Minimally Modified Human Blood Coagulation Factor X to Bypass Direct Factor Xa Inhibitors.

Anticoagulants Antidotes Factor Xa inhibitors Hemorrhage Molecular Dynamics Simulation

Journal

Journal of thrombosis and haemostasis : JTH
ISSN: 1538-7836
Titre abrégé: J Thromb Haemost
Pays: England
ID NLM: 101170508

Informations de publication

Date de publication:
08 May 2024
Historique:
received: 30 10 2023
revised: 09 04 2024
accepted: 23 04 2024
medline: 11 5 2024
pubmed: 11 5 2024
entrez: 10 5 2024
Statut: aheadofprint

Résumé

Direct oral factor Xa inhibitors are widely used as alternatives to conventional vitamin K antagonists in managing venous thromboembolism and nonvalvular atrial fibrillation. Unfortunately, bleeding-related adverse events remain a major concern in clinical practice. In case of bleeding or emergency surgery, rapid-onset reversal agents may be required to counteract the anticoagulant activity. The ability of factor Xa variants to bypass the direct oral factor Xa inhibitors was assessed. Human factor Xa variants were generated through substitution of phenylalanine 174 (F174) for either alanine, isoleucine, or serine. Factor Xa variants were stably expressed in HEK293 cells and purified to homogeneity using ion-exchange chromatography. F174-substituted human factor X variants demonstrated efficacy in restoring thrombin generation in plasma containing direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban). Their ability to bypass the anticoagulant effects stems from a significant reduced sensitivity for the direct factor Xa inhibitors, due to a decrease in binding affinity determined using molecular dynamics simulations and free energy computation. Furthermore, F174 modification resulted in a partial loss of inhibition by tissue factor pathway inhibitor, enhancing the procoagulant effect of F174-substituted factor X. Consequently, the F174A- and F174S-substituted factor X variants effectively counteracted the effects of two widely used anticoagulants, apixaban and rivaxoraban, in plasma of atrial fibrillation and venous thromboembolism patients. These human factor X variants have the potential to serve as a rescue reversal strategy to overcome the effect of direct factor Xa inhibitors in case of life-threatening bleeding events or emergency surgical interventions.

Sections du résumé

BACKGROUND BACKGROUND
Direct oral factor Xa inhibitors are widely used as alternatives to conventional vitamin K antagonists in managing venous thromboembolism and nonvalvular atrial fibrillation. Unfortunately, bleeding-related adverse events remain a major concern in clinical practice. In case of bleeding or emergency surgery, rapid-onset reversal agents may be required to counteract the anticoagulant activity.
OBJECTIVES OBJECTIVE
The ability of factor Xa variants to bypass the direct oral factor Xa inhibitors was assessed.
METHODS METHODS
Human factor Xa variants were generated through substitution of phenylalanine 174 (F174) for either alanine, isoleucine, or serine. Factor Xa variants were stably expressed in HEK293 cells and purified to homogeneity using ion-exchange chromatography.
RESULTS RESULTS
F174-substituted human factor X variants demonstrated efficacy in restoring thrombin generation in plasma containing direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban). Their ability to bypass the anticoagulant effects stems from a significant reduced sensitivity for the direct factor Xa inhibitors, due to a decrease in binding affinity determined using molecular dynamics simulations and free energy computation. Furthermore, F174 modification resulted in a partial loss of inhibition by tissue factor pathway inhibitor, enhancing the procoagulant effect of F174-substituted factor X. Consequently, the F174A- and F174S-substituted factor X variants effectively counteracted the effects of two widely used anticoagulants, apixaban and rivaxoraban, in plasma of atrial fibrillation and venous thromboembolism patients.
CONCLUSIONS CONCLUSIONS
These human factor X variants have the potential to serve as a rescue reversal strategy to overcome the effect of direct factor Xa inhibitors in case of life-threatening bleeding events or emergency surgical interventions.

Identifiants

DOI: 10.1016/j.jtha.2024.04.022 PMID: 38729577
pubmed: 38729577
pii: S1538-7836(24)00254-X
doi: 10.1016/j.jtha.2024.04.022
pii:
doi:

Types de publication

Journal Article

Langues

eng

Sous-ensembles de citation

IM

Informations de copyright

Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.

Auteurs

Mark Schreuder (M)

Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center; Leiden, The Netherlands.

Georges Jourdi (G)

AH-HP. Centre, Service d'hématologie biologique, Hôpital Cochin ; F-75014 Paris, France; Université Paris Cité, Innovative Therapies in Haemostasis, INSERM U1140; F-75006 Paris, France; AH-HP. Nord, Hôpital Lariboisière, Service d'hématologie biologique; F-75010 Paris, France.

Dejvid Veizaj (D)

Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center; Leiden, The Netherlands.

David A Poole (DA)

AIMMS Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam; Amsterdam, The Netherlands.

Ka Lei Cheung (KL)

Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center; Leiden, The Netherlands.

Géraldine Poenou (G)

Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center; Leiden, The Netherlands; Université Paris Cité, Innovative Therapies in Haemostasis, INSERM U1140; F-75006 Paris, France.

Daniël Verhoef (D)

Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center; Leiden, The Netherlands; VarmX B.V.; Leiden, The Netherlands.

Stella Thomassen (S)

Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University; Maastricht, The Netherlands.

Laura F H Janssen (LFH)

AIMMS Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam; Amsterdam, The Netherlands.

Alain Stepanian (A)

AH-HP. Nord, Hôpital Lariboisière, Service d'hématologie biologique; F-75010 Paris, France; EA3518 Institut Universitaire d'Hématologie, Hôpital Saint Louis, Paris-Diderot; Paris, France.

Tilman M Hackeng (TM)

Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University; Maastricht, The Netherlands.

Pascale Gaussem (P)

Université Paris Cité, Innovative Therapies in Haemostasis, INSERM U1140; F-75006 Paris, France; AP-HP. Centre, Hôpital Européen Georges Pompidou, Service d'hématologie biologique; F-75015 Paris, France.

Pieter H Reitsma (PH)

Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center; Leiden, The Netherlands; VarmX B.V.; Leiden, The Netherlands.

Daan P Geerke (DP)

AIMMS Division of Molecular and Computational Toxicology, Department of Chemistry and Pharmaceutical Sciences, Vrije Universiteit Amsterdam; Amsterdam, The Netherlands.

Virginie Siguret (V)

Université Paris Cité, Innovative Therapies in Haemostasis, INSERM U1140; F-75006 Paris, France; AH-HP. Nord, Hôpital Lariboisière, Service d'hématologie biologique; F-75010 Paris, France.

Mettine H A Bos (MHA)

Department of Internal Medicine, Division of Thrombosis and Hemostasis, Einthoven Laboratory for Vascular and Regenerative Medicine, Leiden University Medical Center; Leiden, The Netherlands. Electronic address: M.H.A.Bos@lumc.nl.

Classifications MeSH