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The Vulnerable Patient with Diabetes

4
Vulnerable Blood with Diabetes
Hyperglycaemia
Metabolic changes TF expression
Oxidative stress Fibrinogen
Endothelial VWF and FVIII
dysfunction
TF expression Denser clot
Platelet Decreased NO
IFN structure /
dysfunction Production
IL-6 hypofibrinolysis
PAI-1

Increased
shedding

Increase
Increaseofof
Microparticles
microparticles
Vulnerable blood

Katharina Hess et al. Eur Heart J Suppl 2012;14:B4-B13

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2012. For permissions please email: journals.permissions@oup.com
Platelet function and plasma coagulation factors with Diabetes,
favouring platelet aggregation and a propensity for thrombosis.

Creager M A et al. Circulation. 2003;108:1527-1532

Copyright © American Heart Association, Inc. All rights reserved.
Diabetes:
Effects on Thrombosis and Fibrinolysis

Prothrombotic Effects Anti-fibrinolytic Effects

Tissue plasminogen
Platelet aggregability activator (t-PA)

Procoagulants Plasminogen activator
(fibrinogen, von inhibitor type 1 (PAI-1)
willebrand factor,
thrombin)

Anticoagulants ⍺2-Anti plasmin
(antithrombin III,
sulfated heparins)
Diabetes
Postulated Mechanisms of Altered Fibrinolysis

Cytokines Activated
Insulin platelets
Proinsulin
High glucose
Modified LDL Glycation
Modified VLDL
PAI-1 Fibrin
deposits
Plasmin
Plasminogen
(-) t-PA t-PA

(-)
Collagenase
PAI-1
DM die
a thrombotic death.

Deaths due to
cardiovascular complications

Remainder deaths due to
CVE and PVD complications.
Atherothrombosis is commonly found in
more than one arterial bed in an individual patient*

Cerebrovascular Coronary
disease disease
7.4%
24.7% 29.9%

3.3%
3.8% 11.8%

19.2%

Peripheral arterial disease

* Data from CAPRIE study (n=19,185) 

Coccheri S. Eur Heart J 1998; 19(suppl): P1268.
Functions of the Coagulation System

ACTION DESIRED RESULT

Rapid formation of
Stop bleeding quickly
mechanically sound clot

Prevent clot formation at non-
Prevent thrombosis
injured sites

Gradual replacement of clot
Wound healing
with viable tissue
Coagulation Cascade
Intrinsic Pathway Extrinsic Pathway
XII XIIa
VIIa VII

PT
XI XIa
Tissue Factor

IX IXa

PTT X Xa X

V Va XIII

Prothrombin Thrombin
XIIIa

Fibrinogen Soluble Fibrin

Insoluble Fibrin
Coagulation and
Fibrinolysis
The coagulation cascade
FX
Prothrombin
Tissue
+
FXa Plasmin-mediated fibrinolysis
factor FVa +
FVIIa Plasminogen
Prothrombinase
complex + tPA
Thrombin aggregated
platelets
-
PAI-1
+
Fibrinogen
Fibrin Plasmin

Thrombus - ⍺-2-AP
+ TAFI

Fibrin
Degradation
Products
Fibrinolysis

Vascular Thrombogenesis Process
Fibrinolysis AUTOLYTIC
Fibrinolysis

▪ Degradation of fibrin clot by plasmin

▪ Necessary to remove clot so wound healing can
proceed

▪ Plasminogen activators from blood vessels and
other cells convert plasminogen to plasmin to begin
the process
Physiology of the Fibrinolytic System
Plasminogen
Activator
Inhibitor
Unbound Fibrin bound
Plasminogen X Plasminogen

Physiologic Plasminogen
Activators
α2 X Unbound Fibrin bound
-Tissue Plasminogen Activator
Anti Plasmin Plasmin Plasmin
- Urokinase
- Activated Clotting Factor XII

Fibrinogen
Split Products Fibrinogen Fibrin Fibrin – Split
Product
(D-dimer)

Fibrinogenolysis Fibrinolysis

The Annals of Pharmacotherapy, 1998 vol 32
Fibrinolysis

Intact fibrin clot Fibrin clot exposed to plasmin
Fibrinolysis

Red blood cells trapped in a Fibrin mesh
Fibrinolysis
Fibrin Clot Formation

▪ Tissue damage exposes blood to tissue factor
▪ Coagulation cascade: series of enzymatic reactions
leading to thrombin formation
• takes place mainly on membrane surface, eg
platelet membrane
▪ Thrombin converts fibrinogen to fibrin
▪ Fibrin polymerizes and becomes cross linked
Fibrinolysis

The fibrinolytic system,
the primary means of removing clots,
is relatively inhibited in diabetes
due to abnormal clot structures that are
more resistant to degradation
and an increase in (PAI-1).

20
Platelets
Platelets
▪ Stick to damaged blood vessels
• requires von Willebrand factor
▪ Spread out to cover damaged area
▪ Activate and release contents
• partly blocked by aspirin
▪ Aggregate
▪ Cause blood vessel constriction
▪ Cause retraction of clot to draw wound edges together
Endothelial abnormalities undoubtedly play a
role in the enhanced activation of platelets
and clotting factors seen in diabetes.

23
Circulating platelet aggregates,
Platelet aggregation in response to platelet agonists,
Platelet contractile force (PCF)

24
Higher plasma levels of platelet
release products;
-beta-thromboglobulin,
-platelet factor 4,
-thromboxane B(2),

demonstrate
platelet hyperactivity in diabetes.

25
This constellation of findings
supports the clinical observation
that diabetes is a
hypercoagulable state.

26
The result is an imbalance between
thrombus formation and dissolution,
favouring the former.

27
28
HYPERGLYCAEMIA
probably determines the onset
of these abnormalities through
three mechanisms:
1. Non-enzymatic glycation,
2. Increased oxidative stress
3. Decrease in the levels of
heparan sulphate.
Non-enzymatic glycation
seems to affect the
functionality of key
molecules of coagulation in
a negative sense.
Numerous studies have
shown that coagulation
abnormalities occur in the
course of DM, resulting in a
state of thrombophilia.
Thrombophilia
Tendency to form Thrombi
Hypercoagulable state
Arterial thrombi:
Usually in areas of
atherosclerotic plaques
Venous thrombi:
Thrombophlebitis, DVT,
Pulmonary embolism
These observations are
supported by epidemiological
studies which demonstrate
that thromboembolic events
are more likely to occur in
diabetic patients.
The abnormalities observed
involve
all stages of coagulation,
affecting both thrombus
formation and its inhibition,
fibrinolysis,
platelet
and
endothelial function.
Good metabolic control could play a key role in
controlling the coagulation irregularities in
diabetes.
However,
considering the difficulties in achieving such an
objective,

it is possible that the use of drugs may
represent a valid alternative.

In fact, several drugs exist which are of
potential interest.
It is, however, necessary to perform
long-term studies which demonstrate
unequivocably that by controlling the
coagulation abnormalities in diabetic
patients, prolongation of life is
possible.
Principals Therapy of Thrombosis based on pathogenesis

Pathogenesis Therapy

Risk Factors Prevention

- Platelet Adhesion
Anti Platelet

- Platelet Agregasion

Anti Coagulant
- Blood Coagulation

- Thrombosis Thrombolitic
38
Therapy of Atherothrombosis
Plaque Rupture
or Erosion

ASA Platelet Coagulation Heparin
Activation Cascade Low molecular
weight heparin
Clopidogrel
Direct
Adhesion/ Fibrin Thrombin
Aggregation Formation Inhibitors
Glycoprotein
IIb/IIIa
Inhibitors

Platelet-Rich
Thrombus Thrombolysis
1. Anti-coagulants
2. Anti-platelet Drugs
3. Thrombolytic Agents
Oral Trombolytic,

A challenging Opportunity
Atherothrombosis* is a

Leading Cause of Death Worldwide1†

AIDS 5.1

Pulmonary disease 6

Injuries 9.1

Cancer 12.6

Infectious disease 17.8

Atherothrombosis* 28.7

0 5 10 15 20 25 30

Mortality (%)

* Ischemic heart disease, cerebrovascular disease, inflammatory heart disease and hypertensive heart disease
† Worldwide defined as Member States by WHO Region (Africa, Americas, Eastern Mediterranean, European,
South-East Asia and Western Pacific)

1. The World Health Report, 2002, WHO Geneva, 2002
Atherothrombosis
Definition

■ Atherothrombosis is a chronic disease,
characterized by unpredictable disruption of an atherosclerotic
plaque, leading to platelet activation and thrombus formation.


■ Underlying condition for ischemic stroke, myocardial infarction,
transient ischemic attack, acute coronary syndrome, and
vascular death.


■ Atherothrombosis is a leading cause of morbidity and mortality.
Secara Signifikan, Aterotrombosis akan Memperpendek
Usia Harapan Hidup
Aterotrombosis menurunkan usia harapan hidup sekitar 

8–12 pada penderita dengan usia lebih dari 60 tahun1

Rata-rata perkiraan usia harapan hidup pada laki-laki di atas 60 tahun

20
18

16
-7.4
14 tahun -9.2
tahun
12
-12
tahun
Tahun

10

8

6
4

2
0

Sehat Riwayat Penyakit Riwayat Riwayat
Infark Stroke
Kardiovaskular
Data Analisis dari “the Framingham Heart Study” Miokard
1. Peeters et al. Eur Heart J 2002; 23: 458–466
Akut
Mechanism of Actions
Anti-platelet
aggregation

Anti-thrombosis
Fibrinogenolytic

DISOLF
DLBS1033

Clot Lysis
Thrombolytic

Fibrinolytic
Anti-thrombosis

47
Mechanism of Actions
Anti-platelet
aggregation

Anti-thrombosis
Fibrinogenolytic

DISOLF
DLBS1033

Clot Lysis
Thrombolytic

Fibrinolytic
Anti-platelet
aggregation

Trombosit
DISOLF
Adenilat
PDE III
siklase

ATP cAMP 5’AMP
Inhibit PDE III

Ca2+ TXA2
Intracell cAMP

Primer Sekunder

Intracell Ca2+
ADP

Agregasi
trombosit
Platelet activation
inhibition
The Role of Platelets in Atherothrombosis

1 Adhesion 3 Aggregation

2 Activation Anti-platelet
aggregation
Anti-platelet
aggregation

Mechanism of Actions
Anti-platelet
aggregation

Anti-thrombosis
Fibrinogenolytic

DISOLF
DLBS1033

Clot Lysis
Thrombolytic

Fibrinolytic
Fibrinogenolytic

Trombin

Fibrinogen
X Fibrin

DISOLF
Anti-platelet
aggregation

Mechanism of Actions
Anti-platelet
aggregation

Anti-thrombosis
Fibrinogenolytic

DISOLF
DLBS1033

Clot Lysis
Thrombolytic

Fibrinolytic
Thrombolytic

54
Mechanism of Actions
Anti-platelet
aggregation

Anti-thrombosis
Fibrinogenolytic

Disolf
DLBS1033

Clot Lysis
Thrombolytic

Fibrinolytic
Clot Lysis

DISOLF
Clot Lysis

DLBS 1033 – Thrombolysis
DISOLF

Low Molecular Weight DLBS 1033 allows it to penetrate the
depth of thrombus and lysing the blood clots
Mechanism of Actions
Anti-platelet
aggregation

Anti-thrombosis
Fibrinogenolytic

Disolf
DLBS1033

Clot Lysis
Thrombolytic

Fibrinolytic
Fibrinolytic

Plasminogen

t-PA

Plasmin DISOLF

Fibrin Fibrin Degradation Product
Lumbrokinase Oral Function
• Fibrinolytic
Being an exogenous t-PA
Stimulating the vascular endothelial cells to secrete
endogenous t-PA
* Indirect Thrombolysis
Being an exogenous plasmin
* Direct Thrombolysis
Lumbrokinase Oral Function

• Anticoagulation
Specific binding to fibrinogen (specific affinity with
fibrinogen)
Hydrolyze fibrinogen (generate soluble degraded
products)
* Decrease concentration of fibrinogen
Lumbrokinase Oral Function

• Antiplatelet
It decreases significantly the levels of Gmp-140,
TXB2 and S-HT
*Inhibiting platelet activation and vasoconstriction

Plus (+) Endothelin ↓
Common Sense of Daily Practices

Vascular Thrombosis Obstruction can’t be open
automatically

Insufficiency of Autolytic activity
Common Sense of Daily Practices

Neither Anticoagulant oral nor anti platelet
increase Autolytic activity

Different mechanism
Common Sense of Daily Practices

Oral Fibrinolytic is needed to increase Autolytic activity
common sense

“Lumbrokinase ( Oral Fibrinolytic)
has opportunity for these cases
Challenge of Oral Fibrinolytics
(Lumbrokinase)
Lumbrokinase berasal dari sumber alami

❑ Naskah kuno Cina Cao Gang Ben Ma (Compendium of
Materia Medica), cacing tanah (Lumbricus rubellus) dapat
membuka sumbatan pembuluh darah
❑ Charles Darwin (1883), observasi pada cairan digestif
cacing tanah yang dapat melarutkan fibrin.
❑ Mihara et al. (1991), melarutkan fibrin dgn enzim yg
diekstraksi dari cacing Lumbricus rubellus, enzim tsb terdiri
dari 6 enzim proteolitik yang lumbrokinase
❑ Tahun 1992, lumbrokinase telah diteliti dan digunakan di
Cina sebagai obat.
❑ Lumbrokinase dapat meningkatkan aktivitas fibrinolitik.
Lumbrokinase Mechanism of Action

Lumbrokinase

Fibrinogen

Fibrin ✂ ✂ ✂ Fibrin Degradation
t-PA
Plasmin

Plasminogen

Li G, Wang KY, Li D, Wang N, et al. (2012) Cloning, Expression and Characterization of a Gene from Earthworm Eisenia
fetida Encoding a Blood-Clot Dissolving Protein. PLoS ONE 7(12): e53110. doi:10.1371/journal.pone.0053110
http://www.plosone.org/article/info:doi/10.1371/journal.pone.0053110
Successful results of Lumbrokinase
in some cases:
1. Acute Limb Ischemia

2. Acute DVT

3. PAD
Medical Management of Acute Limb Ischemia
The Role of Lumbrokinase
Acute Limb Ischemia ( A L I )
Definition :

Acute limb ischemia ( ALI ), is any sudden decrease in limb
perfusion causing a potential threat to limb viability.
Presentation is normally up to 2 weeks following the acute
event.
Diagnosis/ Clinical presentations
5 P’ s :
Pain

Pulselessness

Pallor

Paresthesia

Paralysis
• 60 yrs man
• Stage IIb Acute Limb Ischemia
• Atrial fibrilation with normoventricular response
• Moderate mitral stenosis
• Type-2 DM
• Stage-1 hypertension
CT Angiography (MSCT) 23 Sept 2008

• Kanan
Thrombus a. Femoralis superficial didua
tempat dengan panjang sumbatan 3,5 cm
dan 13 cm
Thrombus a. Poplitea distal sehingga a.
Tibialis ant, post, dan peronea tidak terisi
kontras

• Kiri
Thrombus a. Iliaka communis sepanjang
7,4 cm.
Thrombus a. Poplitea distal, hanya
sebagian a. Tibialis ant 13 proksimal
terisi kontras dan a. Peronea. Sedangkan
a. Tibilais post tidak terisi kontras
Treatment

• Surgical Procedures (Surgical Thrombectomy)
Refused
• Lumbrokinase, 3 x 3 capsule
• Cilostazol, 2 x 100mg
• Digoxin, 1 x 0,25mg
• ISDN, 3 x 10mg
• Metformin, 2 x 500mg
• Irbesartan, 1 x 100mg
Pain and numbness of both legs disappear
Day-4 Patient only felt stiffness on dorsum pedis and toes
Physical examination: weak pulsation of tibialis anterior and dorsalis pedis arteries

CT angiography: better contrast flow on both legs
Day-15 After 2 weeks of treatment with Lumbrokinase
discharged with good conditions

Day-50 CT angiography: normal contrast flow on both legs
Conclusion
• Lumbrokinase could be considered as an alternative
medical treatment for acute limb ischemia, especially
in patient who refused surgical treatment.

• The role of lumbrokinase as a treatment option of
acute limb ischemia need further evaluation on large,
well design, study.
Treatment of Acute DVT with
Lumbrokinase
• Laki2, 56 thn
• Old Anterior MCI
• CHF (EF 27 %)
• RF: HHD, Dislipidemi, Smoker, FH
• Tiba2 saja tungkai kiri lutut kebawah bengkak, sakit,
berat pegal.
• Rx/ start Lumbrokinase 3 x 3 caps,
• on top aspirin, nitrat, ACE, lasix, Statin, dan BB
Duplex Sonography tungkai:
Dx/ DVT
Duplex Sonography DVT tungkai
satu bulan setelah terapi Lumbrokinase
Conclusion

Treatment with LUMBROKINASE has a place and
promissing effect in thrombotic and
thromboembolic cardio vascular disorders , needs
more clinical experiences and further large clinical
trial.
Ny. YF, 47 th
Tgl 16 Mei 2011:Kateterisasi di RS.F
Tgl 27 Mei 2011:Kaki mulai bengkak
Tgl 30 Mei 2011:Hasil Doppler—DVT
Tgl 3Jun 2011:Datang ke RSJHK untuk periksa ulang
Diagnosis: DVT dengan oklusi total trombus di V Fem ka
Therapy : - Disolf 3x1 Simarc stop,baru dapat 3 hr
- Ardium 3x1
Hasil : Pengobatan Disolf selama 2 minggu berhasil
merekanalisasi Vena femoralis
6 Juni 2011 10 Juni 2011 17 Juni 2011
THE EFFECT OF DLBS1033(DISOLF)
IN PERIPHERAL ARTERY DISEASE

Randomized Clinical Controlled Trial, 20 number of
subject , mean age of all 55,4 years old , for 2 weeks
evaluation

Ndraha S et al. Depart of Intern Med UKRIDA Christian
University, Jakarta-indonesia 2013
90
Baseline characteristic of patients with intermittent claudication in Koja Hospital (n=20)
Baseline Characteristic DLBS 1033 (n:10) Control ( n:10 )
n % n %
1. Age
a. < 60 years old 6 30 8 40
B. 60-80 years old 4 20 2 10
C. > 80 years old 0 0 0 0
d. Mean age (years old) 55.8 7.8 53.2 6.8
2. Sex
Female 9 45 9 45
Male 1 5 1 5
3. Subjective complaint
a. Pain
b. Numbness
7
3
35
15
5
1
25
5
Jakarta , April – Aug 2013
c. Leg heaviness 0 0 4 20
4. Smoker
a. Non Smoker 7 35 9 45 Measurement :
b. Ex-smoker 2 10 0 0
c. Smoker 1 5 1 5 ABI ( Ankle Brachial Index )
d. > 10 cigarettes per day 0 0 0 0
5. Exercise
a. Never
b. Once a month
7
1
35
5
9
1
45
5
Dose :
c. Once a week
d. 2-3 times a week
2
0
10
0
0
0
0
0
DISOLF 3 x 1
6. Body mass index (BMI) Versus Placebo
a. Underweight (BMI < 18.5 kg/m2) 2 10 2 10
b. Normoweight (BMI 18.5 – 25 kg/m2) 5 25 5 25
c. Overweight (BMI > 25 – 29.9 kg/m2) 3 15 3 15
e. Obese (IMT ≥ 30 kg/m2) 0 0 0 0
7. Hypertension
a. Yes 8 40 6 30
b. No 2 10 4 20
8. Diabetes mellitus (DM)
a. Yes 7 35 5 25
b. No 5 25 3 15
9. Dyslipidemia
a. Yes 6 30 6 30
b. No 4 20 4 20
10. Ankle Brachial Index (ABI)
a. Mild – moderate 0.41 – 0.9) 10 50 10 50
b. Severe (0.00 – 0.40) 0 0 0 0
Results after 2 weeks

Figure 1. Ankle-Brachial Index (ABI) values in DLBS1033 and Control
group, pre- and post-treatment
Improvement after 2 weeks

Figure 2. Improvement of Ankle-Brachial Index (ABI) values from baseline. Improvement of Ankle-Brachial Index
(ABI) values in DLBS1033 group was significantly higher than that in Control group (p < 0.01)
UJI KLINIS

Sub Bagian Endokrin Metabolik FK Universitas Andalas /

RSUP Dr M Jamil Padang ( 2014 – 2015 )

• Suatu uji klinis tentang khasiat serta kemanan penggunaan
lumbrokinase terhadap penderita DMT2 sebagai prevention ( laporan
pendahuluan, dari 25 subjek ).

• Satu kelompok penderita DMT2 ( 68 orang ) diberi pengobatan ( tablet
berisi zat aktif lumbrokinase ) selama 8 minggu dengan dosis 3 x 490
mg perhari, sedangkan kelompok kontrol ( dengan jumlah sama ) diberi
tablet yang sama bentuknya berisi bahan tanpa materi zat aktif
( plasebo ).

• Variabel yang diteliti : Kadar fibrinogen, thromboxan B2, dan D-
dimer. Pemeriksaan dilakukan pada awal ( 0 , 4, dan akhir atau 8
minggu penelitian.
Pengaruh pemberian lumbrokinase terhadap penurunan kadar
tromboksan B2 pada DMT2

Rerata kadar Tx B2 pada awal, minggu ke-4 dan ke-8 pada klp
Lumbrokinase dan kontrol (ng/mL), rerata(SB)

Minggu awal Minggu ke-4 Minggu ke-8 P

Lumbrokinase 12,07(8,43) 10,85(8,34) 8,32(4,31) 0,023

Plasebo 11,05(6,99) 10,42(4,59) 9,02(3,2) 0,212

Ket: analisis statistik : uji Friedman

LK berpengaruh terhadap penurunan kadar TxB2 pada DMT2

95
Changes of Fibrinogen level from baseline to Week 4
and 8
50
Placebo DLBS1033
38
Changes of fibrinolgen level (mg/dL)

25

13
11.5

5.0833
0
-21.56 -12.4

-13

-25 p = 0,298
p = 0,471

-38

-50

Week 4 Week 8
Pengaruh pemberian lumbrokinase terhadap penurunan
kadar fibrinogen serum pada DMT2
Conclusion
• Oral thrombolytics can be considered to treat and
prevent certain clinical conditions of arterial
thrombosis
in T2DM
• Risk and benefit of aspirin ( hemorrhage risk and
low of
effectiveness due to drug resistance ) make it
controversial.
• Based on study in its pharmacologic actions,
DLBS1033
( lumbrokinase, Disolf ) may be effective in the
treatment or prevention of atherothrombosis in
T2DM
• More clinical trials are needed to confirm its
efficacy and safety
● Almost all PAD subjects were females, mean age of
all subjects was 55.4 years old.
● The most prevalent independent risk factors for
PAD observed in the study were hypertension,
diabetes, dyslipidemia, and lack of exercise.
● DBLS1033 showed to improve ABI in patients
with intermittent claudication.
Oral Fibrinolytics can be considered in certain
clinical conditions of arterial and venous thrombosis

Based on its pharmacological actions,
Lumbrokinase would be a rational drug in the
treatment of Atherothrombosis and Venous
thromboembolism

99
DiSOLF
Bioactive protein fraction DLBS1033
(Lumbrokinase) 490 mg

DLBS1033 contains Lumbrokinase from Lubricous
rubellus, produced via biotechnology process in a
GMP environment

Lumbrokinase has potent fibrinolytic and
fibrinogenolytic activities,
lower blood viscosity and
reduce platelet aggregation

100