Intravenous and oral anticoagulants Mechanisms of action

Intravenous and oral anticoagulants Mechanisms of action Grigoris T Gerotziafas Groupe de Thrombose Equipe de recherche ER2UPMC Interactions cellulaires tumorales et leur environnement et réponses aux agents anticancéreux. Service d Hématologie Biologique Hôpital Tenon, APHP, Paris, France

+ F VIIIa + Phospholipids Blood borne TF Vascular lesion Atherosclerotic plaque Tissue Factor VII VIIa // FXIa X Xa IX IXa FXI NAPC2 ASIS-rTFPI // Anti-IXa (aptamers, and others) amplification Prothrombinase Va - Xa Phospholipids Va // Anti-Xa Pentasaccharide+AT Heparins + AT Rivaroxaban V Apixaban DX-9065a Semuloparin Thrombin VIII VIIIa Intrinsic Tenase Platelets Fibrinogen // Anti-IIa Heparins+AT Bivalirudin Argatroban Dabigatra Semuloparin Activation Fibrin

thrombin (nm) Thrombin generation after TF pathway activation in platelet rich plasma 200 150 Activation of TAFI* to TAFIa * Thrombine Activatable Fibrinolysis Inhibitor The activation of TAFI to TAFIa increases the resistance of the clot to fibrinolysis 100 50 0 VIIa / FT Xa free Initiation phase First traces of thrombin PROTHROMBINASE TENASE IXa+VIIIa+ PS Clot formation activation of platelets, FVIII and FV 0 10 20 time (min) (according to C. Hemker et K. Mann) G.T. Gerotziafas and M.M. Samama

Thrombogenicity of thrombus Thrombin FXa Thrombin FXa

Thrombogenicity of thrombus In accelerated lysis Activation of platelets Thrombin generation Re-occlusion thrombin FXa thrombin FXa Rivaroxaban, dabigatran, bivalirudin : Inhibition of clot bound FXa or thrombin

thrombine (nm) Profile of thrombin generation 250 200 Hypercoagulable state Antithrombotic treatment 150 normal 100 50 0 hypocoagulability 0 10 20 time (min)

Simple classification of anticoagulants Factor Xa Thrombin AT-dependent inhibitors: Pentasaccharide, heparins AT-dependent inhibitors: Heparins, danaparoid HCII-dependent inhibitors Direct inhibitors: Rivaroxaban, apixaban, edoxaban Direct inhibitors: Dabigatran, lepirudin, bivalirudin Parenteral Oral Gerotziafas GT, Samama MM. Current Pharmaceutical Design, 2005,

Mechanism of action of UFH and LMWHs AT Xa AT IIa Below Critical Length Material MW<5400 Da (<18 monosaccharides) Above Critical Length Material >5400 Da (>18 monosaccharides) Similar mechanism for the inhibition of FIXa 8

Heparin Macrophage Endothelial cells Fondaparinux Idraparinux antithrombin fondaparinux other plasma proteins Heparin 9

Selective binding of rivaroxaban on the active site of FXa focus on the active site showing the key interaction between rivaroxaban and Tyr228 in the S1 pocket Perzborn et al Arterioscler Thromb Vasc Biol. 2010;30:376-381

Effect of FXa inhibitors on free and prothrombinase bound FXa Direct inhibitors of FXa (rivaroxaban, DX9065a, ) Fluide phase FXa AT/pentasaccharide AT/Heparins (UFH and LMWHs) FXa FVa Phospholipids Ca ++ prothrombinase Barrowcliffe et al Biochem J 1987; 243:31 37. Pieters et al, J Biol Chem 1988; 263:15313 15318. Hemker et al, Biochim Biophys Acta 1989; 992:409 411. Herault et al J Pharmacol Exp Ther 1997; 283:16 22 Rezaie AR. Blood 2001; 97:2308 2313. Herault et al J Thromb Haemost 2003;1:1959-65 Perzborn et al J Thromb Haemost 2005; 3: 514 21

thrombin (nm) Comparison of the effect of enoxaparin and fondaparinux on thrombin generation Influence of fondaparinux 200 180 160 140 120 100 80 60 40 20 control 0.1 μg/ml 0.25 μg/ml 0.5 μg/ml 0.8 μg/ml 1.25 μg/ml 0 0 10 20 30 time(min) PRP and Recombiplastin 1/1000 f.d. erotziafas et al, Blood Coagul Fibrinolysis 2004;15:149 156 Gerotziafas et al. Journal Thromb Haemost 2007

Concentrations plasmatiques Rivaroxaban (µg/l) Xarelto : pharmacocinétique 300 250 200 150 80% inhibition of TG Patient moyen (étude ODIXa-OD.PTH): 65 ans, 75 kg, CLCr 90 ml/min Intervalle de confiance 95% Patient de 90 ans Patient-clairance créatinine de 30 ml/min Patient de 40 kg Patient de 90 ans et de 40 kg 100 50 20% inhibition of TG 0 0 2 4 6 8 10 12 14 16 18 20 22 24 Durée (h) Mueck et al, Thromb Haemost 2008

Heterogenity of specific FXa inhibitors Gerotziafas and Samama MM Curr Pharm Des 2005;11:3855-76 Idraparinux Fondaparinux Rivaroxaban Otamixaban Mode of action AT-dependent Kd for AT= 1,4 AT-depentent Direct Direct Kd for AT= 58 Administration route s.c. s.c. orall i.v. Half life >80 h 17 h 4h 30 min Cmax in plasma 0,3 1,5 μg/ml 0,3 1,5 μg/ml 500 nm 150-735 ng/ml PT prolongation no no +++ ++ aptt prolongation no no +++ +++ Inhibition of prothrombinase bound FXa Inhibition of fibrin bound FXa Not assessed no yes Not assessed Not assessed no yes Not assessed Inhibition of FVIIa Not assessed yes Not assessed Not assessed

Direct inhibition of thrombin Dabigatran IIa

Reversible inhibition of thrombin by bivalirudin Arginine replaces lysine: the Arg-Pro bond is cleaved by thrombin A non-natural amino acid initiates the chain The [GLY]4 spacer provides the minimum distance to optimize the simultaneous binding of Angiox to the catalytic site and to the binding site 1 NH2 D+PHE PRO PRO GLY GLY GLY GLY ARG N G D THROMBIN exosite 2 E E E F I P E L Y 20 COOH The terminal dodecapeptide is the same as in hirudin

Influence of Rivaroxaban fondaparinux and dabigatran on TF-triggered whole blood thromboelastometry Rivaroxaban Fondaparinux Dabigatran

Direct FXa inhibitors AT -heparin stop = clot bound FXa = free thrombin = fibrin bound thrombin rhirudin dabigatran

RIVAROXABAN : ABSORPTION, DISTRIBUTION, MÉTABOLISATION, ELIMINATION Absorption Biodisponibilité : 80-100 % C max : 2-4 h Distribution Liaison aux protéines plasmatiques de 92-95 % Volume de distribution modéré Métabolisation ~ 2/3 métabolisé, pas de métabolite actif circulant majeur CYP 3A4, CYP 2J2, mécanismes indépendants des CYP Elimination ~ 1/3 non métabolisé : excrété sous forme active par voie rénale 2/3 métabolisé : 50 % éliminés par voie rénale, Demi-vie d'élimination : 7-11 heures Pernzborn et al, Arterioscler Thromb Vasc Biol 2010

Xarelto : pharmacodynamique Accumulation si : inhibiteur CYP3A4 (CI : ketoconazole, ritonavir ) grand âge insuffisance rénale sévère, atteinte hépatique Absorption accrue si prise alimentaire concomitante Pas d interférence : inhibiteurs anti-acides aspirine et AINS digoxine amiodarone

Xarelto : Impact sur les tests 23 Kubitza et al., Eur J Clin Pharmacol 2005

Prothrombin Time (s) Correlation between PT and Rivaroxaban plasma concentration 40 30 20 1,4 x PT Prothrombin time Model r = 0.958 10 10 mg 0 0 100 200 300 400 500 600 Plasma Concentration of Rivaroxaban (µg/l) PT x 2 : 0,23 mm ApTT x 2 : 0,69 mm 389±106 to 617±149 ng/m Perzborn et al. J Thromb Haemost 2005; Hillarp et al J Thromb Haemost 2011

Mesure de l activité anti-xa : méthode spécifique de l anti-xa direct 10 mg/j Au pic n=135 MM Samama et al., Thromb Haemost 201

Effect of dabigatranon clotting tests in patients with AF Van Ryn et al Thromb Haemost 2010

Effect of dabigatran on clotting assays in patients with AF Pharmacodynamics of dabigatran following a single dose oral dose of 200 mg Distribution of patients according to mean trough aptt after oral administration of dabigatran etexilate twice daily Van Ryn et al Thromb Haemost 2010

Messages clés sur les nouveaux antithrombotiques Les inhibiteurs spécifique du FXa ou du FIIa sont efficaces Dans la prophylaxie de la MTEV Le traitement de la MTEV Le traitement des SCA ont une large fenêtre thérapeutique Sont associés à un risque hémorragique négligeable mais prèsent Les inhibiteurs spécifiques du FXa ou du FIIa sont des molécules hétérogènes Dabigatran (inhibiteur spécifique de la thrombine) est efficace dans la prévention des AVC chez les patients avec ACFA et mieux toléré vs le traitement par AVK La multiplication des options thérapeutiques permettra l optimisation de la stratégie antithrombotique à l échelle individuelle