Wolfgang Wienen

Dabigatran etexilate - a novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversal of anticoagulant activity

Dabigatran etexilate is an oral, reversible direct thrombin inhibitor that is approved in the EU and several other countries for the prevention of venous thromboembolism after elective hip and knee replacement, and is in advanced clinical development for other thromboembolic disorders. Dabigatran has a predictable pharmacokinetic profile, allowing for a fixed-dose regimen without the need for routine coagulation monitoring. In certain clinical situations such as serious bleeding into critical organs (e.g. intracerebral bleeding), potential overdose and emergency surgery, clinicians will need to make an assessment of the anticoagulant status of a patient receiving dabigatran before deciding on future management strategies. If available, thrombin clotting time (TT), ecarin clotting time (ECT) and TT determined by Hemoclot thrombin inhibitor assay are sensitive tests to evaluate the anticoagulant effects of dabigatran. Prothrombin time (INR) is less sensitive than other assays and cannot be recommended. The activated partial thromboplastin time (aPTT) can provide a useful qualitative assessment of anticoagulant activity but is less sensitive at supratherapeutic dabigatran levels. There are limited data for activated clotting time (ACT). Overall, the aPTT and TT are the most accessible qualitative methods for determining the presence or absence of anticoagulant effect. Although there is no specific antidote to antagonise the anticoagulant effect of dabigatran, due to its short duration of effect drug discontinuation is usually sufficient to reverse any excessive anticoagulant activity. In case of potential overdose, the feasibility of early administration of activated charcoal and subsequent charcoal filtration are undergoing preclinical evaluation. Dabigatran can also be dialysed in patients with renal impairment. In instances of life-threatening bleeding, where conventional measures have failed or are unavailable, other non-specific prohaemostatic agents such as recombinant activated factor VII and prothrombin complex concentrates can be considered.

Pharmacological characterization of the novel nonpeptide angiotensin II receptor antagonist, BIBR 277

1 The pharmacological profile of BIBR 277, 4′‐[(1,4′‐dimethyl‐2′‐propyl[2,6′‐bi‐1H‐benzimidazol]‐1′‐yl)methyl]‐[1,1′‐biphenyl]‐2‐carboxylic acid, a novel, nonpeptide angiotensin II receptor antagonist has been investigated by use of receptor binding studies, enzymatic assays, functional in vitro assays in rabbit aorta as well as in vivo experiments in pithed, anaesthetized and conscious rats. 2 BIBR 277 potently interacted with rat AT1 receptors (Ki 3.7 nm). Competitive receptor interaction was shown by radioligand saturation experiments performed in the presence of BIBR 277. The failure to inhibit radioligand binding to AT2 sites demonstrates the selectivity of BIBR 277 for AT1 receptors. This is further substantiated by the findings that BIBR 277 neither interacted with other receptor systems investigated nor affected the activity of components of the human renin‐angiotensin system, such as plasma renin or serum converting enzyme. 3 In rabbit aorta, BIBR 277 had no agonistic properties and was shown to be an insurmountable antagonist of angiotensin II‐induced contractions (KB 0.33 nm). The antagonistic effect persisted even after several wash‐out procedures. However, this interaction was not irreversible since the insurmountable antagonism was concentration‐dependently reversed when BIBR 277 (0.1 μm) and the surmountable antagonist, losartan (0.1 and 1.0 μm) were incubated simultaneously. The specificity of BIBR 277 for the AT1 receptor was further substantiated in this preparation since micromolar concentrations of BIBR 277 neither affected potassium chloride and noradrenaline‐induced contractions nor acetylcholine‐mediated tissue relaxation. 4 In pithed rats, i.v. administration of BIBR 277 (0.1, 0.3 and 1.0 mg kg−1) shifted the dose‐pressor response curve to angiotensin II dose‐dependently to the right with ED50 values of 0.23 μg kg−1 (control) and 1.4 μg kg−1, 4.7 μg kg−1 and 20 μg kg−1, respectively. As observed in the in vitro experiments no agonistic effect was detected and the maximum of the blood pressure response to angiotensin II at the highest dose of BIBR 277 was decreased by 29%. 5 In anaesthetized rats, bolus i.v. administration of 0.1, 0.3 and 1.0 mg kg−1 BIBR 277 attenuated the blood pressure response to bolus i.v. injections of angiotensin II (0.1 μg kg−1). At the highest dose an almost complete blockade was observed even after 2 h. 6 Single oral administration of BIBR 277 (0.3 and 1.0 mg kg−1) to conscious, chronically instrumented renovascular hypertensive rats dose‐dependently decreased the mean arterial blood pressure by 15 and 30 mmHg, respectively. At the higher dose a significant antihypertensive effect was maintained for more than 24 h. Moreover, consecutive daily dosing of 1 mg kg−1 orally resulted in a sustained reduction in blood pressure over the 4 day observation period. 7 It is concluded that BIBR 277 is an effective and selective angiotensin II antagonist with antihypertensive activity after oral administration.

Structural basis for inhibition promiscuity of dual specific thrombin and factor Xa blood coagulation inhibitors.

BACKGROUND A major current focus of pharmaceutical research is the development of selective inhibitors of the blood coagulation enzymes thrombin or factor Xa to be used as orally bioavailable anticoagulant drugs in thromboembolic disorders and in the prevention of venous and arterial thrombosis. Simultaneous direct inhibition of thrombin and factor Xa by synthetic proteinase inhibitors as a novel approach to antithrombotic therapy could result in potent anticoagulants with improved pharmacological properties. RESULTS The binding mode of such dual specific inhibitors of thrombin and factor Xa was determined for the first time by comparative crystallography using human alpha-thrombin, human des-Gla (1--44) factor Xa and bovine trypsin as the ligand receptors. The benzamidine-based inhibitors utilize two different conformations for the interaction with thrombin and factor Xa/trypsin, which are evoked by the steric requirements of the topologically different S2 subsites of the enzymes. Compared to the unliganded forms of the proteinases, ligand binding induces conformational adjustments of thrombin and factor Xa active site residues indicative of a pronounced induced fit mechanism. CONCLUSION The structural data reveal the molecular basis for a desired unselective inhibition of the two key components of the blood coagulation cascade. The 4-(1-methyl-benzimidazole-2-yl)-methylamino-benzamidine moieties of the inhibitors are able to fill both the small solvent accessible as well as the larger hydrophobic S2 pockets of factor Xa and thrombin, respectively. Distal fragments of the inhibitors are identified which fit into both the cation hole/aromatic box of factor Xa and the hydrophobic aryl binding site of thrombin. Thus, binding constants in the medium-to-low nanomolar range are obtained against both enzymes.

Comparative antihypertensive and renoprotective effects of telmisartan and lisinopril after long-term treatment in hypertensive diabetic rats

This study compared the cardiovascular and renal effects of long-term telmisartan (3 and 10 mg/kg/day) and lisinopril (10 mg/kg/day) in an animal model combining hypertension and diabetes mellitus. It was a parallel-group study of diabetic, spontaneously hypertensive rats (SHR), treated with control or active treatment for eight months. A non-diabetic SHR control group was run in parallel. Diabetes was induced by streptozotocin (45 mg/kg i.v.) in SHRs aged 9—10 weeks. Animals were treated with telmisartan (3 or 10 mg/kg/day), lisinopril (10 mg/kg/day) or vehicle. Plasma glucose levels, blood pressure (BP), and urinary protein and albumin excretion were measured monthly. Telmisartan treatment significantly reduced BP of diabetic SHRs in a dose-dependent manner (p<0.05, low-dose, n=18; p<0.01, high-dose, n=15). The BP reduction in the lisinopril group was similar to that in the telmisartan 10 mg/kg/day group. Compared with non-diabetic SHRs, untreated diabetic SHRs developed severe proteinuria and albuminuria over the experimental period (p<0.01). In diabetic SHRs, proteinuria and albuminuria were dose-dependently and significantly attenuated by treatment with telmisartan (p<0.01 with the higher dose) and lisinopril (p<0.01). Compared with the untreated diabetic SHRs, cardiac hypertrophy was significantly reduced after treatment with both doses of telmisartan and with lisinopril. Telmisartan, 10 mg/kg/ day, but not lisinopril, significantly attenuated the diabetes-induced increase in glomerular volume. In conclusion, telmisartan, 10 mg/kg/day, is at least as beneficial as lisinopril, 10 mg/kg/day, in lowering BP, reducing cardiac hypertrophy and attenuating renal excretion of protein and albumin in this model.

Dabigatran Acylglucuronide, the Major Human Metabolite of Dabigatran: In Vitro Formation, Stability, and Pharmacological Activity

Glucuronidation of the carboxylate moiety is the major human metabolic pathway of dabigatran (β-alanine, N-[[2-[[[4-(aminoiminomethyl)phenyl]amino]methyl]-1-methyl-1H-benzimidazol-5-yl]carbonyl]-N-2-pyridinyl). It results in the formation of the 1-O-acylglucuronide. Four isomeric acylglucuronides of dabigatran were isolated and purified from urine of dosed rhesus monkeys. NMR analysis confirmed the structures of the four metabolites as the 1-O-acylglucuronide (β anomer) and the 2-O-, 3-O-, and 4-O-acylglucuronides (α and β anomers). Experiments with the purified 1-O-acylglucuronide and its isomeric rearrangement products revealed equipotent prolongation of the activated partial thromboplastin time compared with dabigatran. The 1-O-acylglucuronide, in addition to minor hydrolysis to the aglycon, underwent nonenzymatic acyl migration in aqueous solution, resulting in the formation of the 2-O-, 3-O-, and 4-O-acylglucuronides with an apparent half-life of 1 h (37°C, pH 7.4). The glucuronidation of dabigatran was catalyzed by human hepatic and intestinal microsomes with Km values in the range of 180 to 255 and 411 to 759 μM, respectively. Three UDP-glucuronosyltransferases (UGTs), namely, UGT1A9, UGT2B7, and UGT2B15, exhibited glucuronidation of dabigatran. Based on a comparison of the in vitro intrinsic clearances, UGT2B15 was considered the major contributor to the glucuronidation of dabigatran. The major contribution of UGT2B15 and the minor contribution of at least two more UGT enzymes together with the lack of potent inhibition of dabigatran glucuronidation by several potential UGT inhibitors indicate a low risk of interaction by comedications on dabigatran glucuronidation in the clinic.

Antithrombotic and anticoagulant effects of the direct thrombin inhibitor dabigatran, and its oral prodrug, dabigatran etexilate, in a rabbit model of venous thrombosis

Summary.  Background: Oral anticoagulant therapies targeted at thrombin are being developed to overcome limitations associated with current standard therapies. Objectives: This study was undertaken to assess and compare the antithrombotic and anticoagulant effects of the novel, selective and reversible, direct thrombin inhibitor (DTI), dabigatran, and its oral prodrug dabigatran etexilate, to that of unfractionated heparin (UFH), hirudin and melagatran using a rabbit model of venous thrombosis. Methods: A rabbit model of venous thrombosis consisting of endothelial damage with blood flow reduction was used with minor modifications. Results: All compounds demonstrated a dose‐dependent reduction in thrombus formation following i.v. administration with complete or almost complete inhibition at the highest doses. Dabigatran (in the dose range 0.03–0.5 mg kg−1) had a 50% effective dose of 0.066 mg kg−1. By comparison, UFH (5–50 U kg−1), hirudin (0.01–0.05 mg kg−1) and melagatran (0.01–0.3 mg kg−1) had a 50% effective dose of 9.8 U kg−1, 0.016 mg kg−1 and 0.058 mg kg−1, respectively. Similarly, oral dabigatran etexilate (1–20 mg kg−1) inhibited thrombus formation in a dose‐dependent manner. Maximum inhibition was achieved within 1 h of administration, suggesting a rapid onset of action. For both routes of administration, inhibition of thrombus formation directly correlated with prolongation of the activated partial thromboplastin time. Conclusions: These findings demonstrate the potent anticoagulant and antithrombotic activity of dabigatran as a selective thrombin inhibitor in a rabbit model of venous thrombosis. Notably, dose‐dependent and long‐lasting antithrombotic efficacy was observed after application of its oral form dabigatran etexilate, which is currently undergoing phase III clinical development.

The Discovery of Dabigatran Etexilate

Thromboembolic disease is a major cause of mortality and morbidity in the developed world and is caused by an excessive stimulation of coagulation. Thrombin is a key serine protease in the coagulation cascade and numerous efforts have been made to develop safe and effective orally active direct thrombin inhibitors (DTIs). Current anticoagulant therapy includes the use of indirect thrombin inhibitors (e.g., heparins, low-molecular-weight-heparins) and vitamin K antagonists such as warfarin. However there are several caveats in the clinical use of these agents including narrow therapeutic window, parenteral delivery, and food- and drug–drug interactions. Dabigatran is a synthetic, reversible DTI with high affinity and specificity for its target binding both free and clot-bound thrombin, and offers a favorable pharmacokinetic profile. Large randomized clinical trials have demonstrated that dabigatran provides comparable or superior thromboprophylaxis in multiple thromboembolic disease indications compared to standard of care. This minireview will highlight the discovery and development of dabigatran, the first in a class of new oral anticoagulant agents to be licensed worldwide for the prevention of thromboembolism in the setting of orthopedic surgery and stroke prevent in atrial fibrillation.

Heterocyclic Thrombin Inhibitors. Part 2: Quinoxalinone Derivatives as Novel, Potent Antithrombotic Agents

Quinoxalinone derivatives as prototypes of dual thrombin and factor Xa inhibitors have been discovered. Nanomolar inhibition of both coagulation enzymes resulted in very potent antithrombotic activity in vitro.

Effects of telmisartan, hydrochlorothiazide and their combination on blood pressure and renal excretory parameters in spontaneously hypertensive rats

The effects of telmisartan and hydrochlorothiazide (HCTZ) alone and in combination on blood pressure (BP) and renal excretory function were investigated in male spontaneously hypertensive rats (SHR) after oral administration for five consecutive days. Four treatments were studied: vehicle (0.5% Natrosol™), telmisartan 3 mg/kg, HCTZ 10 mg/kg, and telmisartan 3 mg/kg+ HCTZ 10 mg/kg. The effects on BP and heart rate were studied in 40 SHRs (10 animals per group) using an implanted telemetry device. Renal excretory function was assessed in 76 SHRs (18 animals per group, of which nine were used for urine sampling and nine for blood sampling). The telmisartan/HCTZ combination produced the greatest reductions in trough DBP (—44±1.5 mmHg), SBP (—60±1.9 mmHg) and mean BP (mBP; —53±1.7 mmHg) after five days of therapy (p<0.05 vs. vehicle and vs. telmisartan). Telmisartan monotherapy also decreased DBP, SBP and mBP significantly (p<0.05), but only minor BP fluctuations occurred in SHRs receiving HCTZ or vehicle. Telmisartan/HCTZ elevated heart rate by approximately 12 beats per minute (p<0.05 vs. control). Significant increases in urine volume and Na+, Cl—, K+, creatinine and glucose excretion were observed with HCTZ treatment (p<0.01). Telmisartan/HCTZ also promoted renal water and electrolyte excretion (p<0.01); the diuretic effect appeared to be greater with the combination than with HCTZ alone, and there was some attenuation of urinary K+ loss. Elevated blood urea nitrogen levels were observed only in HCTZ-treated SHRs. These results indicate that the antihypertensive efficacy of telmisartan in SHRs is augmented by co-administration with HCTZ. The combination did not affect renal excretory function, with the exception of an increase in blood urea nitrogen and a possible amelioration of HCTZ-related K+ depletion.

Peptidomic analysis of blood plasma after in vivo treatment with protease inhibitors--a proof of concept study.

Native peptides can be regarded as surrogate markers for protease activity in biological samples. Analysis of peptides by peptidomics allows to monitor protease activity in vivo and to describe the influence of protease inhibition. To elucidate the potential of peptides as markers for in vivo protease inhibition we analyzed plasma samples from animals treated with either the indirect FXa inhibitor FONDAPARINUX or the dipeptidylpeptidase IV inhibitor AB192. Signals correlating with the treatment were subsequently identified and assessed with respect to protease-dependent consensus cleavage motifs and occurrence of downstream targets. It could be shown that regulated peptides were either substrates, products or downstream targets of the inhibited protease. The results from the present study demonstrate that the in vivo analysis of peptides by peptidomics has the potential to broaden the knowledge of inhibitor related effects in vivo and that this method may pave the way to develop predictive biomarkers.