (PT)

Prothrombin time (PT)

Tissue Thromboplastin factor III Mix with phospholipid extract Add calcium and blood sample Determine clotting time

Generally 12 - 14 seconds Used to detect defects in extrinsic pathway

Activated partial thromboplastin time (APTT)

Blood sample + EDTA or Citrate No clot ( recalcification will result in clot in about 2 - 4 min) Add calcium Mix with negatively charged phospholipid Kaoline (aluminum silicate) Determine clotting time Generally clotting occurs in 26 to 33 seconds Used to detect defects in the intrinsic pathway

Diagnosis of coagulation defects

Prolonged APTT No change in PT Defective Intrinsic Pathway

No change in APTT Prolonged PT

Defective Extrinsic Pathway

Prolonged APTT Prolonged PT

Defective in Common pathway

Intrinsic Pathway
Blood Vessel Injury XII XI IX X Factors affected By Heparin Prothrombin Fibrinogen XIII XIIa XIa IXa Xa

Extrinsic Pathway
Tissue Injury Tissue Factor Thromboplastin

VIIa X Thrombin

VII

Fribrin monomer Fibrin polymer

Vit. K dependent Factors Affected by Oral Anticoagulants

Activation
XIIa

Inactive XI

Active XIa

Thrombosis


Arterial Thrombosis :


Adherence of platelets to arterial walls - White in color - Often associated with MI, stroke and ischemia Develops in areas of stagnated blood flow (deep vein thrombosis), Red in color- Associated with Congestive Heart Failure, Cancer, Surgery.

Venous Thrombosis :


Anticoagulant drugs to treat thromboembolism

Drug Class Anticoagulant Parenteral Prototype Heparin Action Inactivation of clotting Factors Effect Prevent venous Thrombosis Prevent venous Thrombosis Prevent arterial Thrombosis Breakdown of thrombi

Anticoagulant Warfarin Decrease synthesis of Oral Clotting factors Antiplatelet drugs Thrombolytic Drugs Aspirin Decrease platelet aggregation

Streptokinase Fibinolysis

Heparin
Sulphated carbohydrate  Purified from bovine lungs  Different size  Active in vitro and in vivo  Administration - parenteral- Do not inject IM only IV or deep s.c.  Half-life 1 - 5 hrs - monitor aPTT  Adverse effect - hemorrhage - antidote protamine sulphate


Heparin mechanism of action

Heparin Antithrombin III

Thrombin

Oral anticoagulants : warfarin, dicumarol

Coumarins - warfarin, dicumarol  Isolated from clover leaves  Structurally related to vitamin K  Inhibits production of active clotting factors  Absorption rapid - binds to albumin  Clearance is slow - 36 hrs  Delayed onset 8 - 12 hrs  Overdose - reversed by vitamin K infusion  Can cross placenta - do not use during late pregnancies


Mechanism of action
Descarboxy Prothrombin Prothrombin

Reduced Vitamin K Oxidized Vitamin K

NAD NADH

Warfarin

Antiplatelet drugs
Aspirin  Prevents platelet aggregation /adhesion  Clinical use - prevents arterial thrombus



Myocardial infarction (MI), stroke, heart valve replacement and shunts

Other antiplatelet drugs are - Dipyridamole, sulfinpyrazone and Ticlopidine

Mechanism of action
 Aspirin

inhibits cyclooxygenase (COX)  COX is a key enzyme involved in the synthesis of thromboxane 2 (prostaglandins)  Inhibits platelet aggregation

Prophylactic use of Aspirin

Low dose daily ( 180 mg/day)  Prevents ischemic attack (ministroke) and MI  335 mg/day reduced the risk of heart attack in patients over 50  More than 1000 mg/day NO EFFECT



High dose inhibits prostacyclin synthesis in cells surrounding vessels. PS normally prevents platelet aggregation. Therefore, inhibition of PS leads to abrogation of the prophylactic benefit of Aspirin

Contraindication - DO NOT give to patients with glucose 6-PO4 dehydrogenase deficiency

Drug interactionprototype Warfarin

Category Mechanism Representative Drugs

Drugs that Increase Warfarin Activity

Decrease binding to Albumin Inhibit Degradation Decrease synthesis of Clotting Factors

Aspirin, Sulfonamides

Cimetidine, Disulfiram Antibiotics (oral)

Drug interactionprototype Warfarin

Drugs that promote bleeding Inhibition of platelets Inhibition of clotting Factors Induction of metabolizing Enzymes Drugs that decrease Warfarin activity Aspirin heparin antimetabolites Barbiturates Phenytoin

Promote clotting factor Vitamin K Synthesis OC Reduced absorption cholestyramine colestipol

Fibrinolysis
Enhance degradation of clots  Activation of endogenous protease  Plasminogen (inactive form) is converted to Plasmin (active form)  Plasmin breaks down fibrin clots


Fibrinolysis


Exogenously administered drugs



Streptokinase - bacterial product - continuous use - immune reaction Urokinase - human tissue derived - no immune response Tissue plasminogen activator (tPA) - genetically cloned - no immune reaction - EXPENSIVE Lysine analog- inhibits proteases

Inhibitors of fibrinolysis - aminocaproic acid



Drug preparations : To reduce clotting

 Heparin


(generic, Liquaemin sodium)

Parenteral - 1000 - 40,000 U/ml Oral : 2 - 20 mg tablets Oral : 25,50,75 mg tablets

Warfarin (generic , Coumadin)



Dipyridamole (Persantine)


Drug preparations : to lyse clots



Alteplase recombinant (tPA, Activase)



20, 50 mg Lyophilized powder - reconstitute for iv Parenteral : 250000 - 1.5 million units per vial . Lyophilized powder. Reconstitute for iv Parenteral : 250000 units per vial. Powder to reconstitute to 5000 u/ml for injection

streptokinase (Kabikinase, streptase)



Urokinase ( Abbokinase)


Drug preparations : clotting deficiencies



Vitamin K ( Phytonadione (K1), Mephyton



Oral : 5 mg tablets Antihemophilic factor ( VIII, AHF) Parenteral Parenteral : in vials

Plasma fractions - for hemophilia

 

Factor IX complex (konyne HT, proplex T)



Due to HIV risks in blood products recombinant proteins of the factors are made.


E.g. transgenic goats secreting factors into milk

Drug preparations : to stop bleeding

Systemic use : aminocaproic acid (Amicar); Tranexamic acid (cyclokapron),Vitamin K  Local adsorbable drugs

    

Gelatin sponge (Gelfoam) Gelatin film Oxidized cellulose ( Oxycel) Microfibrillar collagen (Avitene) Thrombin