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this complex can then inactivate thrombin and factors IXa, Xa, XIa and XIIa. LMWH
interacts with antithrombin III in a different manner to unfractionated heparin, and the
LMWHantithrombin complexes have a more selective anticoagulant action, mainly inhibiting
factor Xa. Also act by promotion of tissue factor pathway inhibitor (TFPI) release from the
vascular wall. TFPI inhibits formation of factor Xa. Also acts by inhibition of platelet aggregation
through binding to platelet factor 4 (mainly unfractionated heparin). Finally, acts by activation
of lipoprotein lipase, which in addition to promoting lipolysis also reduces platelet adhesiveness.
Unfractionated heparin - This is extracted from porcine intestinal mucosa or bovine lung. It has
dose-dependent pharmacokinetics: the half-life is very short (about 30min) at low doses,
increasing some five-fold at higher doses (30 mins to 2.5 hrs). Low-dose subcutaneous
injections are used for prophylaxis against venous thrombosis, although bioavailability by this
route is only about 30%.
Low-molecular-weight heparins - They are almost completely absorbed after subcutaneous
administration. LMWHs have a low affinity for plasma protein binding sites and for endothelial
cell heparin receptors (where unfractionated heparin is metabolized). They have two routes of
elimination: a rapid, saturable liver uptake and slower renal excretion. The different LMWHs
have half-lives in the range 26h. Lovenox is 4.5 hours. The anticoagulant effect of
LMWHs can be monitored by the degree of factor Xa inhibition, but this is not carried out
routinely since their effect is much more predictable than that of unfractionated heparin.
The effect of unfractionated heparin can be rapidly reversed by intravenous injection of
protamine sulphate, a basic peptide which binds strongly to the acidic heparin components.
Protamine binds poorly to LMWHs and only partially reverses their action.
Heparin-induced thrombocytopenia (HIT) usually occurs 515 days after starting intravenous
heparin in about 2% of people, and arises from the development of antibodies to the heparin
platelet factor 4 complex. This causes platelet activation, aggregation and thrombosis.
LMWHs are much less likely to cause HIT.
Platelets are critical components of the blood for initiating thrombus formation, and have a
lifespan in the circulation of 810 days, with about 1012% being replaced each day.
Mechanism of action
These drugs inhibit hepatic vitamin K epoxide reductase, which is
the enzyme that converts vitamin K to its active (hydroquinone)
form. As a result, the hepatic synthesis of the vitamin Kdependent clotting factors II (prothrombin), VII, IX and X is
impaired ( Fig. 11.3 ). There is a delay in the onset of the
anticoagulant effect, due to the presence of previously synthesised
clotting factors, which must be cleared from the circulation.
Unwanted effects
Warfarin is an important example of a drug that has a narrow
therapeutic index.
Haemorrhage. The most effective antidote to warfarin is
phytomenadione (vitamin K 1 ). For major bleeding, this is
given intravenously and controls bleeding within 6h. An
immediate coagulant effect is achieved by also giving an
intravenous injection of prothrombin complex concentrate
(vitamin K-dependent clotting factors) or an infusion of
fresh frozen plasma. After giving a large dose of
activation.
Fig. 11.1
Platelets and platelet aggregation.
Subendothelial macromolecules such as von Willebrand factor and
collagen interact with glycoprotein receptors (GPVI and GPIb) on platelets,
causing activation of platelets and upregulation of GPIIb/IIIa receptors,
which are crosslinked by fibrinogen, resulting in aggregation. During the
Fig. 11.2
Sites of action of major drugs used in haemostasis.
Drugs act directly or indirectly to inhibit activation of platelets or to block or
reduce upregulation of the glycoprotein GPIIb/IIIa receptors (integrin
receptor family), which are necessary for aggregation of platelets.
Abciximab is an antibody, tirofiban a non-peptide inhibitor and eptifibatide a
peptide inhibitor of these glycoprotein receptors. Epoprostenol and
dipyridamole inhibit activation of platelets and downregulate the
glycoprotein receptors by increasing cAMP. Clopidogrel inhibits ADP
Fig. 11.3
The coagulation cascade and action of anticoagulants.
The complex cascade of clotting factor synthesis is initiated extrinsically by
tissue damage. Activation of the clotting factors after damage depends
upon platelet factors, tissue factor, phospholipids, Ca 2+ and vitamin K. The
provision of platelet products is further enhanced by the formation of
thrombin, which then activates further platelets as well as causing fibrin
formation. Heparin acts at various sites in the cascade by complexing with
the anticlotting factor antithrombin III (AT) and inhibiting thrombin (IIa) and
the other activated clotting factors shown. Low-molecular-weight heparin
(LMWH) complexes with AT but in a different manner to unfractionated
heparin and inhibits only factor Xa. Bivalirudin and dabigatran etexilate
inhibit thrombin (IIa) action. Warfarin inhibits the synthesis of the vitamin Kdependent clotting factors VII, IX, X and II (prothrombin). Roman numerals
indicate the individual clotting factors; PL, phospholipid; TF, tissue factor.
Antiplatelet drugs
Cyclo-oxygenase inhibitors
Examples
aspirin
Phosphodiesterase inhibitors
Example
dipyridamole
Mechanism of action
Dipyridamole has multiple mechanisms of action; the most
important is probably inhibition of the reuptake of adenosine by
cells. The increased plasma concentration of adenosine promotes
vasodilation and inhibits platelet aggregation by stimulation of
intracellular adenylyl cyclase and production of the intracellular
cyclic nucleotides cGMP and cAMP. Dipyridamole also inhibits
phosphodiesterase types 3 and 5, which degrade cyclic
nucleotides. High intracellular cyclic nucleotide concentrations
inhibit activation of cell surface GPIIb/IIIa receptors, leading to
reduced platelet activation ( Fig. 11.2 ). Dipyridamole has a
number of other actions that are of uncertain significance,
including antioxidant properties.
Pharmacokinetics
Dipyridamole is incompletely absorbed from the gut and is
metabolised in the liver. It has a half-life of 12h. A modifiedrelease formulation is better tolerated than the standard
formulation.
Unwanted effects
Gastrointestinal effects.
Myalgia.
Dizziness, headache.
Flushing, hypotension, tachycardia.
Hypersensitivity reactions, including rash, urticaria,
bronchospasm and angioedema.
Mechanism of action
ADP activates platelets via two purinergic surface receptors, P2Y 1
and P2Y 12 . P2Y 1 receptors increase intracellular Ca 2+ and initiate
platelet shape change. Activation of P2Y 12 receptors inhibits
adenylyl cyclase, and reduces generation of the intracellular cyclic
nucleotides that inhibit activation of GPIIb/IIIa receptors.
ADP receptor antagonists inhibit platelet aggregation by binding
selectively to P2Y 12 receptors ( Fig. 11.2 ). Inhibition of P2Y 12
receptors also reduces the production of thromboxane A 2 by the
platelet. Clopidogrel and prasugrel are irreversible receptor
inhibitors, while ticagrelor binds to a different site on the receptor
and produces reversible inhibition. There is considerable interindividual variability in the degree of platelet inhibition by
clopidogrel, and it has a slow onset of action (about 5 days for full
effect) without a loading dose. Both prasugrel and ticagrelor are
more predictable inhibitors of platelet activation than clopidogrel
and have a more rapid onset of action.
Pharmacokinetics
Clopidogrel is a prodrug. It is well absorbed from the gut, and is
activated by metabolism in the liver to a derivative that has a halflife of 7h. Prasugrel is also a prodrug that is well absorbed from
the gut and metabolised rapidly in the liver to an active metabolite
which has a long half-life of 8 days. Ticagrelor is active as the
parent drug, and also has an active metabolite. The offset of action
of ticagrelor over 3 days is much slower than would be predicted
from the short half-life.
Unwanted effects
abciximab, eptifibatide
Mechanism of action
Abciximab is a murine/human chimaeric monoclonal antibody to
the GPIIb/IIIa receptors with the Fc fragment removed to prevent
clearance of antibody-bound platelets from the circulation.
Abciximab binds irreversibly to the GPIIb/IIIa receptors and
blocks the binding of fibrinogen ( Fig. 11.2 ). Abciximab can reduce
platelet aggregation by more than 90%.
Eptifibatide is a synthetic peptide that binds reversibly to and
blocks the GPIIb/IIIa receptor.
Pharmacokinetics
All GPIIb/IIIa antagonists are given intravenously, usually as an
initial bolus to achieve rapid inhibition of platelets followed by
continuous infusion. The duration of receptor blockade with
abciximab is longer than predicted from its very short half-life of
30min due to slow dissociation from the receptor over several
hours. After stopping abciximab, platelet aggregation largely
recovers by 48h as new platelets are synthesised.
Eptifibatide has a short half-life of about 2.5h, and is eliminated
by the kidney. Platelet aggregation recovers more rapidly after
treatment than with abciximab, due to rapid dissociation of the
drug from the receptor after a few seconds.
Unwanted effects
Epoprostenol
Mechanism of action
Epoprostenol (PGI 2 ) increases platelet cAMP, which at low
concentrations inhibits platelet aggregation and at higher
concentrations reduces platelet adhesion. Epoprostenol is also a
peripheral arterial vasodilator.
Pharmacokinetics
Epoprostenol is given by intravenous infusion. Unlike most other
prostaglandins it is not significantly metabolised in the lung, as it
is rapidly metabolised by hydrolysis in plasma and peripheral
tissues, giving a very short half-life of about 3min.
Unwanted effects
These can be reduced by starting the infusion with a low dose and
include:
facial flushing,
headache,
hypotension,
gastrointestinal disturbances.
end ngRepeat: item in XocsCtrl.sections
Anticoagulant drugs
Anticoagulation can be achieved with either injectable or oral
drug therapy. Increasingly, oral anticoagulant therapy with newer
agents is likely to supersede the long-established use of heparin
followed by warfarin to initiate anticoagulation.
Injectable anticoagulants
Heparins
Heparins are a family of highly sulphated acidic
mucopolysaccharides (glycosaminoglycans) that are found in
mast cells, basophils and endothelium. Heparins have a variable
molecular weight of between 3000 and 30000Da according to
the numbers of polysaccharide subunits.
Pharmacokinetics
Heparins are inactive orally and are given intravenously or by
subcutaneous injection. They have a rapid onset of action.
Heparins do not cross the placenta or enter breast milk. The two
principal forms of heparin have different pharmacokinetic
properties.
Unfractionated heparin
This is extracted from porcine intestinal mucosa or bovine lung,
and consists of a mean of 45 polysaccharide units. It has dosedependent pharmacokinetics: the half-life is very short (about
30min) at low doses, increasing some five-fold at higher doses.
Variable binding to plasma proteins contributes to interindividual variation in the dose required to achieve target levels of
anticoagulation. Most heparin is metabolised in endothelial cells
after binding to cell surface receptors. Unfractionated heparin is
usually given by continuous intravenous infusion for full
Low-molecular-weight heparins
LMWHs have a mean of 15 polysaccharide units. They are almost
completely absorbed after subcutaneous administration and only
need to be given once or twice daily by subcutaneous injection for
full anticoagulation. LMWHs have a low affinity for plasma
protein binding sites and for endothelial cell heparin receptors.
They have two routes of elimination: a rapid, saturable liver
uptake and slower renal excretion. The different LMWHs have
half-lives in the range 26h. When the dose of a LMWH is based
on body weight they produce a more predictable anticoagulant
effect compared with unfractionated heparin.
Unwanted effects
Fondaparinux
Mechanism of action
Fondaparinux is a synthetic pentasaccharide almost identical to
the natural pentasaccharide sequence of heparin that binds to
antithrombin. Like LMWH, it enhances the innate ability of
antithrombin to inhibit factor Xa.
Pharmacokinetics
Fondaparinux is given by subcutaneous injection. It is predictably
absorbed from the injection site, is eliminated unchanged by the
kidney and has a long half-life (18h).
Unwanted effects
Haemorrhage.
Thrombocytopenia.
Oedema.
Gastrointestinal upset.
Oral anticoagulants
Vitamin K antagonists
Examples
Mechanism of action
These drugs inhibit hepatic vitamin K epoxide reductase, which is
the enzyme that converts vitamin K to its active (hydroquinone)
form. As a result, the hepatic synthesis of the vitamin Kdependent clotting factors II (prothrombin), VII, IX and X is
impaired ( Fig. 11.3 ). There is a delay in the onset of the
anticoagulant effect, due to the presence of previously synthesised
clotting factors, which must be cleared from the circulation.
Pharmacokinetics
Warfarin is the most widely used vitamin K antagonist. It is
almost completely absorbed from the gut and is highly bound to
plasma albumin. It is eliminated by cytochrome P450-mediated
hepatic metabolism (CYP2C9) and has a very long half-life of 12
days. Functional CYP2C9 polymorphisms contribute to
considerable inter-individual variability in warfarin sensitivity.
The plasma concentration of warfarin does not correlate directly
with the clinical effect of the drug, which is determined by the
balance between the rates of synthesis and degradation of clotting
factors. The maximum effect of an individual dose of warfarin is
reflected in the blood coagulation time some 2436h later. On
stopping treatment, the duration of anticoagulant action is
determined largely by the time required to synthesise new clotting
factors.
Unwanted effects
Warfarin is an important example of a drug that has a narrow
therapeutic index.
Haemorrhage. The most effective antidote to warfarin is
phytomenadione (vitamin K 1 ). For major bleeding, this is
given intravenously and controls bleeding within 6h. An
immediate coagulant effect is achieved by also giving an
intravenous injection of prothrombin complex concentrate
(vitamin K-dependent clotting factors) or an infusion of
fresh frozen plasma. After giving a large dose of
phytomenadione, it can be difficult to restore therapeutic
anticoagulation with warfarin for up to 3 weeks. If the INR is
>8.0 but there is no bleeding or only minor bleeding, then a
smaller dose of phytomenadione can be given intravenously
or orally with less disturbance to subsequent
anticoagulation.
apixaban, rivaroxaban
Mechanism of action
Apixaban and rivaroxaban are orally active factor Xa inhibitors
that bind reversibly to the active site of factor Xa. They inhibit
both free factor Xa and that bound to the prothrombinase
complex, and unlike warfarin produce a rapid onset of predictable
anticoagulation.
Pharmacokinetics
Apixaban and rivaroxaban are well absorbed from the gut. They
are partially metabolised in the liver and partially excreted by the
kidneys. Their half-lives are around 10h.
Unwanted effects
dabigatran etexilate
Mechanism of action
Dabigatran is a selective, direct competitive thrombin inhibitor
that binds to and inhibits both free circulating and thrombusbound thrombin (factor IIa). It produces a rapid onset of
predictable anticoagulation.
Pharmacokinetics
Dabigatran etexilate is a prodrug that has a low oral
bioavailability and undergoes first-pass metabolism to its active
derivative dabigatran. The active metabolite is excreted
unchanged by the kidneys, and has a short half-life of about
40min.
Unwanted effects
Venous thromboembolism
Acute pulmonary embolism can present with a wide variety of
symptoms. Massive emboli produce shock or sustained
hypotension, while smaller emboli can present with chest pain,
dyspnoea or haemoptysis. Pulmonary embolism is a major cause
of morbidity and death. Most serious pulmonary emboli arise
from deep vein thrombosis in the lower limb, particularly if the
thrombus extends to the larger veins above the calf. Massive
pulmonary emboli causing haemodynamic instability are fatal in
about 60% of cases if untreated. Mortality is much lower in stable
patients. Many episodes of deep vein thrombosis occur in
hospital, particularly in people over 40 years of age following
major illness, trauma or surgery. Pulmonary embolism has been
estimated to be responsible for 10% of all deaths in hospital.
Chronic pulmonary embolic disease can lead to pulmonary
arterial hypertension with progressive dyspnoea ( Ch. 6 ).
Factors predisposing to venous thromboembolism in hospital (
Table 11.1 ) include prolonged immobility and a variety of
coexisting medical conditions such as cancer. Spontaneous
thromboembolism can occur after long journeys, such as by road
Risk
Procedure
Low
Minor surgery, no other risk factor
Major surgery, age <40 years, no other risk factors
Minor trauma or illness
Moderate
Major surgery, age 40 years or other risk factor
Heart failure, recent myocardial infarction, malignancy,
inflammatory bowel disease
Major trauma or burns
Minor surgery, trauma or illness in patient with previous deep vein
thrombosis or pulmonary embolism
High
Fracture or major orthopaedic surgery of pelvis, hips or lower limb
Major pelvic or abdominal surgery for cancer
Major surgery, trauma or illness in patient with previous deep vein
thrombosis or pulmonary embolism
Lower limb paralysis
Major lower limb amputation
After an initial spontaneous deep vein thrombosis, the risk of
recurrence is about 25% after 4 years, but is much lower after
postoperative thrombosis. Following a deep vein thrombosis,
chronic post-phlebitic syndrome can develop, with pain, swelling
and ulceration of the affected leg.
Mechanical methods
These are used for people in hospital who are at moderate risk of
thromboembolism and include graduated elastic compression
stockings and intermittent pneumatic compression devices to
improve venous flow and limit stasis in venous valve pockets.
They can also be used to supplement pharmacological prophylaxis
in people at high risk.
Oral anticoagulants
Low-dose dabigatran, apixaban and rivaroxaban are at least as
effective as LMWHs for thromboprophylaxis in people
undergoing hip and knee orthopaedic surgery. Bleeding rates with
dabigatran, apixaban and LMWH are similar, but may be higher
with rivaroxaban. Prophylaxis should be started before surgery.
Warfarin may be more effective than heparin for prophylaxis in
people at highest risk of thromboembolism, but is not widely
used. Although a meta-analysis of several studies suggests that
low-dose aspirin reduces deep venous thrombosis, it is less
effective than heparin.
Therapeutic anticoagulation
This is the treatment of choice for deep vein thrombosis and for
most pulmonary emboli since anticoagulation substantially
reduces mortality. Heparin is still the most widely used initial
treatment for its rapid onset of effect. LMWH or fondaparinux
given subcutaneously are preferred to unfractionated heparin,
except in people with significant renal impairment. Heparin is
usually given for 35 days, with concurrent initiation of treatment
with warfarin. Heparin can be stopped once warfarin has
produced adequate anticoagulation (i.e. the INR is within the
therapeutic range; see above). When deep vein thrombosis occurs
in someone with cancer there is a high risk of both bleeding and
recurrence during treatment with warfarin. In this situation,
prolonged treatment with LMWH (6 months, or lifelong if
remission is not achieved) is usually advocated. The optimal
duration of anticoagulant therapy is not well defined, but
suggested periods are shown in Table 11.2 .
Table 11.2
Suggested duration of anticoagulant therapy for venous thromboembolism
Risk of recurrence
Clinical setting
Duration
Low
Temporary risk factors for thromboembolism
3 months
Intermediate
Continuing medical risk factors for thromboembolism
36 months
High
Recurrent thromboembolism; inherited thrombophilic tendency
Indefinite
Other treatments
When pulmonary emboli recur despite adequate anticoagulation,
or when anticoagulation is contraindicated, inferior vena caval
plication or insertion of a filter device to trap emboli in the
inferior vena cava can be considered.
Arterial thromboembolism
Warfarin is used long term for the prevention of thrombosis on
prosthetic heart valves. Atrial fibrillation and mural thrombus in
the left ventricle following a myocardial infarction predispose to
arterial embolism and are indications for anticoagulation with
warfarin. Dabigatran, apixaban and rivaroxaban are at least as
effective as warfarin for prevention of thromboembolism in atrial
fibrillation and may have a lower risk of haemorrhage ( Ch. 8 ).
When combined with antiplatelet therapy, apixaban reduces the
composite endpoint of mortality, reinfarction and ischaemic
stroke after an acute coronary syndrome ( Ch. 5 ).
end ngRepeat: item in XocsCtrl.sections
Fig. 11.4
The fibrinolytic system.
The fibrinolytic system is linked intimately with the coagulation cascade and
platelet function. When a clot is formed via the prothrombotic system,
activation of plasminogen to the fibrinolytically active plasmin is initiated by
several tissue plasminogen activators, thus lysing the clot. The drugs
promoting this act as plasminogen activators (alteplase (recombinant
tissue-type plasminogen activator, rt-PA) and derivatives) or bind to
plasminogen (streptokinase), promoting plasmin activity. The antifibrinolytic
drug tranexamic acid inhibits plasminogen activation.
Mechanism of action
Fibrinolytic drugs enhance fibrinolysis by substituting for the
naturally occurring t-PA. They bind to and activate plasminogen,
which degrades fibrin thrombi. Alteplase is a genetically
engineered copy of the naturally occurring t-PA that binds directly
to fibrinogen and fibrin. It has a wide range of clinical uses.
Tenecteplase is a genetically engineered modified form of t-PA
with increased fibrin specificity, less sensitivity to plasminogen
activator inhibitors and a longer duration of action than alteplase.
Tenecteplase is only licensed for treatment of myocardial
infarction
Streptokinase is obtained from haemolytic streptococci, and is
inactive until it forms a complex with circulating plasminogen; the
resultant streptokinaseplasminogen activator complex
substitutes for t-PA in the fibrinolytic cascade, causing
plasminogen activation. Streptokinase is now used less frequently
than other fibrinolytic drugs.
The effectiveness of any fibrinolytic agent is greatest with fresh
thrombus and if a large surface area of thrombus is exposed to the
drug.
Pharmacokinetics
All fibrinolytic agents are given intravenously or intra-arterially.
Alteplase and related compounds are metabolised in the liver. The
streptokinaseplasminogen activator complex is degraded
enzymatically in the circulation. Some streptokinase is cleared
from the plasma before it forms an active complex, by combining
with circulating neutralising antibody formed during previous
exposure to streptokinase. After the use of streptokinase, or
following a streptococcal infection, neutralising antibodies can
persist in high titre for several years and substantially reduce the
Unwanted effects
tranexamic acid
Mechanisms of action
Tranexamic acid competitively inhibits the activation of
plasminogen, so fibrinolysis is inhibited. The theoretical risk of
creating a thrombotic tendency does not appear to be a clinical
problem.
Pharmacokinetics
Tranexamic acid is a synthetic amino acid that is incompletely
absorbed from the gut and can also be given intravenously. It is
excreted unchanged by the kidney and has a short half-life (1
2h).
Unwanted effects
Desmopressin
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