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proteolytically cleaves small peptides from fibrinogen, allowing attenuate the blood clotting cascade by proteolysis of the two
fibrinogen to polymerize and form a fibrin clot cofactors Va and VIIIa
activates many upstream clotting factors, leading to more factors V and VIII have an identical overall domain structure and
thrombin generation considerable homology
activates factor XIII, a transaminase that cross-links the fibrin descendants of a trypsin-like common ancestor
polymer and stabilizes the clot most common defect in the natural anticoagulant system is a
mutation in factor V (factor V Leiden), results in resistance to
potent platelet activator and mitogen
inactivation by the protein C, protein S mechanism
exerts anticoagulant effects by activating the protein C pathway,
which attenuates the clotting response Fibrinolysis
The Tissue Factor-VIIa Complex process of fibrin digestion by the fibrin specific protease,
plasmin
main initiator of blood coagulation in vivo
precursor form of the serine protease plasmin circulates in an
TF - transmembrane protein ubiquitously expressed outside the
inactive form as plasminogen
vasculature
- not normally expressed in an active form within vessels endothelial cells synthesize and release tissue plasminogen
activator (t-PA), which converts plasminogen to plasmin
exposure on damaged endothelium or to blood that has
extravasated into tissue binds TF to factor VIIa Plasmin remodels the thrombus and limits its extension by
proteolytic digestion of fibrin
propagation of the clot is by feedback amplification of thrombin
through the intrinsic pathway factors VIII and IX
specialized protein domains (kringles) bind to exposed lysines
on the fibrin clot and impart clot specificity to the fibrinolytic
process
Negative Regulators of Fibrinolysis
endothelial cells synthesize and release plasminogen
activator inhibitor (PAI), which inhibits t-PA
α2 antiplasmin circulates in the blood at high
concentrations and will rapidly inactivate any plasmin that is
not clot-bound
Disseminated Intravascular Coagulation (DIC)
hemostatic system may careen out of control, leading to
generalized intravascular clotting and bleeding
follow massive tissue injury, advanced cancers, obstetric
emergencies such as abruptio placentae or retained
products of conception, or bacterial sepsis
Tx control the underlying disease process; DIC is often fatal
Increased fibrinolysis is effective therapy for thrombotic disease
Tissue plasminogen activator, urokinase, and streptokinase
all activate the fibrinolytic system
decreased fibrinolysis protects clots from lysis and reduces the
bleeding of hemostatic failure
Aminocaproic acid is a clinically useful inhibitor of fibrinolysis
Drug Class & its PK & Chemistry PD Uses Toxic Effect D-D Interaction & CI
members
INDIRECT THROMBIN INHIBITORS
Unfractionated inhibit blood prevents bleeding Px with renal
heparin (UFH) coagulation by pulmonary emboli loss of hair and failure are more
inhibiting all three in patients with reversible alopecia prone to
factors, especially established venous osteoporosis and hemorrhage
thrombin and thrombosis spontaneous use cautiously in
factor Xa fractures px with allergy
molecular weight accelerates the px recently had
range of 5000– clearing of surgery of the
30,000 postprandial brain, spinal cord,
Low molecular- inhibit activated lipemia or eye
weight heparin factor X but have mineralocorticoid px undergoing
(LMWH) less effect on deficiency lumbar puncture
enoxaparin thrombin than the Heparin-Induced or regional
dalteparin HMW Thrombocytopenia anesthetic block
tinzaparin
ORAL DIRECT FACTOR XA INHIBITORS
Rivaroxaban inhibit factor Xa, excreted in part prevention of increase in bleeding patients with
in the final by the kidneys venous risk without a renal impairment
common pathway thromboembolism significant decrease
of clotting following hip or in ischemic events
rapid onset of knee surgery
Apixaban action and shorter venous
half-lives than thromboembolism
warfarin stroke prevention
(approximately 10 in patients with
hours) atrial fibrillation