Recombinant factor VIIa partially reverses the inhibitory effect of fondaparinux on thrombin generation after tissue factor activation in platelet rich plasma and whole blood

Grigoris T. Gerotziafas; François Depasse; Tahar Chakroun; Meyer M. Samama; Ismail Elalamy

doi:10.1160/TH03-07-0483

Thrombosis and Haemostasis, Table of Contents

Thromb Haemost 2004; 91(03): 531-537
DOI: 10.1160/TH03-07-0483

Blood Coagulation, Fibrinolysis and Cellular Haemostasis

Schattauer GmbH

Recombinant factor VIIa partially reverses the inhibitory effect of fondaparinux on thrombin generation after tissue factor activation in platelet rich plasma and whole blood

Grigoris T. Gerotziafas

¹Service d’Hématologie Biologique, Hôpital Hôtel-Dieu de Paris, France

²LCL, Ivry sur Seine, France

,

François Depasse

²LCL, Ivry sur Seine, France

,

Tahar Chakroun

¹Service d’Hématologie Biologique, Hôpital Hôtel-Dieu de Paris, France

,

Meyer M. Samama

¹Service d’Hématologie Biologique, Hôpital Hôtel-Dieu de Paris, France

²LCL, Ivry sur Seine, France

,

Ismail Elalamy

¹Service d’Hématologie Biologique, Hôpital Hôtel-Dieu de Paris, France

› Author Affiliations

Abstract

Summary

Fondaparinux (Arixtra®), a specific AT-dependent FXa inhibitor, is effective and safe in the prevention and treatment of venous thromboembolism, but some major hemorrhagic events may occur. No specific antidote to fondaparinux has been proposed. Recombinant FVIIa (Novoseven®) could be used as an haemostatic treatment, but this option has not been well documented. We studied the effect of rFVIIa (1 µg/ml) on the inhibition of thrombin generation induced by fondaparinux (0.1µg/ml to 1 µg/ml). Coagulation was triggered in platelet rich plasma (PRP) or in whole blood by recalcification in the presence of diluted thromboplastin. In PRP thrombin generation was assessed using the thrombinoscope assay. In whole blood, prothrombin activation was assessed by measuring the kinetics of F₁₊₂ formation using an ELISA assay. Fondaparinux at concentrations equal or greater than 0.5 µg/ml prolonged the initiation phase of thrombin generation, and reduced the velocity of prothrombin activation. It also decreased by 60% the endogenous thrombin potential. In the presence of fondaparinux (0.5 µg/ml to 1 µg/ml) rFVIIa accelerated the initiation phase of thrombin generation, but it did not significantly increase the endogenous thrombin potential. However, rFVIIa did not completely reverse the inhibitory effect of fondaparinux on the parameters of thrombin generation and prothrombin activation. This study shows that rFVIIa accelerates thrombin generation, but does not completely reverse the inhibitory effect of fondaparinux on thrombin generation. The potential clinical use of rFVIIa as haemostatic treatment of major bleedings related to fondaparinux has to be evaluated.

Keywords

Pentasaccharide - fondaparinux - thrombin generation - novoseven - tissue factor

Full Text

References

References
1 Choay J, Petitou M, Lormeau JC. et al. Structure-activity of relationship in heparin: a synthetic pentasaccharide with high affinity for antithrombin III and eliciting high antifactor Xa activity. Biochem Biophys Res Comm 1983; 116: 492-9.
2 Samama MM, Gerotziafas GT. Evaluation of the pharmacological properties and clinical results of the synthetic pentasaccharide (Fondaparinux). Thromb Res 2003; 109: 1-11.
3 Lormeau JC, Hérault JP. The effect of the synthetic pentasaccharide SR 90107/ORG 31540 on thrombin generation ex vivo is uniquely due to ATIII-mediated neutralization of factor Xa. Thromb Haemost 1995; 74: 1474-7.
4 Lormeau JC, Hérault JP. Comparative inhibition of extrinsic and intrinsic thrombin generation by standard heparin, a low molecular weight heparin and the synthetic AT-IIIbinding pentasaccharide. Thromb Haemost 1993; 69: 152-6.
5 Beguin S, Choay J, Hemker HC. The action of a synthetic pentasaccharide on thrombin generation in whole plasma. Thromb Haemost 1989; 61: 397-401.
6 Lassen MR, Bauer KA, Eriksson BI. et al. Postoperative fondaparinux versus preoperative enoxaparin for prevention of venous thromboembolism in elective hip-replacement surgery: a randomized double-blind comparison. Lancet 2002; 359: 1715-20.
7 Turpie AG, Bauer KA, Eriksson BI. et al. Postoperative fondaparinux versus postoperative enoxaparin for prevention of venous thromboembolism after elective hip-replacement surgery: a randomized double-blind trial. Lancet 2002; 359: 1721-6.
8 Bauer KA, Eriksson BI, Lassen MR. et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after elective major knee surgery. N Engl J Med 2001; 345: 1305-10.
9 Eriksson BI, Bauer KA, Lassen MR. et al. Fondaparinux compared with enoxaparin for the prevention of venous thromboembolism after hip-fracture surgery. N Engl J Med 2001; 345: 1298-304.
10 Turpie AGG, Bauer KA, Eriksson BI. et al. Fondaparinux versus enoxaparin for the prevention of venous thromboembolism in major orhtopedic surgery. A metaanalysis of 4 randomized double-blind studies. Arch Intern Med 2002; 162: 1833-40.
11 The Matisse investigators. Subcutaneous fondaparinux versus intravenous unfractionated heparin in the initial treatment of pulmonary embolism. N Engl J Med 2003; 349: 1695-702.
12 Coussement PK, Bassand JP, Convens C. et al. A synthetic factor-Xa inhibitor (ORG31540/ SR9017A) as an adjunct to fibrinolysis in acute myocardial infarction. Eur Heart J 2001; 22: 1716-24.
13 Hedner U. General haemostatic agents – fact or fiction. Pathophysiol Haemost Thromb 2002; 32 suppl 33-6.
14 Friederich PW, Levi M, Bauer KA. et al. Ability of recombinant factor VIIa to generate thrombin during inhibition of tissue factor in human subjects. Circulation 2001; 103: 2555-9.
15 Deveras RAE, Kessler CM. Reversal of warfarin induced excessive anticoagulation with recombinant factor VIIa concentrate. Ann Intern Med 2002; 137: 884-8.
16 Sørensen B, Johansen P, Nielsen GL. et al. Reversal of the International Normalized Ratio with recombinant activated factor VII in central nervous system bleeding during warfarin thromboprophylaxis: clinical and biochemical aspects. Blood Coagul Fibrinolysis 2003; 14: 469-77.
17 Hemker HC, Wielders S, Kessels H. et al. Continuous registration of thrombin generation in plasma, its use for the determination of the thrombin potential. Thromb Haemost 1993; 70: 617-24.
18 Hemker HC, Giesen PLA, Ramjee M. et al. The thrombogram: monitoring thrombin generation in platelet rich plasma. Thromb Haemost 2000; 83: 589-91.
19 Walenga JM, Petitou M, Lormeau JC. et al. Antithrombotic activity of a synthetic heparin pentasaccharide in a rabbit stasis thrombosis model using different thrombogenic challenges. Thromb Res 1987; 46: 187-98.
20 Boneu B, Necciari J, Cariou R. et al. Pharmacokinetics and tolerance of the natural pentasaccharide (SR90107/ORG31540) with high affinity to antithrombin III in man. Thromb Haemost 1995; 74: 1468-73.
21 Gerotziafas GT, Zervas K, Arzoglou P. et al. On the mechanism of action of rFVIIa administered to patients with severe thrombocytopenia and life-threatening haemorrhage. Focus on prothrombin activation. Br J Haematol 2002; 117: 705-8.
22 Butenas S, Brummel KE, Branda RF. et al. Mechanism of factor VIIa–dependent coagulation in hemophilia blood. Blood 2002; 99: 923-30.
23 Kjalke M, Ezban M, Monroe DM. et al. High dose factor VIIa increases initial thrombin generation and mediates platelet activation in thrombocytopenia-like conditions in a cellbased model system. Br J Haematol 2001; 114: 114-20.
24 Rosing J, Tans G, Grovers-Riemslag JWP. et al. The role of phospholipids and factor Va in the prothrombinase complex. J Biol Chem 1980; 255: 274-83.
25 Esmon CT, Owen WG, Jackson CM. A plausible mechanism for prothrombin activation by factor Xa, factor Va, phospholipid, and calcium ions. J Biol Chem 1974; 249: 8045-47.
26 Carr ME, Martin EJ, Kuhn JG. et al. Effects of recombinant factor VIIa on platelet function and clot structure in blood with deficient prothrombin conversion. Thromb Haemost 2003; 89: 803-11.
27 Mann KG, Butenas S, Brummel K. The dynamics of thrombin formation. Arterioscler Thromb Vasc Biol 2003; 23: 17-25.
28 Hemker HC, Beguin S. Phenotyping the clotting system. Thromb Haemost 2000; 84: 741-51.
29 Barrowcliffe TW, Havercroft SJ, Kemball-Cook G. et al. The effect of Ca²⁺, phospholipids and factor V on the anti-factor Xa activity of heparin and its oligosaccharides. Biochem J 1987; 243: 31-7.
30 Pieters J, Willemsg G, Hernker HC. et al. Inhibition of factor IXa and factor X, by Antithrombin III/Heparin during factor X activation. J Biol Chem 1988; 263: 15313-18.
31 Rezaie AR. Prothrombin protects factor Xa in the prothrombinase complex from inhibition by the heparin-antithrombin complex. Blood 2001; 97: 2308-13.
32 Hemker HC, Choay J, Beguin S. Free factor Xa is on the main pathway of thrombin generation in clotting plasma. Biochimica et Biophysica Acta 1989; 992: 409-11.
33 Bijsterveld NR, Moons AH, Boekholdt AM. et al. Ability of recombinant factor VIIa to reverse the anticoagulant effect of pentasaccharide fondaparinux in healthy volunteers. Circulation 2002; 106: 2550-4.