Chapter 6 .

- Pharmacology of hemostasis and fibrinolysis

Chapter 7 .- Antiplatelet
Chapter 8 .- Anticoagulants
 Chapter 6 PHARMACOLOGY OF
HEMOSTASIS AND FIBRINOLYSIS
HEMOSTASIS FIBRINOLYSIS

+ _
+

I. HEMOSTATICS II. THROMBOLYTICS

Dissolution of an
established thrombus
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

HEMOSTASIS: Physiological process that prevents blood loss

• VASCULAR INJURY
• CHANGES IN THE WALL (plaques, endothelial denudation)

THROMBOSIS: Pathological formation of a 'haemostatic' plug within the vasculature in

the absence of bleeding

Inactivation of
thrombin

+
Fibrinolysis
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

ALTERATIONS IN HEMOSTASIS Hemostasis

PRIMARY
platelet activation
• HEMORRHAGES (poor hemostasis) platelet aggregation

• THROMBUS FORMATION (stimulated hemostasis) adhesión platelet

DAMAGED VESSEL Hemostasis

SECONDARY
WALL
Coagulation Cascade

PLATELET COAGULATION
ADHESION CASCADE
DRUGS IN THE TREATMENT OF
HEMOSTASIS DISORDERS

PLATELET TO INCREASE TO REDUCE

FIBRIN HAEMOSTASIS THROMBOSIS
AGGREGATION

THROMBI 1. COAGULATION 1. THROMBOLYTIC

2. PLATELET STIMULATION 2. ANTIPLATELET
3. FIBRINOLYSIS INHIBITORS 3. ANTICOAGULANTS
FIBRINOLYSIS
(Dissolution of thrombi)
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

HEMOSTASIS
• VASCULAR INJURY
• CHANGES IN THE WALL (plaques, endothelial denudation)
Vasoconstriction

Platelet-vessel wall interaction Plasma clotting cascade

Adhesion, platelet activation Intrinsic pathway: cascade

Extrinsic pathway
and aggregation reactions of plasma
Tissue factor
proteolytic proteins
Secretion of
mediators X Factor Factor Xa

More platelet aggregation

 Thrombin IIa Prothrombin II

 Fibrin
Fibrinogen
Mesh of insoluble proteins
balance

HEMOSTATIC PLUG
OR WHITE THROMBUS BLOOD CLOTS
OR RED THROMBUS
Inactivation of
Fibrinolysis + thrombin
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

THROMBUS FORMATION DISORDERS

THROMBUS: hemostatic plug or fixed clot
In veins
Accompanied by PHLEBITIS
VENOUS THROMBOSIS

In arteries
Source: atheroma plaques
ARTERIAL THROMBOSIS

EMBOLUS: circulating clot in arteries or veins  EMBOLISM or STROKE

THERAPEUTIC INTERVENTIONS
 Control of risk factors
 Dissolution of established thrombus
Surgery
Thrombolytics = Fibrinolytics
 Prevention of a new thrombus
Anticoagulants
(In venous sector)
Antiplatelets
(In arterial sector)
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

II. THROMBOLYTICS: Dissolution of an established thrombus

FIBRINOLYSIS
Endothelium

tPA (Inactive)
XIIa
+
+

tPA - fibrin uPA Prourokinase

+ + +

Plasminogen Plasmin serine protease

serine proteases +
tPA: Tissue plasminogen Fibrin
activator Fibrin degradation
uPA: Urokinase products
plasminogen activator
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

II. THROMBOLYTICS: Dissolution of an established thrombus

Bind plasminogen
(free & fibrin-bound)

↑ activation to plasmin

Parenteral via

1. NOT FIBRIN-SELECTIVE AGENTS

 STREPTOKINASE (SK) Streptococci b-haemolytic type C (antigenic)
 STAPHYILOKINASE (SAK): Staphylococcus aureus / recombinant
 UROKINASE (UK): human kidney cells (not antigenic)
 SARUPLASE
2. INTERMEDIATE SELECTIVE AGENTS
 ANISTREPLASE (APSAC) acylated SK-lys-plasminogen complex
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

II. THROMBOLYTICS: Dissolution of an established thrombus

Bind fibrin-bound
plasminogen

“selective for blood clots”

Parenteral via
No effect on
circulating
plasminogen
3. FIBRIN-SELECTIVE AGENTS
 ALTEPLASE: recombinant single-chain t-PA (rt-PA), very short half-life (not antigenic)
 TENECTEPLASE (TNK): triple mutant t-PA  higher fibrin specificity and greater
resistance to inactivation by its endogenous inhibitor (PAI-1) compared to native t-PA
 RETEPLASE: recombinant non-glycosylated form of t-PA activator (contains 357 of
the 527 amino acids of native t-PA)  longer half-life
 PROUROKINASE
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

II. THROMBOLYTICS:
PHARMACOKINETICS
Parenteral administration (i.v. or arterial)
• Bolus: Coronary Heart Disease CHD
• Continuous infusion

ADVERSE REACTIONS
Hemorrhage is a major side effect: thrombolytic
therapy may always cause bleeding complications
by degradading physiological hemostatic plugs

THERAPEUTIC USES
ACUTE MYOCARDIAL INFARCTION (main indication) within 12 hours!
Heparin (bolus i.v.) before
 DEEP VEIN THROMBOSIS and / or PULMONARY EMBOLISM all of thrombolytic drugs
except streptokinase
 PERIPHERAL ARTERIAL THROMBOEMBOLISM
+ Antiplatelet and vasodilatory agents (PGE1) the sooner the better!!!
 ACUTE ISCHEMIC BRAIN STROKE within 3 hours!
 CENTRAL RETINAL VEIN THROMBOSIS
 RESTORATION OF CLOTTED CATHETERS (extracorporeal)
 Chapter 7 : ANTIPLATELET

Antiplatelet drugs inhibit platelet activation

(shown in green) to prevent their aggregation
and their cross-linking by fibrin strands (shown
in red). (Photograph: D. PHILLIPS / SCIENCE
PHOTO LIBRARY)
http://www.mims.co.uk/news/937891/Phase-III-
success-platelet-inhibitor/

• INTRODUCTION: Platelet aggregation

• PLATELET AGGREGATION INHIBITORS:
(A) INHIBITORS OF TXA2 SYNTHESIS
(B) CYCLIC NUCLEOTIDE STIMULATORS
(C) GP IIb / IIIa GLYCOPROTEIN COMPLEX BLOCKERS
(D) OTHER
• THERAPEUTIC USES
Chapter 7. ANTIPLATELET

ANTIPLATELET  PREVENTION OF ARTERIAL THROMBOSIS

In case of HEMORRHAGE, platelets:
Adhere to the injured vessel
Get activated and change shape
Secrete granular contents and
biosynthesize mediators that promote:
• Platelet aggregation
• Thrombin secretion
HEMOSTASIS

ATHEROSCLEROSIS
Chapter 7. ANTIPLATELET

Thrombus formation at the site of the damaged vascular wall

EC, endothelials cell.
Platelet membrane receptors = glycoproteins:
GP Ia receptor, binding to collagen (C)
GP Ib receptor, binding von Willebrand factor (vWF)
GP IIb/IIIa receptor, binding fibrinogen and other molecules
Antiplatelet prostacyclin (PGI2) is released from the endothelium
Aggregating substances released from the degranulating platelet:
adenosine diphosphate (ADP)
thromboxane A2 (TXA2)
serotonin (5-HT)
Chapter 7. ANTIPLATELET

BROKEN ATHEROMATOUS PLAQUE PLATELET ACTIVATION

Adhesion of platelets
to endothelial surface

Exposed
CONTRACTION Platelet Activation
+ acidic
phospholipids
+
Generation of AA +
COX-1 coagulation
TX synthase

Release of ADP, Serotonin TXA2 +

Thrombin
Activation
Expression of
+ GP IIb / IIIa receptors

Binding of fibrinogen to
GP IIb / IIIa receptors

- Endogenous antiplatelet agents:

- Prostacyclin (PGI2)
Platelet aggregation - NO
- Adenosine
Chapter 7. ANTIPLATELET

BROKEN ATHEROMATOUS PLAQUE

PLATELET AGGREGATION INHIBITORS:
Adhesion of platelets
to endothelial surface (A) INHIBITORS OF TXA2 SYNTHESIS
1. COX-1 inhibitors
CONTRACTION Platelet Activation 2. Specific TX synthase inhibitors
+
3. Dual TX synthase and TX receptors
+
Generation of AA
- inhibitors

COX-1 -
TX synthase

Release of ADP, Serotonin TXA2

Expression of
+ GP IIb / IIIa receptors
- (B) CYCLIC NUCLEOTIDE
STIMULATORS
- 1. Cyclases stimulators
2. PDEs inhibitors

- -
Binding of fibrinogen to
GP IIb / IIIa receptors
(C) GP IIb / IIIa GLYCOPROTEIN COMPLEX
BLOCKERS
1. ADP antagonists
- 2. Glycoprotein complex antagonists

Prostacyclin - Platelet aggregation

- NO
Adenosine  CAMP  CGMP (D) OTHER
Chapter 7. ANTIPLATELET

ANTIPLATELET  PREVENTION OF ARTERIAL THROMBOSIS

(A) INHIBITORS OF TXA2 SYNTHESIS

1. COX-1 INHIBITORS Generation of AA
COX-1
-
TX synthase
TXA2

ASPIRIN TRIFLUSAL Expression of

= Acetyl Salicylic Acid (ASA) GP IIb / IIIa receptors

MECHANISM OF ACTION
• Irreversible inactivation of COX-1 by acetylation 
↓ synthesis of TXA2 (aggregating agent from platelets) and
↓ PGI2 (endogenous antiplatelet agent from endothelium)
 D↓ + Oral
IMPORTANT  inability of platelets to synthesize more enzyme ADVERSE
REACTIONS
• Stimulate synthesis of NO Bleeding
Bruising
Chapter 7. ANTIPLATELET

Efficacy of aspirin and streptokinase for myocardial infarction

(ISIS-2 trial 1988 Lancet ii: 350-360.)

Chapter 7. ANTIPLATELET

ANTIPLATELET  PREVENTION OF ARTERIAL THROMBOSIS

(A) INHIBITORS OF TXA2 SYNTHESIS

2. Specific TX synthase inhibitors Generation of AA
DITAZOL, CAMONAGREL COX-1
-
• Imidazole derivative TX synthase
• Due to inhibition of TXA2 synthesis, redirection of TXA2
COX pathway to the formation of PGI2
-
• Weak antiplatelet activity. Very limited use Expression of
GP IIb / IIIa receptors
Clinical results are not superior to aspirin

3. Dual TX synthase and TX receptors inhibitors

RIDOGREL

Clinical results are not superior to aspirin

Chapter 7. ANTIPLATELET

ANTIPLATELET  PREVENTION OF ARTERIAL THROMBOSIS

(B) CYCLIC NUCLEOTIDE STIMULATORS Antiplatelet and

vasodilatory effects
Prostacyclin - -
Platelet aggregation NO
Adenosine  cAMP Release of mediators  cGMP Hypotension

1. Cyclases Stimulators
• Adenylate cyclase stimulators EPOPROSTENOL (prostacyclin)
ILOPROST (PGI2 semisynthetic derivative)
• Guanylate cyclase stimulators NITRATES and NITRITES

Clinical results are not superior to aspirin

2. Phosphodiesterase inhibitors
DIPYRIDAMOLE
• Inhibition of PDE ↓ degradation of cAMP and cGMP
Effect by ≠
• ↑ extracellular adenosine
mechanisms: • ↑ synthesis of PGI (indirect)
2

May be associated with AAS

Chapter 7. ANTIPLATELET

ANTIPLATELET  PREVENTION OF ARTERIAL THROMBOSIS

(C) GP IIb / IIIa GLYCOPROTEIN COMPLEX BLOCKERS

1. ADP antagonists
Liberation of ADP BE TXA2
CLOPIDOGREL, PRASUGREL

- + Expression of
GP IIb / IIIa receptors

Binding of fibrinogen to
Prodrugs irreversible antagonists of GP IIb / IIIa receptors
purinergic P2Y12 receptors
TICAGRELOR: Non-competitive antagonist of P2Y12 receptors -
↑ extracellular adenosine

2. GP IIb / IIIa complex blockers for hospital use ONLY!

ABCIXIMAB: Monoclonal antibody
EPTIFIBATIDE: Synthetic cyclic heptapeptide antagonist of GP IIb/IIIa receptor
TIROFIBAN: Non-peptide antagonist of GP IIb/IIIa receptor

(D) OTHER  Dextran (MW 65-80 kD)

 Antioxidants
 Fatty acids in the diet: unsaturated or polyunsaturated
Chapter 7. ANTIPLATELET

Effect of adding clopidogrel to aspirin on the cumulative hazard rates

for major vascular events in patients with acute coronary syndromes

(CURE Investigators 2001 N Engl J Med 345: 494-502)

Chapter 7. ANTIPLATELET

ANTIPLATELET  PREVENTION OF ARTERIAL THROMBOSIS

•Tobacco
THERAPEUTIC USES •Elderly
•Obesity
PRIMARY PREVENTION •Diabetes
• Healthy people with > 3 risk factors •Hypertension
• No other risk factors: not recommended •Hypercholesterolemia

SECONDARY PREVENTION
Coronary conditions
Angina
Acute myocardial infarction
Coronary revascularization (bypass)
Cerebrovascular conditions
Non-hemorrhagic cerebral ischemic accidents
Peripheral vascular conditions
Intermittent claudication
Complications in bypass surgery
Other cardiopathies
Cardiac Vascular Surgery
Diabetic angiopathy
 Chapter 8:ANTICOAGULANTS
I. COAGULATION CASCADE
II. ANTICOAGULANTS  PREVENTION OF VENOUS THROMBOEMBOLISM
DEEP VEIN THROMBOSIS (DVT)

a) Heparins:
UFH, LMWH, FONDAPARINUX
b) Classic oral anticoagulants =
Antivitamin K (VKA):
Coumarins: ACENOCOUMAROL,
WARFARIN
PHENINDIONE
DIPHENADIONE
c) New oral anticoagulants (NOAC):
DABIGATRAN
RIVAROXABAN, APIXABAN
d) Anticoagulant poisons
DESIRUDIN
LEPIRUDIN (withdrawn)
Chapter 8. ANTICOAGULANTS

a) HEPARINS
STRUCTURE:

TYPES: HEPARIN
Unfractionated heparin
(UFH) Pm ~ 16 KD
extracted from porcine
intestinal mucosa

LMWHs
Fractionated heparin
(UFH) Pm ~ 16 KD
ENOXAPARIN
DALTEPARIN
…

ULMWH = FONDAPARINUX

Appl Microbiol Biotechnol (2012) 93:1–16

Chapter 8. ANTICOAGULANTS

a) HEPARINS
MECHANISM OF ACTION

Heparin accelerates inactivation of

coagulation factors by antithrombin
Chapter 8. ANTICOAGULANTS

a) HEPARINS
PHARMACOLOGICAL ACTIONS
A. DEPENDENT ON ANTITHROMBIN III (AT-III) ACTIVATION
Inactivation of thrombin and factor Xa Inactivation of factor Xa
UFH > LMWH > pentasaccharide Pentasaccharide > LMWH > UFH

Bleeding complications Therapeutic effects

B. INDEPENDENT ON ANTITHROMBIN III (AT-III) ACTIVATION

 Fibrinolytic: LMWH  endothelial release of tPA
 Lipolytic: UNF  hepatic lipoprotein-lipases
 Activation of resting platelets: UNF binds platelet surface

ADVERSE REACTIONS: UNF >> LMWH  ULMWH

• Bleeding: antidote PROTAMINE SULFATE (1:1)
• Hypersensitivity reactions (porcine origin) (UNF)
• Thrombosis (UNF)
• Thrombocytopenia (UNF)
• Osteoporosis
• Alopecia
Chapter 8. ANTICOAGULANTS

a) HEPARINS
PHARMACOKINETICS

• Parenteral administration (iv or sc)

HEPARIN, iv immediate effect (dose adjusted to APTT)
LMWH, sc 60 min, 1-2 doses/day
FONDAPARINUX, sc 60 min, 1 dose/day
• Do not cross membranes
• Heparin can bind to proteins and be metabolized by
monocytes / macrophages
• Renal elimination

INDICATIONS:
• Treatment and Prevention of:
Pulmonary embolism
Deep Vein Thrombosis
Myocardial infarction
Coronary ischaemia
• Hemodialysis patients
CONTRAINDICATIONS:
• Hemophilia
• History of thrombocytopenia
• Bleeding wounds / surgery
• Hypersensitivity to heparin
• Alcoholics
Chapter 8. ANTICOAGULANTS

b) CLASSIC ORAL ANTICOAGULANTS = ANTIVITAMIN K (VKA)

CLASSIFICATION
A. COUMARINS
DICOUMAROL
ACENOCOUMAROL (Sintrom®)
WARFARIN
B. PHENINDIONE, DIPHENADIONE -R

MECHANISM OF ACTION Acenocoumarol R = NO2

Warfarin R = H

profactors VII, Factors II, VII,

IX and X IX and X
Vitamin K  cofactor in the post-translational
γ-carboxylation of coagulation
factors II, VII, IX and X

VKA: Competitive inhibition of

Vitamin K reduction
Chapter 8. ANTICOAGULANTS

b) CLASSIC ORAL ANTICOAGULANTS = ANTIVITAMIN K (VKA)

ADVERSE REACTIONS PHARMACOKINETICS

• Bleeding • Oral Absorption
• Hypersensitivity • Delayed onset of action (8 to 12 hours)
• Teratogenesis: Warfarin
• Strong binding to plasma proteins (99%)
• Crossing barriers (BBB, placenta...)

INTERACTIONS
INCREASE ITS EFFECT DIMINISH ITS EFFECT
 Malabsorption of vitamin K  Diet rich in vegetables
 Antibiotics  Enzyme inducers
 NSAIDs

INDICATIONS: CONTRAINDICATION:
• Prevention of: • Pregnancy
myocardial infarction
coronary ischemia
Chapter 8. ANTICOAGULANTS

c) NEW ORAL ANTICOAGULANTS (NOAC)

C1. DABIGATRAN MECHANISM OF ACTION

New antidote!
IDARUCIZUMAB

REVERSIBLE
direct
thrombin
inhibitor

ADVERSE REACTIONS Similar risk-benefit than ENOXAPARIN

• Nausea INDICATIONS
• Vomiting
• Primary prevention of venous thromboembolism
• Constipation
• Insomnia
in adults undergoing elective surgery for total
• Peripheral edema hip replacement or knee.
• Primary prevention of stroke and systemic
PHARMACOKINETICS embolism in non-valvular atrial fibrillation
• Oral Absorption • Treatment and secondary prevention of deep
• Hepatic metabolism venous thrombosis and pulmonary embolism
• Renal elimination
Chapter 8. ANTICOAGULANTS

c) NEW ORAL ANTICOAGULANTS (NOAC)

C2. RIVAROXABAN, APIXABAN ADVERSE REACTIONS
• Nausea
MECHANISM OF ACTION • Tachycardia
• Anemia
• Thrombocytopenia
• ↑Transaminase
PHARMACOKINETICS
Direct
bind directly • Oral Absorption
factor Xa to FXa • Hepatic metabolism
inhibitors • Binding to plasma proteins
(95%)
• Renal and fecal elimination

Antidote: INDICATIONS
recombinant
enzymatically • Primary prevention of venous thromboembolism
inactive factor FXa in adults undergoing elective surgery for total
traps circulating
Xa inhibitors hip replacement or knee.
• Primary prevention of stroke and systemic
embolism in non-valvular atrial fibrillation
• Treatment and secondary prevention of deep
venous thrombosis and pulmonary embolism
Ansell J. (2013)
Nature Medicine 19:402–404
Chapter 8. ANTICOAGULANTS

d) Anticoagulant poisons
HIRUDIN: From leech (Hirudo medicinalis)
DESIRUDIN
recombinant derivatives
LEPIRUDIN
(withdrawn) • Parenteral administration

MECHANISM OF ACTION

One molecule binds to one molecule of

thrombin, blocking itsthrombogenic activity Hirudin
active center

IRREVERSIBLE
direct thrombin
inhibitor
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

I. HEMOSTATICS: DRUGS USED TO TREAT BLEEDING

Hemostasis Fibrinolysis

In case of HEMORRHAGE due

to a wound: apply pressure to
decrease blood loss and
promote hemostasis + _

HEMOSTATICS
1. AGENTS ACTING ON THE VESSELS
2. AGENTS STIMULATING PLATELET FUNCTION
3. AGENTS STIMULANTING COAGULATION
4. AGENTS THAT INHIBIT FIBRINOLYSIS OR ANTIFIBRINOLYTIC
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

I. HEMOSTATICS
1. AGENTS ACTING ON THE VESSELS

a. PROMOTING HEMOSTATIC PLUG

 GELATIN or FIBRIN SPONGES
 STRIPS OF HUMAN FIBRIN OR BOVINE THROMBIN
b. VASOCONSTRICTORS
 ADRENALINE
c. NONSPECIFIC AGENTS capillary protectors (antioxidants)
 RUTINE (quercetine-3-rutinoside)
 VITAMIN C
2. AGENTS STIMULATING PLATELET FUNCTION
 FRESH BLOOD OR PLATELET CONCENTRATES
 DESMOPRESSIN:
Peptide related to ANTIDIURETIC HORMONE = VASOPRESSIN
Administration i.v. in severe cases ADVERSE REACTIONS
↑ factor VIII vasodilation
↑ von Willebrand factor water retention
Infarction (> 60 year old, angina)
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

I. HEMOSTATICS
3. AGENTS STIMULANTING COAGULATION
 CONCENTRATES OF CLOTTING FACTORS or antihemophilic agents
 factor VIII (hemophilia type A)
 factor IX (hemophilia type B)
 PROTAMINE SULFATE = heparin antidote
 VITAMIN K
 Vit K1 or PHYTONADIONE (vegetables) Vitamin K1 Phytonadione

 Vit K2 or MENAQUINONE (saprophyte flora)

 Vit K3 or MENADIONE (synthetic)

Factors II,
VII, IX and X
Menaquinone Menadione

Hepatic synthesis of coagulation factors
is mediated by vitamin. K
INDICATIONS of Vitamin K
1. Bleeding caused by ORAL ANTICOAGULANTS
2. Deficiency in the diet
3. Deficit synthesis by intestinal microflora
4. Intestinal malabsorption
5. Liver disease
6. Newborns and premature
Chapter 6. PHARMACOLOGY OF HEMOSTASIS AND FIBRINOLYSIS

I. HEMOSTATICS
4. AGENTS THAT INHIBIT FIBRINOLYSIS OR ANTIFIBRINOLYTIC
a. NATURAL
 APROTININ (Iv): serine protease inhibitor inhibits proteolytic enzymes: trypsin
and plasmin
b. SYNTHETIC (Orally, iv): Inhibit plasminogen activation
 TRANEXAMIC ACID p-AMINOMETHYLBENZOIC ACID
 -AMINOCAPROIC ACID

INDICATIONS
1. Obstetric complications: Heavy Menstrual Bleeding
Placenta detachment
2. Surgery with bleeding tendency (GI surgery or prostatectomy)
3. Gastrointestinal bleeding, severe liver disease and ovarian carcinomas
4. Drug-induced bleeding, mainly fibrinolytics