Blood Thinners

Hussein Hallak, Ph.D.

 Drugs which affect blood clotting
 Normal clotting
 Abnormal clotting: thrombosis
 Drugs that inhibit clotting function of platelets
 antiplatelet drugs
 Drugs that inhibit protein clotting factors
 anticoagulants
 Drugs that lyse thrombi
 thrombolytic drugs
 Normal Blood Clotting
 Platelet clot formation

 “Intrinsic Pathway” of clotting factor activation

 “Extrinsic Pathway” of clotting factor activation

 Platelet Clot Formation

Damaged vessel wall

Platelet clot sealing breach

 Platelet Aggregation & Adhesion
1
Platelets don’t adhere Breach in endothelium reveals collagen
to normal endothelium
Platelets adhere to collagen

TxA2 More platelets aggregate

3
 Clotting Factor Activation
Intrinsic Extrinsic
Abnormal vessel wall Damaged tissue

XII XIIa VIIa VII

XI XIa
Thrombin-fibrin
IX IXa clot

X Xa

Prothrombin Thrombin Fibrinogen

 Thrombin Inactivation:
Antithrombin III (AT III)

AT III Thrombolyis

Thrombin-fibrin
AT III clot
Inactive Complex
Thrombin

Thrombin Fibrinogen
Why interfere with blood clotting?
 Damaged endothelium

Thrombin-fibrin clot
Platelet clot
2

Thrombus
3
Thrombosis Syndromes
 Venous thrombosis
 myocardial infarction (heart attack)
 cerebral artery occlusion (stroke)
 peripheral artery thrombosis
 etc.......
 Deep vein thrombosis (DVT):

(DVT) is the formation of blood

clots (thrombi) in the deep veins.

It commonly affects the

deep leg,pelvis veins

major complication is
pulmonary embolism (PE)
 Atrial fibrillation (AF)

Its is the most common cardiac

arrhythmia (irregular heart beat)

Results from
disorganized electrical
impulses in SA node
 Atrial fibrillation (AF)

The prevalence of AF in a
population increases with
age, with 10% of people
over 75 having AF.

A third of all strokes

are caused by AF.
 Preventing & Treating Thrombosis
 Drugs that deplete functional clotting factors
 Warfarin
 Heparin
 Drugs that accelerate clot lysis
 Antiplatelet drugs
 Interference with synthesis of clotting
factors: Warfarin

Factors II, VII, IX & X

–Post-translational carboxylation of glutamic acid groups.

–Vitamin K is a cofactor for carboxylation

–Warfarin is an analogue of Vitamin K

–Warfarin inhibits Vitamin K recycling

 O
CH3

O
R

O
KO
Vitamin K
Epoxide
Reductase

OH
CH3
Warfarin

KH2 OH
 COO- COO- COO-
Decarboxy- CH2 (prothrombin)
CH2
(prothrombin)
CH2 CH2

CO2 Carboxylase
O2

OH O
CH3 CH3

R R

OH O
KH2 KO

Warfarin
Pharmacokinetics of Warfarin
 Weak acid
 Well absorbed orally
 Hepatic clearance, using Cytochrome P450
 Strongly bound to plasma protein albumin
Pharmacodynamics of Warfarin
 Clotting factors deplete at a rate
determined by half-life
 Protein S and Protein C are quickly
depleted: they are anticoagulant.
Congenital deficiency of Protein S or C
permits a transient hypercoagulable state,
manifest as skin necrosis on starting
warfarin.
Uses and Adverse Effects of Warfarin
 Long-term oral anticoagulation
 Prevent thromboses from extending

 Prophylaxis against thrombosis on

mechanical heart valves
Adverse Effect
 Risk of bleeding: coagulation needs regular
monitoring
 Teratogenic: can’t be used in pregnancy
Warfarin: Contraindications and
Cautions
 Peptic ulcer, without confirmation of healing
 History intracranial bleeding
 Hypertension (relative)
 Liver disease with defective clotting factor
synthesis
 Renal failure (dependent on degree)
 Pre-existing platelet clotting defects (eg,
thrombocytopaenia)
 Warfarin: Contraindications and
Cautions
 Therapy with anti-platelet agents
 Old age (relative)
 Pregnancy (teratogenic)
 Alcohol abuse
 History of protein S or protein C deficiency:
increased risk of coumarin skin necrosis
(start with heparin)
Warfarin Induced Skin necrosis
Drug Interactions with Warfarin
 Absorption  Protein Binding
 cholestyramine anion  weak acid
binding resin antiinflammatory drugs
 antacids and oil
laxatives
Drug Interactions with Warfarin
 P450 Induction  P450 Inhibition
 Barbiturates  Ketconazole
 Carbamazepine  Metronidazole
 Phenytoin  Cotrimoxazole
 Rifampicin  HMG-CoA Reductase
 Griseofulvin inhibitors ("Statins")
 ⇒ ⇓ efficacy  Omeprazole
 Cimetidine
 Amiodarone
 Allopurinol
 ⇒ ⇑ bleeding risk
Drug Interactions with Warfarin:
Indirect
 Thyroxine accelerates catabolism of clotting
factors
 Estrogens increase synthesis of clotting factors
 Long-term broad-spectrum antibiotics: reduced
gut Vit K synthesis
 Heparin or antiplatelet drugs increase risk of
bleeding by interfering with other aspect of
hemostasis
Monitoring Warfarin
 Measure activity in the extrinsic and
common pathways, by activating with
“Thromboplastin”
– Prothrombin time
 Standardised to International Normalised
Ratio (INR)
 INR 2 to 3 for most indications
Reversing Warfarin
 FFP (Fresh Frozen Plasma).
 Vitamin K, subcutaneously,
 Anticoagulant Drugs

Anticoagulants are among the most

frequently used drugs to prevent and treat
venous and arterial thromboembolism.

Highest incidence of adverse effects, second

only to cytotoxic drug

Problem with dosing, monitoring,

compliance.
 Why new drugs?
 Warfarin is underused in pts who need it
most:
 Only 47% of patients with thrombosis are
taking warfarin
 This is often due to hemorrhagic
contraindications
 Convenience issues due to the need for
frequent monitoring
 Difficulty in maintaining optimal
anticoagulation
 New Oral Anticoagulants:

TF-VIIa
IXa
VIII Factor Xa Inhibitors
Direct: Oral
X Xa
Rivaroxaban
Apixaban
Xa
Va
PL Fibrin
Direct Thrombin
II Thrombin Inhibitors (DTI)
Oral: Dabigatran

Fibrinogen Fibrin
Features of New Anticoagulants With Those
of Warfarin

features warfarin New agents

Onset slow Rapid
Dosing variable fixed
Food effect yes no
Drug Many few
interaction
monitoring yes no
Half life Long short
antidote yes No
Dabigatran
Pradaxa®
9/20/10: FDA approval for stroke prevention in Afib
 Dabigatran
 Dabigatran Etexilate, a pro-drug, is rapidly
converted to dabigatran

 6.5% bioavailability, 80% excreted by kidney

 Half-life of 12-17 hours

 Phase II data identified 110 mg BID and 150

mg BID as viable doses
Dabigatran as a prodrug:
Intracranial Bleeding Rates
 Direct FXa inhibitors:

Rivaroxaban

Xarelto®
7/1/11: FDA approval for DVT prophylaxis after
hip or knee surgery
9/8/11: FDA approval for stroke prevention in Afib
Inactivation of thrombin: heparin
 Mixture of glycosaminoglycans
 Molecular weight ranges 3000 to 58000

 Strong acid, so strong electronegative

charge
 Heparin: mechanism of action

Binds to Lysine on ATIII

 Conformational change to ATIII.

  affinity for factors XIIa, XIa, IXa, Xa, IIa (thrombin).

 Accelerated inactivation of XIIa, XIa, IXa, Xa, IIa

 Prevents conversion of fibrinogen to fibrin

 Stops clot propagation.

 Heparin: Action on AT III

Hep
AT III

Thrombin-fibrin
AT III Hep clot
Inactive Complex
Thrombin

Thrombin Fibrinogen
 Uses & Adverse Effects of Heparin
 Given parenterally
 Rapid anticoagulation

 Clinical Uses of Heparin

 Arterial and venous thrombi and emboli

 Treatment

 Prophylaxis

 Not teratogenic: can be used in pregnancy

Adverse Effects of Heparin
 Bleeding
 Immune-mediated platelet activation
 thrombosis, paradoxically
 bleeding from thrombocytopenia
Monitoring Heparin
 Measure activity of Intrinsic and Common
Pathway
 “Activated Partial Thromboplastin Time (APTT)”
 Therapeutic goal – 2-2.5 times normal control
value (-30 sec)

 Antidote: Slow IV injection of Protamine Sulfate

Low MW Heparin:
Enoxaparin, Dalteparin, Nadroparin
 Fractionated from total heparin
 More predictable: can be given on a weight
adjusted basis
 Longer half-life, so can be given by
subcutaneous injection
 Less heparin-induced thrombocytopenia
 More expensive, but saves staff time &
hospitalization
 Low MW Heparin

Administered by SC injection
No need for therapeutic monitoring
Lower Risk of Bleeding than unfractioned Heparin

Antidote: Slow IV injection of Protamine Sulfate

Platelet-fibrin clot
 PLATELET INHIBITORS

 ASA
 Clopidogrel (Plavix®), Ticlodipine (Ticlid®)
 Tirofiban (Aggrastat®)
 Abciximab (ReoPro®)
 Eptifibatide (Integrilin®)
Synthesis of Thromboxane A2 (TxA2) in Platelets
Arachidonic acid
Cyclooxygenase (Pg Synthase)

Prostaglandin G2
Aspirin

Prostaglandin H2

TxA2
Other Pg’s
 Aspirin (acetyl salicylic acid)
COOH

OCOCH3

Salicylic acid -acetyl

COOH OCOCH3

Acetylation of NH2-terminal serine

of cyclooxygenase (irreversible)

Competitive blockage of cyclooxygenase

 Acetylation of NH2-terminal
serine of cyclooxygenase (irreversible)

Permanent loss of TxA2 production

Permanent defect in platelet clot formation

Protection from thrombotic disorders

 Gp IIb/IIIa ANTAGONISTS

 Platelet Gp IIb/IIIa receptors play a pivotal

role in platelet-mediated thrombus
formation, binding to fibrinogen and vWF

 IIb/IIIa antagonists differ in receptor

affinity, reversibility, and specificity
 Platelet Activation Pathways
Collagen Thrombin
Epinephrine ADP
Arachidonic
acid

TxA2

GP IIb/IIIa
Clopidogrel
 Also inhibit platelet activation
 Blocks platelet ADP receptors irreversibly
– Prevents ADP-induced activation.
 Prodrug, requiring activation by the liver.
Clopidogrel
 Clinical Use
 Alternative to aspirin (reserved for aspirin-
intolerant or unresponsive patients, because of
cost & ADR’s)
 Added to aspirin in management of some
coronary artery syndromes
Clopidogrel
 – Adverse Effects
diarrhea and nausea,
bleeding complications
 Ticlodipine (Ticlid®)
 Oral Tablets
 Interferes with platelet function by inhibiting ADP-induced platelet-
fibrinogen binding and platelet-platelet interactions
 Indication: to reduce the risk of thrombotic stroke (fatal or nonfatal) in
patients with stroke precursors, or thrombotic stroke
 Can cause life-threatening hematological reactions, including
neutropenia/ agranulocytosis, thrombocytopenic and aplastic anemia
 Should be reserved for patients who are intolerant or allergic to aspirin
therapy or who have failed aspirin therapy
Abciximab (ReoPro®)
 Monoclonal antibody that binds to glycoprotein (GP)
IIb/IIIa receptor of human platelets and inhibits platelet
aggregation.
 Abciximab is intended for use with aspirin and heparin
and has been studied only in that setting
 Abciximab is indicated for prevention of cardiac ischemic
complications like unstable angina or if coronary
intervention is planned within 24 hours
 GP IIb/IIIa antagonist

Inhibition of platelet
aggregation
Agonist
GP IIb/IIIa receptors occupied by
ADP, antagonists
thrombin,
Resting collagen
platelet Fibrinogen
GP IIb/IIIa
receptors in
unreceptive
state

Aggregating
platelets
 Tirofiban (Aggrastat®)
 Tirofiban is a nonpeptide inhibitor of the platelet glycoprotein (GP)
IIb/IIIa receptor, the final common pathway for platelet aggregation.
 Tirofiban is available as an IV drug only
 Tirofiban is a safe and effective agent in combination with heparin
and aspirin in the setting of an acute coronary syndrome.
 It has also been shown to significantly reduce cardiac events in
patients with an acute coronary syndrome who undergo angioplasty
Eptifibatide (Integrilin®)
 Eptifibatide is a cyclic six amino acids peptide
 Eptifibatide binds to the platelet receptor glycoprotein (GP)
IIb/IIIa of human platelets and inhibits platelet aggregation
 Efficacy of eptifibatide established with concomitant use of
heparin and aspirin
 Available as IV drug only
 Dose adjusted based on renal function
Promoting Clot Lysis: Tissue
plasminogen activator (t-PA)
Plasminogen

t-PA

Plasmin

Thrombin-fibrin Degradation
clot products
Tissue plasminogen activator (t-PA):
Alteplase or Reteplase

 Recombinant human protein

 Given by intravenous infusion
 Used to relieve blockage of critical vessels,
e.g. coronary artery occlusion (heart
attack)
 Streptokinase:

Streptokinase binds to plasminogen and forms an

activator complex by which plasmin is formed
Streptokinase is more expensive than t-PA
ANTICOAGULANTS: IN -VITRO
 Heparin Tubes
 Sodium citrate, EDTA → bind Ca++
 Use: Prevention of blood coagulation in
laboratory methods
The in vivo pathway The in vitro contact system
(extrinsic pathway) (intrinsic pathway)
Contact
Tissue damage (e.g. with endoth)

Tissue factor XIIa XII

VIIa
PL XIa XI
Ca2+
IXa IX Platelets
VIIIa, PL, Ca2+ +
X Xa +

+
XIII
Va, PL, Ca2+
Ca2+
II (Prothrombin IIa (Thrombin)
XIIIa
Fibrinogen Fibrin Stabilised fibrin