Jean-Louis David

Inhibition of 5-hydroxytryptamine-induced and-amplified human platelet aggregation by ketanserin (R 41 468), a selective 5-HT2-receptor antagonist

Ketanserin, a selective 5-HT2-receptor antagonist, inhibits the reversible aggregation induced by 5-hydroxytryptamine (5-HT) in human platelet-rich plasma (PRP). In this respect, the compound is equipotent to cyproheptadine and more active than methysergide (IC50: 1.66×10−8M, 1.44×10−8M and 5.62×10−8M respectively). Ketanserin is active against 5-HT-induced platelet aggregation after bothin vitro and oral administration to human volunteers. At concentrations up to 500 times in excess of the IC50 for 5-HT-induced platelet reactions, ketanserin does not affect the aggregation induced by ADP, epinephrine, collagen or Thrombofax®, the prostaglandin biosynthesis of thrombin-stimulated platelets, nor the active uptake of14C-5-HT by platelets.5-Hydroxytryptamine amplifies the human platelet aggregation induced by threshold concentrations of ADP, collagen, epinephrine, norepinephrine and induced irreversible aggregation of platelets pre-sensitized with Thrombofax®. This amplification by 5-hydroxytryptamine results in a platelet response typical for the potentiated agonist; for the combination of the monoamine with collagen, the serotonergic amplification results in enhanced aggregation, release of β-TG and PF4 and excessive formation of TXB2. Ketanserin, after bothin vitro and oral administration to man reduces the amplified response to the level of the potentiated agonist.The present evidence suggests the presence of functional 5-HT2 receptors on the human platelet, different from those involved in the uptake of the monoamine.

New Developments on Thromboxane and Prostacyclin Modulators Part II: Prostacyclin Modulators

Prostacyclin (PGI(2)) is a potent endogenous inhibitor of platelet function and possesses a strong vasodilator effect. Furthermore, prostacyclin is currently presented as the physiologic antagonist of thromboxane A(2)(TXA(2)), which exhibits pro-aggregatory and vasoconstrictor properties. So, the balance between PGI(2) and TXA(2) production is crucial for the cardiovascular system. Indeed, an imbalance in the production or effect of these products is deleterious for the circulatory system and can lead to characterized vascular diseases such as hypertension, stroke, atherosclerosis or myocardial infarction. Although the biological effects of PGI(2) are considered to be clinically useful, its use as therapeutic agent is largely limited by both its chemical and metabolic instability. Actually, several prostacyclin agonists have been synthesized and pharmacologically evaluated. Among these, some have been clinically evaluated as therapeutic agents in several vascular diseases. This review focuses on the latest chemical and pharmacological developments in the field of the prostacyclin agonists.

Effect of ticlopidine on saphenous vein bypass patency rates: a double-blind study.

The effects of ticlopidine, a new antiplatelet agent, on graft patency rate was investigated in a group of 150 consecutive patients undergoing aortocoronary bypass graft procedures. In a double-blind study, two groups of 75 patients each received ticlopidine (250 mg twice daily) or a placebo during a three-month period. Graft patency was evaluated by repeat angiography in 38 patients and by rest and stress myocardial scintigraphy in 93. Combined angiographic and scintigraphic analysis was performed in 36 patients. The biological effects of ticlopidine on platelet activity were assessed by bleeding time and appropriate ex vivo tests. Graft patency was evaluated in 131 patients (87%). Evaluation was performed at the end of the three-month therapy period in 77 patients (Groups T1 [ticlopidine] and P1 [placebo]) and five months later in 54 patients. The total graft attrition rate was 10.1% in Group T1 compared with 20.3% in Group P1 (p less than 0.1). Excluding patients with discordant biological data, the attrition rate was 7.1% for Group T1 compared with 21.8% for Group P1 (p less than 0.02). There was no difference between the subgroups evaluated five months after the end of therapy. Ticlopidine appears to be an effective means of protecting graft patency as long as the biological effects of the drug are present. This protective effect disappears when the drug is discontinued, which suggests that ticlopidine should be prescribed for a longer period, at least for the first year after operation.

Hemostasis profile in women taking low-dose oral contraceptives

Thirty-six young, healthy, nonsmoking women have been selected to check the effect of low-dose oral contraceptives on hemostasis. Two identical groups were treated by Marvelon (a monophasic oral contraceptive containing ethinyl estradiol and desogestrel) or Trigynon (a triphasic oral contraceptive containing ethinyl estradiol and levonorgestrel) for a 6-month period. In the absence, previously controlled, of substantial differences between the effects of each treatment on hemostasis, all the results were pooled at the third and sixth month of the study. The effects of oral contraceptive treatment were as follows: (1) platelet number, platelet aggregating ratio, and plasma beta-thromboglobulin level were not significantly altered, and (2) antithrombin III activity was not reduced despite a slight decrease or antigen concentration. The von Willebrand factor parameters, factor VIII:C, factor VII:C, and clottable fibrinogen were significantly increased. Plasminogen (activity and antigen concentrates) and alpha 2-antiplasmin levels were also significantly increased. Activated partial thromboplastin time and euglobulin lysis time measured after venous occlusion were significantly shortened. Although statistical analysis did not show dramatic changes in all these parameters, some individual extreme values were substantially altered. Therefore we believe that these later values are worthy of cautious consideration for weighing the role that hemostasis factors might play in individual thrombotic risk.

Is thrombin generation the new rapid, reliable and relevant pharmacological tool for the development of anticoagulant drugs?

The ex vivo testing emerges as an essential and critical step for the selection of the most promising prospective anticoagulant agents. The aim of the present study was to validate the thrombin generation assay as an ex vivo pharmacological screening test for measuring the anticoagulant behaviour and potency of molecules. The effects of six thrombin and/or factor Xa (FXa) inhibitors (argatroban, lepirudin, PPACK, enoxaparin, ZK-807834, fondaparinux) were investigated on the time course of thrombin catalytic activity triggered by the tissue factor pathway in platelet-poor plasma (PPP) of male healthy volunteers using the Calibrated Automated Thrombogram((R)) (CAT) method. In the presence of the anticoagulant drugs, the thrombin activity profiles were dose-dependently modified according to their specific enzyme inhibitory activity. ZK-807834 was the most potent drug for reducing the C(max) and the V(max) but also for prolonging the T(max). Lepirudin most efficiently delayed the lag time whereas enoxaparin was the most powerfully drug for diminishing the endogenous thrombin potential (ETP). In conclusion, the thrombin activity profile performed with the CAT method is a very rapid, suitable and reliable pharmacological tool for screening thrombin and/or FXa inhibitors whatever their inhibition mode. It consists of a powerful alternative for the classical PT clotting assay, especially regarding to the time course and the total amount of active thrombin generated. Last but not least, it provides insight into the mechanism of action of the compounds.

Recent Advances in Antiplatelet Agents

Platelet aggregation plays a key role in the pathogenesis of thromboembolic diseases such as myocardial infarction, stroke, unstable angina and peripheral artery disease. Until recently, aspirin was the only antiplatelet agent available to prevent or treat these events. Over the past several years, there has been a substantial expansion in the antiplatelet armamentarium as well as in the understanding of the clinical importance of antiplatelet therapy in limiting the complications of thrombosis. Aspirin was one of the first agents to be adopted and it remains as the standard therapy with the higher amount of available clinical information. Following aspirin, ADP receptor antagonists like ticlopidine and clopidogrel as well as phosphodiesterase inhibitors dipyridamole and cilostazol have been introduced. Glycoprotein (GP) IIb/IIIa receptor antagonists like eptifibatide, tirofiban and abciximab are the newer antiplatelet agents which act at the end of the common pathway of platelet aggregation. Although results of clinical studies with the first oral GPIIb/IIIa antagonists were disappointing, agents of the new generation might expand the potential application of GPIIb/IIIa targeted therapy. This review will highlight recent advances in the development of aspirin, phosphodiesterase inhibitors, ADP receptor antagonists and the platelet glycoprotein IIb/IIIa inhibitors. The emphasis of this paper has been placed on the chemical aspects of these agents.

SMA circuits reduce platelet consumption and platelet factor release during cardiac surgery

BACKGROUND Platelet count and function are particularly damaged by cardiopulmonary bypass (CPB). This study evaluated the effects of a novel CPB circuit in terms of platelet count and activation, and postoperative need for blood products. METHODS One hundred patients undergoing coronary grafting were randomized in two groups: control group (n = 50) and test group (n = 50, surface modifying additives circuit, SMA group). Blood samples were taken before, during, and after CPB. Postoperative blood loss, number of transfused blood products, and postoperative variables were recorded. RESULTS The platelet count decreased less in the SMA group compared to the control group (end of CPB: respectively, 165 +/- 9 x 10(3)/mm3 vs 137 +/- 8 x 10(3)/mm3; p < 0.01). This was paralleled by a reduction in beta-thromboglobulin plasma levels in the SMA group. There was a trend to decreased blood loss in the SMA group, but the difference was significant only in patients taking aspirin preoperatively (p < 0.05). In the SMA group nearly 50% less fresh frozen plasma and platelet units were administered (p < 0.01). No operative deaths were observed. CONCLUSIONS The use of circuits with surface additives is clinically safe, preserves platelet levels, and attenuates platelet activation. This may lead to a reduced need for blood products.

Pharmacological evaluation of the novel thromboxane modulator BM-567 (II/II). Effects of BM-567 on osteogenic sarcoma-cell-induced platelet aggregation

Evidence exists that a large number of tumor cells such as osteosarcoma cells stimulate platelet aggregation, which can be an early step in the metastatic processes of these tumors. Thromboxane A(2) (TXA(2)) is released during platelet aggregation, and it has been suggested that this release may be pathogenic for tumor metastasis for several reasons:Some tumors release large amounts of TXA(2) compared to normal tissue.TXA(2) potentiates tumor growth in culture and increases metastasis in animals.TXA(2) is a potent stimulant of platelet aggregation and causes vascular injuries that may promote implantation of tumor cell-platelet aggregates. If TXA(2) participates in tumor metastasis, it may be hypothesized that TXA(2) inhibitors should decrease tumor metastasis. So, we have evaluated the effects of the original TXA(2) synthase inhibitor and TXA(2) receptor antagonist BM-567 on platelet aggregation induced by osteosarcoma cells using MG-63 tumor cells. Results obtained showed that this drug inhibited both MG-63 tumor-cell-induced platelet aggregation and platelet TXA(2) release following the tumor cell stimulation with IC(50) values of 3.04x10(-7) and 2.51x10(-8)M, respectively.

Progress in the field of GPIIb/IIIa antagonists.

Platelet aggregation plays an important role in pathological situations such as myocardial infarction, unstable angina, peripheral artery disease, and stroke. Thus, pharmacological agents that specifically inhibit platelet aggregation are of great interest in the treatment and prevention of these cardiovascular diseases. Since binding of activated glycoprotein IIb/IIIa complex, a platelet surface integrin, to fibrinogen is the final step leading to platelet aggregation regardless of the initial stimulus, many researches have focused on the development of drugs that could antagonize this integrin. Three intravenous glycoprotein IIb/IIIa antagonists are currently marketed for the prevention of myocardial infarction in patients undergoing percutaneous intervention: Abciximab, Eptifibatide and Tirofiban. To further test the clinical efficacy of these agents, oral glycoprotein IIb/IIIa antagonists have been developed but only led to disappointing clinical results. Nevertheless, due to recognized usefulness of oral agents for the prevention and treatment of cardiovascular diseases, a great number of new orally active compounds are under clinical or preclinical evaluation. The aim of this review is to describe the chemical, pharmacological and clinical properties of existing and forthcoming glycoprotein IIb/IIIa antagonists.

Heparin-Induced Thrombocytopenia: A Case Report

The authors report a case of heparin-induced thrombocytopenia, in whom massive pulmonary embolism occurred in spite of heparin anticoagulation. Suc cessful pulmonary thrombectomy was carried out under cardiopulmonary by pass, with limitation of platelet clumping during bypass by aggregation inhibitors. This report is a comprehensive contribution to a better understanding of this rare immunoallergic complication of heparin administration, with a high incidence of serious thromboembolic events. The optimal management for cases of unavoid able reexposure to heparin is discussed.