THROMBOLYTIC DRUGS

Thrombosis

coagulation

Fibrinolysis
 Fibrinolysis

t-PA binds to fibrin and

converts plasminogen α2-Antiplasmin forms a
stable complex with plasmin,
(inactive precursor) to thereby inactivating it
plasmin

Synthesize Plasmin dissolve

intravascular
fibrin

Thrombin converts fibrinogen to fibrin monomers which are bound to each other non-covalently.
Subsequently, factor XIII, activated by thrombin, catalyzes interchain covalent cross-links
between adjacent fibrin monomers, which enhance the strength of the clot.
 Fibrinolysis
tissue plasminogen
activator (t-PA)
 Synthesized by endothelial cells
 t-PA predominates under most
conditions and drives
intravascular fibrinolysis.
 T-PA is a serine protease
 t-PA exerts little effect on
circulating plasminogen in the
absence of fibrin
 Released t-PA is rapidly cleared
from blood (t½=5min) or
inhibited by plasminogen
activator inhibitor-1 (PAI-1) and,
to a lesser extent, plasminogen
activator inhibitor-2 (PAI-2);
Urokinase plasminogen
activator (u-PA), Streptokinase
(SK)
 U-PA
synthesized by endothelial cells, macrophages,

renal epithelial cells and some tumour cells
 is an effective plasminogen activator in both
the presence and the absence of fibrin 
Binds equally to circulating and clot-associated
plasminogen
 SK is not a protease and has no enzymatic activity;
 It forms a complex with plasminogen that
releases plasmin.
Unlike tPA, it does not bind preferentially

to clot-associated fibrin and therefore
binds equally to circulating and non-
circulating plasminogen.
 SK produces significant fibrinogenolysis
along with clot fibrinolysis (La plasmine,
libérée d’une manière non spécifique,
hydrolyse la fibrine du caillot et le
fibrinogène circulant )
Le plasminogène comprend sept domaines structurels : un peptide de préactivation, cinq
domaines en boucle appelés kringles (K1 à K5) et un domaine qui porte le site responsable
de l’activité protéolytique. Les kringles confèrent au plasminogène sa capacité à se lier
aux résidus lysine de différentes molécules (fibrine, α 2-antiplasmine, HRGP…). L

Plasminogen and plasmin bind fibrin via the

kringle domains and digest the fibrin

α2-antiplasmin binds to the first of these kringle

domains and blocks the active site of plasmin.

Binding to 2 antiplasmin
Binding to fibrin

5
Plasminogen
 Plasmin α2-Antiplasmin
 A non specific serine protease  α2-antiplasmin binds to the first of
 Plasminogen and plasmin bind fibrin these kringle domains and blocks
via the kringle domains and digest the active site of plasmin.
the fibrin.
 Plasma concentrations of α2-
 Because the kringle domains are antiplasmin are sufficient to inhibit
occupied when plasmin binds to about 50% of potential plasmin
fibrin, plasmin on the fibrin surface is
protected from inhibition by α2-
antiplasmin
 Degrades other plasma proteins,
including several coagulation factors
impairing the capacity for thrombin
generation, which can contribute to
bleeding.
 THROMBOLYTIC DRUGS
 Thrombolytic drugs = Fibrinolytic drugs =Plasminogen activators
 are used to dissolve (lyse) blood clots (thrombi) by activating
plasminogen, which forms a cleaved product called plasmin
 Blood clots can occur in any vascular bed;
 when they occur in coronary, cerebral or pulmonary vessels, they
can be immediately life-threatening
 coronary thrombi are the cause of myocardial infarctions,
 cerebrovascular thrombi produce strokes,
 pulmonary thromboemboli can lead to respiratory and cardiac
failure..
 THROMBOLYTIC DRUGS
 Tissue Plasminogen Activators
 Alteplase ACTIVASE
 Retaplase RETAVASE

 Tenecteplase

 Streptokinase

 Anistreplase

 Urokinase
THROMBOLYTIC DRUGS
 Used in AMI, cerebrovascular thrombotic stroke and pulmonary embolism.
 Reduce death and reinfarction by 30% in regimens containing aspirin
 Treatment of choice for patients with acute ischemic stroke who present within 3 hours of
symptom onset.
 Alteplase:
 Recombinant form of human tPA ( rtPA )
 T½(~5 min) → IV bolus followed by an infusion.
 Retaplase
 Genetically engineered, smaller derivative of recombinant tPA →
 Potency >>rtPA
 Faster acting than rtPA.
 T½>>T½ rtPA →IV bolus injections.
 It is used for acute myocardial infarction and pulmonary embolism.
 Tenecteplase (TNK-tPA)
 T½>>T½ rtPA →IV bolus injections.
 Binding affinity for fibrin >> rtPA.
 is relatively resistant to inhibition by PAI-1.
 Approved only for use in acute myocardial infarction.
THROMBOLYTIC DRUGS
 Streptokinase
 Natural streptokinase (SK) is isolated and purified from streptococci
bacteria →antigenic
 Lack specificity for fibrin → less desirable thrombolytic drug than tPA
compounds because it produces more fibrinogenolysis.:(La plasmine,
libérée d’une manière non spécifique, hydrolyse la fibrine du caillot et le
fibrinogène circulant )
 Anistreplase
 Complex of SK and plasminogen.
 Fibrin specificity and duration of activity >>natural SK however, it causes
considerable fibrinogenolysis.
 Urokinase =urinary-type plasminogen activator (uPA)
 Formed by kidneys and is found in urine→ non-antigenic
 Like SK, →considerable fibrinogenolysis;
 Used for pulmonary embolism.
 THROMBOLYTIC DRUGS
 Toxicity :
 Hemorrhage due to
 Lysis of fibrin in hemostatic plugs at sites of vascular injury
 Systemic lytic state :
 Massive activation of plasminogen→ α2-antiplasmine depletion→ ↑ free
plasmin generation which induces :
 Fibrinogenolysis : fibrinogen is degraded and fibrinogen degradation
products impair fibrin polymerization and therefore increase bleeding
from wounds.
 degradation of other coagulation factors (factors V and VIII).

 Hemorrhagic stroke occurs with all regimens and is more common when
heparin is used.
 Re-thrombosis can occur following thrombolysis, and therefore anticoagulants such as
heparin are usually co-administered, and continued after thrombolytic therapy for a
period of time.
Absolute Contraindications
Prior intracranial hemorrhage
Known structural cerebral vascular lesion
Known malignant intracranial neoplasm
Ischemic stroke within 3 months
Suspected aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant closed-head trauma or facial trauma within 3 months
Relative Contraindications
Uncontrolled hypertension (systolic blood pressure >180 mm Hg or diastolic
blood pressure >110 mm Hg)
Traumatic or prolonged CPR or major surgery within 3 weeks
Recent (within 2-4 weeks) internal bleeding
Noncompressible vascular punctures
For streptokinase: prior exposure (more than 5 days ago) or prior allergic
reaction to streptokinase
Pregnancy
Active peptic ulcer
Current use of warfarin and INR >1.7
Inhibitors of Fibrinolysis
 Inhibitors of fibrinolysis
14

Aminocaproic acid

Tranexamic acid EXACYL

Lysine analogs that compete

for lysine binding sites on
plasminogen and plasmin,
blocking the interaction of
plasmin with fibrin
 Inhibitors of Fibrinolysis
Aminocaproic Acid and Tranexamic Acid = lysine analogs

 Adverse effects :
 Thrombi formed during treatment with the drug are not
lysed. Ex: patients with hematuria, ureteral obstruction by clots
may lead to renal failure

 Indications:
 Oral or IV adminstration
 Aminocaproic + tranexamic acids   bleeding after
prostatic surgery or after tooth extractions in hemophiliacs
 Tranexamic acid  treatment of heavy menstrual bleeding
ANTIPLATELET DRUGS
PHYSIOLOGY OF BLOOD CLOTTING
Hemostasis is the cessation of blood loss from a damaged vessel
Several steps are involved in this process :
 Vasoconstriction

 Platelet (PL) adhesion:

 GPIa/IIa and GPIb are PL receptors that bind to collagen and von Willebrand
factor (vWF), causing PL to adhere to the subendothelium of a damaged blood
vessel.
 Platelet aggregation :Adherent PL release substances that activate nearby PL,
thereby recruiting them to the site of injury:
 TxA2 (synthesized by COX1), ADP & epinephrine are PL agonists . They bind to
receptors on the surface of PL . P2Y1 & P2Y12 must be both activated to induce
PT aggregation
 Activation of PL GPIIb/IIa R: activation of PL leads to a change in shape of
GPIb/IIa R enabiling it to bind to fibrinogen . One end of fibrinogen molecule
binds to GPIb/IIa R of activated PL and the other to the receptor of another PL,
that bridging PLs and creating a plug PL
 Plasmatic coagulation
 Platelet adhesion and aggregation
18

3. Mediators  expression of GP IIb/ IIIa receptors

that bind to fibrinogen  platelet aggregation

2. Platelet activation = synthesis + release

(degranulation) of mediators of platelet
aggregation e.g., TXA2, ADP & 5-HT

PAR1 & PAR4 are

Protease-Activated
Receptors that
respond to
thrombin (IIa)

1. Adherence to collagen and

von Willebrand factor (vWF) in
subentholium of damaged vessel
 Physiopathology of blood clotting
 Pl play a major role in arterial  Venous thrombosis occurs
thrombosis with additional mostly via the plasma
participation of plasma coagulation system with
coagulation system thrombosis minor Pl participation

Arterial Venous

PL Plasma Plasma
aggregation coagulation coagulation

Treatment Antiplatelet Anticoagulant Anticoagulant

drugs Drugs drugs
 Irreversible COX1 Sites of action of antiplatelet agents
inhibitors : Aspirin
 P2Y12 ADP receptor
inhibitors :
 Irreversible inhibitors
: Ticlopidine,
clopidogrel, and
prasugrel
 Reversible inhibitors:
Cangrelor and
ticagrelor
 Glycoprotein (GP)
IIb/IIIa Inhibitors
 Abciximab,
eptifibatide, and
tirofiban
 Antagonist of the
protease-activated
receptor (PAR)-1:
vorapaxar
 Antiplatelet Drugs

vorapaxar
ASPIRIN
 TxA2 ,major cyclooxygenase product in PL, is released upon PLs adhesion and during PLs
aggregation
 TxA2 is a potent PLs aggregator and vasoconstrictor.
 improves clinical outcome in all CV syndromes in primary and secondary prevention, including
acute events

 MAO:
 Aspirin blocks production of TxA2by acetylating COX1.
 Action of aspirin on platelet COX-1 is permanent, because PLs do not synthesize new
proteins, and last for the life of the platelet (7-10 days)→ repeated doses of aspirin
produce a cumulative effect on platelet function.
 Doses:
 75 mg QD. →complete inactivation of platelet COX-1
 Maximally effective anti-thrombotic doses is 50-320 mg/day
 Higher doses have less efficacy ( PGI2) & more toxicity (mainly bleeding)
 Antithrombotic doses <<< AAI doses
Triflusal
 Triflusal DISGREN
 Metabolised in liver in active metabolite HTB (t1/2 triflusal =
0.5h / HTB = 40h)
 COX-1 inhibition selectively in plt (but efficacy < aspirin )
 Triflusal + HTB  PDE inhibitors
 similar efficacy to aspirin for the secondary prevention of
vascular events in patients with acute myocardial infarction
and stroke
 More favorable safety profile :  incidence of intracranial
and GI hemorrhage compared with aspirin & well tolerated
in patients with aspirin-induced asthma
 P2Y12 receptors Inhibitors
 ADP activates PLs aggregation by
binding to 2 purinergic receptors
P2Y1 and P2Y12 (GPCRs)
 Activation of P2Y1 receptor induces a
shape change and aggregation
through the stimulation of PLC and
phosphatidylinositol-signaling
pathway.
 Activation of P2Y12 receptor inhibits
adenylyl cyclase, → ↓cAMP→
activation of the GPIIb/IIIa receptor
and platelet aggregation.
 Both receptors must be stimulated to
result in platelet activation
BUT
 inhibition of either receptor is
sufficient to block platelet activation
 P2Y12 receptor Inhibitors
 Irreversible inhibitors : thienopyridine derivatives :
 1st generation : ticlopidine  no more used because of high hematologic toxicity :
neutropenia, thrombotic thrombocytopenic purpura)
 2nd generation : clopidogrel, prasugrel
 Prodrug
 Bind permanently to the P2Y12 receptor →potently inhibits ADP-induced platelet
aggregation and also reduces platelet dense granule secretion: ↓of AA-, collagen-
and thrombin-induced platelet activation
 long duration of action
 prolonged effect after discontinuation.
 This can be problematic if patients require urgent surgery. Such patients
are at increased risk for bleeding unless the thienopyridine is stopped at
least 5 days prior to the procedure.
 Potency : prasugrel > clopidogrel > ticlopidine
 Reversible inhibitor :
 Ticagrelor
 Reversible direct noncompetitive inhibitor of P2Y12
 Cangrelor (IV)
 Reversible direct competitive inhibitor of P2Y12 (affinity > clopidrogrel, prasugrel)
Inhibitors of P2Y12 receptor
 Clopidogrel PLAVIX Stuctural analog to ticlopidine
 Prodrug with a slow onset of action :
 need for metabolic activation  maximum antagonism observed 4–5 days after daily
administration of 75 mg  loading facilitates a more intense and rapid platelet
inhibition (300-600mg)
 PK :
 activation by CYP2C19 & CYP3A4 : 15% of the dose
 High interindividual variability in platelet inhibition
 Genetic polymorphism in CYP2C19 : loss-of-function CYP2C19*2 allele exhibit
reduced platelet inhibition compared with those with the wild-type CYP2C19*1 allele
→resistance to clopidigrel
 Drug interactions : inhibitors of CYP2C19 (PPI), CYP3A4
 Diseases : diabetic and obese patients show hyporesponsiveness to clopidogrel
 Uses :
 75mg/day for secondary prevention of stroke
 Better then Aspirin
 Synergistic association with Aspirin
 P2Y12 antagonists
27

CYP2C19, CYP3A4/5, CYP2C9,

CYPP1A2 and CYP2B6
2-oxo-
15% clopidogrel
Substrate of Pgp Active thiol
metabolite

Substrate of Pgp

CYP: Cytochrome P450; PON-1: Paraoxonase-1.

 Inhibitors of P2Y12 receptor
Prasugrel
 PK :

 Rapid & completely absobed & activated →

 Faster action than Ticlopidine or clopidogrel
 inhibition of ADP-induced platelet aggregation>> ticlodipine or
clopidogrel
 CYP2C19 polymorphisms appear to be less important determinants
of the activation of prasugrel →alternative to clopidogrel in patients
with the loss-of-function CYP2C19 allele
Reversible Inhibitors of P2Y12 receptor
 Cangrelor :
 t1/2 : 3-6 minutes IV bolus followed by an infusion.
 Platelet function recovers within 60 minutes after infusion is
stopped .
 Ticagrelor :
 Active orally
 More rapid onset and offset of action than clopidogrel,
 t1/2 = 6–8 h
 Metabolized by CYP3A4/5  some active metabolites
 Eliminated in feces  no need to change dose in renal
impairment
 Adverse effects
 All   risk of bleeding
 Ticagrelor  dyspnea
 P2Y12 antagonists : Indications
30

 Clopidogrel/ prasugrel
 Alternative to aspirin or concomitant with aspirin
 Reduce the rate of stroke, MI , and death in patients with
recent MI or stroke, established peripheral arterial disease,
or acute coronary syndrome
 Prasugrel showed superior efficacy & increased risk of
bleeding

 Ticagrelor
 Prevention of thrombotic events in patients with ACS
(unstable angina,) or a history of MI
 Protease-activated receptors
31

 Cell surface
receptors
activated by
proteolysis

 In human platelets
 PAR-1 : Main
thrombin receptor
activated by low
concentrations of
thrombin
 PAR-4 :
secondary
receptor
 Physiological role of thrombin
32

 Thrombin generates fibrin  protective hemostatic function

 In platelets :
 Thrombin is considered to be one of the most potent platelet activators :
 synthesis + release (degranulation) of mediators of platelet aggregation e.g., TXA2,
ADP & 5-HT
 P2Y12 and PAR-1 pathways are known to cross-react in mediating platelet activation

 In vessel walls
 Endothelial cells express all four PAR family members.
 PARs also mediate responses involved in contractility, proliferation, inflammation, and
repair.
 PAR-1 mediates pro-inflammatory signaling  PAR-1 antagonism has been shown to be
protective in animal models of vascular injury

 thrombin-mediated cleavage of fibrinogen into fibrin is more important for

haemostasis than thrombin-mediated platelet activation.
 Physiological role of thrombin
33

Platelets / Coagulation

Vessel walls

APC : activated protein C

EPCR : endothelial cell protein C receptor
 The inhibition of the protease-activated
receptor-1 (PAR-1) for thrombin inhibits
PAR-1 antagonist
thrombin-mediated platelet activation
without increasing bleeding
: vorapaxar
34

PAR-1 inhibition in fa
does not interfere w
thrombin-dependent
fibrin generation and
coagulation, which a
essential for
haemostasis.
 Rationale for PAR-1 antagonists
35

 Hypothesis : PAR-1 inhibition would reduce ischemic events without

significant increase in bleeding
 Why ?
 ADP and the TXA2 platelet activation pathways are crucial for both routine
haemostasis and pathological thrombosis,
 PAR-1-mediated platelet activation contributes to pathological thrombosis
(formation of occlusive platelet-rich thrombus) but may not be required for
protective haemostasis (formation of the initial platelet monolayer).
 thrombin-mediated cleavage of fibrinogen into fibrin is more important for
haemostasis than thrombin-mediated platelet activation  little risk of
bleeding from PAR blockade
 PAR-1 antagonists do not block platelet activation mediated by collagen, ADP
or TXA2
 PAR-1 antagonism does not affect : activated clotting time, activated partial
thromboplastin time, and prothrombin times, haematological parameters (RBC,
Ht, WBC, Plt count)
 Platelets retain responsiveness to thrombin (albeit at much higher doses) via
intact PAR-4 signals
 Formation of thrombus
36
 PAR-1 antagonist : vorapaxar
37

 Selective competitive PAR-1 antagonist

 Approved in USA & Europe for reduction of thrombotic CV events in
patients with a history of myocardial infarction (MI) (United States and
Europe) and peripheral arterial disease (PAD) (United States) without
history of stroke or transient ischemic attack (TIA)
 To be added to standard-of-care therapy

 PK
 Oral drug administered without consideration of meals or antacid use
 Metabolized by CYP3A4 enzyme  drug-drug interactions
 Slow elimination : disposition t1/2 = 3-4 days / terminal t1/2 = 8 days
 Eliminated primarily in the form of metabolites (feces > urine)

 Adverse effects
 Bleeding
Glycoprotein IIb/IIIa Inhibitors

 Glycoprotein IIb/IIIa = integrin-αIIbβ3 is inactive on resting platelet

 Platelet agonists (thrombin, collagen, or TxA2 ) induces a conformational
transformation of Glycoprotein IIb/IIIa
 This transformation endows glycoprotein IIb/IIIa with the capacity to serve as a
receptor for fibrinogen and von Willebrand factor, which anchor platelets to
foreign surfaces and to each other, thereby mediating aggregation.
 GPIIb/IIIa inhibitors are potent antiplatelet agents that block plt aggregation
induced by any agonist
 GPIIb/IIIa inhibitors
39

 IV injection
 Adverse effect  Bleeding
 Use  Prevent platelet aggregation and thrombosis in
patients undergoing percutaneous coronary interventions,
including coronary angioplasty and stent placement.

Feature Abciximab Eptifibatide Tirofiban AGGRASTAT

Description Fab fragment of Cyclical KGD- Nonpeptidic RGD-
humanized mouse containing mimetic (Arg–Gly–Asp )
monoclonal antibody heptapeptide
Specific for GPIIb/IIIa No Yes Yes
Mechanism of inhibition Noncompetitive Competitive Competitive reversible
irreversible reversible
Thrombocytopenia +++ + +
Platelet-bound t1/2 Long (days) Short (sec) Short (sec)
 Phosphodiesterase inhibitors
40

 Dipyridamole
 Coronary vasodilator + relatively weak antiplatelet drug
  cAMP levels (PDE3/5 I and/or blockade uptake of
adenosine  A2 receptor  activates AC )
 Used mainly with aspirin for secondary prevention in
patients with stroke or transient ischemic attacks

 Cilostazol
 PDE3I   cAMP levels in plt (anti-aggregation) & vessels
(vasodilation)
 Metabolized by CYP3A4
 Indicated for treatment of intermittent claudication
 Benefits versus Risks
41

The influence of major

bleeding on mortality
seems equivalent to
the effect of an MI