Pharmacology of Antithrombotic/Antiplatelet, Anticoagulant,

and Thrombolytic/Fibrinolytic

There are three major steps in homeostasis: vascular spasm, formation of a platelet plug
and blood coagulation/clotting.

Platelet Plug
Physiologically, platelet does not adhere to the endothelial surface of the blood vessel.
However, in disruption of the endothelial surface smoothness, platelets will stick to the collagen
exposed in the endothelial surface. The layers formed by the tethered platelets are labeled as
platelet plug.
Exposed collagen resulted in activation of platelet membrane glycoprotein (GP) IIb/IIIa
receptors to bind with fibrinogen molecules for adhesion and release several chemicals such as
adenosine diphosphate (ADP) to activate more platelets in the blood to form layers on the
platelet plug. This aggregating process is further enforced by secretion of thromboxane A2
(TXA2) from platelet plasma membrane.
Platelet activation is regulated by Ca++ from platelet-dense tubular system that results in
increase of cytosolic calcium concentration. The augmented cytosolic Ca++stimulates
phospholipase A2 (PLA2) that in turns release the precursor of TXA2, arachidonic acid. TXA2
increases the intracellular Ca++ that inhibits the activity of adenylate cyclase and reduce cAMP
formation that augments the release of Ca++. Conversely, PGI2 is an endothelial cell-derived
prostacyclin that stimulates adenylate cyclase activity and increases platelet cAMP concentration
and in turn, inhibits Ca++ release from the dense tubular system.
The aggregation process is inhibited by the secretion of prostacyclin and nitric oxide
from the adjacent normal endothelium that is stimulated by ADP and other chemicals secreted by
activated platelets. Therefore, the platelet plug is limited to the injured site and does not spread to
other healthy tissues.

Clotting
Clotting is defined as a change of state of blood from liquid into solid gel. It is one of the
hemostatic mechanisms. Formation of clot requires conversion of fibrinogen into fibrin with
thrombin as the catalyst at the site of injury. Fibrin molecules formed a net-like meshwork that
traps blood cells and aggregating platelets. The mass as an end product is defined as a clot.
Fibrin mesh is vulnerable as the strands are loosely structured, hence it requires factor XIII as a
fibrin-stabilizing factor to strengthen the connection.
Other than being a catalyst, thrombin also activates factor XIII to stabilize the fibrin
mesh, stimulates positive-feedback for further thrombin formation, and enhances platelet
aggregation. Since, thrombin plays a crucial role in clot formation, it is usually absent in plasma
if there is no vessel injury within vicinity. In an inactivated state, thrombin exists in the plasma
as prothrombin and requires factor X for conversion into thrombin.
Activation of clotting factors through clotting cascades available through two pathways:
intrinsic and extrinsic pathways. Intrinsic pathway begins with the activation of factor XII in the
blood by coming into contact with exposed collagen in an injured vessel or foreign substances.
Whereas in extrinsic pathway, the tissue factors external to the blood known as tissue
thromboplastin directly activates factor X, bypassing the preceding steps in the intrinsic pathway.

Antithrombotic/Antiplatelet
Platelet functions are regulated by three categories of substances. First group are
substances generated outside of platelet that interact with platelet membrane receptor. The
second group is substances from inside the platelet that interacts with the platelet membrane
receptor. And the third group comprises of agents that generates within the platelet and act
within the platelet. These substances became target for platelet inhibitory drugs in principle.

1. Aspirin
Aspirin inhibits the synthesis of TXA2 through irreversible acetylation of enzyme
cyclooxygenase. Other non-steroid anti-inflammatory drugs (NSAID) are also known to inhibit
cyclooxygenase, however the duration of inhibitory action is lower than aspirin as they are not
able to acetylate cyclooxygenase. At lower doses, aspirin is known to inhibit platelet TXA2
synthesis without interfering with the presence and benefits of PGI2.
Aspirin has been proven to be clinically effective in patients with cardiovascular diseases
in reducing the incidence of future coronary events and lessens the occurrence of infarction.
However, it is still unknown of the benefit of aspirin for primary prevention. The recommended
dose for aspirin is between 75-325mg/day. The adverse effect of aspirin is related to the
gastrointestinal system such as dyspepsia and nausea. Reducing the adverse effect is effective
through reducing the dose and/or using enteric-coated or buffered tablets.

2. Thienopyridines
Thienopyridine inhibit ADP-mediated pathway of platelets by irreversibly blocking the ADP
receptor of P2Y12. The most common form of thienopyridines are clopidogrel, and ticlopidine.
Thienopyridines has clinically superior effect to aspirin in reducing the risk of myocardial
infarction, stroke or vascular death but with higher economic cost and side effect. Hence, the
indication of thienopyridine is as an antiplatelet substitute in patients allergic to aspirin and to
prevent thrombotic complication after percutaneous coronary stenting. The most common side
effect of thienopyridines are bleeding, dyspepsia and diarrhea.
Clopidogrel’s antithrombotic effect are dose dependent that is within 5 hours of oral loading
dose of 300mg, 80% of platelet activity will be inhibited. The maintenance dose of clopidogrel is
75mg/day to achieve maximum platelet inhibition. The duration of the effect is 7 to 10 days.
Recommended dose of ticlopidine is 250mg twice a day. Ticlopidine has more side effects
compared to clopidogrel, making physicians to prefer clopidogrel over ticlopidine.

3. GP IIb/IIIa receptor antagonist

Glycoprotein IIb/IIIa receptor antagonists are classified as the most potent antiplatelet agents
as it reversibly inhibits the binding of platelet GP IIb/IIIa receptors to fibrinogen and von
WIllebrand factor resulting in preventing the formation of hemostatic plug. There are three types
of GP IIb/IIIa antagonists:
a. Monocolonal antibodies – abciximab
b. Synthetic peptide antagonists – eptifibatide
c. Synthetic nonpeptide antagonist – tirofiban.

GPIIb/IIIa are mostly administered parenterally as oral dose has not shown to be beneficial
on clinical trials. The side effects of GP IIb/IIIa receptor antagonist are bleeding, and
thrombocytopenia.

4. Others
 Dipyridamole is a vasodilator that inhibits platelet function by inhibiting adenosine uptake
and cyclic GMP phosphodiesterase activity. It is mostly combined with aspirin to prevent
cerebrovascular ischemia, or with warfarin for patients with recurrent thromboembolism from
prosthetic heart valves.
Cilostazol, a phosphodiesterase inhibitor, promotes vasodilation and inhibition of platelet
aggregation that is used to treat intermittent claudication.

Anticoagulant
Anticoagulant drug are prescribed to prevent pathologic thrombosis and limit reperfusion
injury. Katzung classified anticoagulant drugs by their binding site into indirect thrombin
inhibitors that binds to antithrombin (AT) and direct thrombin inhibitors that binds to an active
thrombin.

1. Indirect Thrombin Inhibitors

a. Unfractioned Heparin (UFH)
UFH is a heterogenous mixture of sulfated mucopolysaccharides that binds to endothelial
cell surface and plasma proteins such as AT. When bound to AT, it increases the affinity of AT
for thrombin by 1000 fold subsequently reducing thrombin’s ability to generate fibrin from
fibrinogen.
UFH is administered through parenteral, as it is not absorbed from the gastrointestinal
tract. UFH needs to be frequently monitored through blood samples as its bioavailability varies
from patient to patient. Indications for IV UFH are unstable angina and NSTEMI, acute
myocardial infarct after fibrinolytic therapy, and pulmonary embolism or deep venous
thrombosis.
The side effect of UFH is bleeding. Intravenous protamine sulfate is frequently used for
treating overdose of UFH as it bounds to UFH and reverses the anticoagulation effect. Heparin-
induced thrombocytopenia (HIT) is a side effect of UFH that causes systemic hypercoagulation
in 7-15% of patients receiving UFH. It is usually asymptomatic, dose dependent, and self-
limited. However, immune-mediated HIT can lead to life-threatening bleeding and paradoxically
causes thrombosis from the formation of antibodies directed against heparin-platelet complex.
 Monitoring of UFH are often from the activated partial thromboplastin time (aPTT).
Cessation of heparin and replacement with a substitute antithrombotic therapy is used to manage
HIT and prevent further clotting.

b. Low Molecular Weight Heparin (LWMH)

LWMH is developed to address the shortcomings of UFH. It has approximately one third of
the molecular size of UFH. Like UFH, it binds to AT but the LWMH-AT complex inhibits factor
Xa rather than thrombin. This selevtive inhibition of factor Xa prevents the formation of
thrombin. The common LWMH includes enoxaparin, dalteparin and tinzaparin.
Advantages of LMWH compared to UFH are the selective inhibition of factor Xa, less
binding to plasma protein and endothelial cells that results in predictable bioavailability and
longer half-life, less bleeding complication and lower incidence of immune-mediated HIT.
LWMH is administered in fixed dose twice a day through subcutaneous injection without
frequent blood monitoring like UFH.
Indication for LMWH are prophylaxis against deep venous thrombosis after hip, knee or
abdominal surgery; treatment of deep venous thrombosis; and management of acute coronary
syndromes. However, LMWH should not be used in patients with history of HIT, as LMWH
could not be reversed with administration of protamine.

2. Direct thrombin inhibitors

Direct thrombin inhibitors inhibit thrombin activity independent of AT, hence do not cause
thrombocytopenia and frequently used to prevent thrombosis in patients with HIT.
Lepirudin is an irreversible thrombin inhibitor that inactivates fibrin-bound thrombin in
thrombi. Lepirudin has little effect on platelets or bleeding time. Lepirudin is administered
parenterally and require monitoring of aPTT. Lepirudin is excreted through the kidney and needs
to be used with great caution in patients with renal insufficiency.
Bivalirudin is a bivalent inhibitor of thrombin that is administered intravenously with rapid
onset and offset of action. It has short half-life with only 20% renal clearance. Argatroban is a
small molecule thrombin inhibitor that is used in patients with HIT and coronary angioplasty in
patients with HIT. It has short half-life and administered through continuous intravenous
infusion. Its clearance is not affected by renal disease but dependent on liver function.
Coumarin Anticoagulant
Warfarin is an oral long-term anticoagulation drug that acts as an antagonist to vitamin K
epoxide reductase that is required for vitamin K metabolism. Reduced form of vitamin K
promotes carboxylation of glutamic acid residue within specific coagulation factors (factors II,
VII, IX and X), activates these factors and subsequently involved in process of coagulation. By
interfering in the metabolism of vitamin K, warfarin inhibits the carboxylation of the coagulation
factors and causing them to be inactive.
Warfarin’s action has delayed onset of 2 to 7 days with 37 hours half-life, hence the dose
of warfarin is individualized to achieve therapeutic effect with minimum bleeding complication.
Commonly used initial dose is 5-10mg with maintenance dose of 5-7mg/d after adjustment of
prothrombin time as a monitor within a week. The therapeutic range for oral anticoagulant is
defined as international normalize ratio, a ratio of the patient’s prothrombin time to mean normal
prothrombin time. Recommended INR is 2-3 for prophylaxis and patients with thrombotic
disease.
Warfarin is also known to interact with other drugs that result in altered prothrombin
time. Reversing the effect of warfarin is done through administration of oral or parenteral
vitamin K (phytonadione), fresh-frozen plasma, prothrombin complex concentrates, and
recombinant factor VIIa (rFVIIa). Reversing warfarin effect should accommodate the long half-
life of warfarin as single doses of vitamin K or rFVIIa might not be sufficient.

Thrombolytic/Fibrinolytic
Fibrinolytic drug works by catalyzing the formation of serine protease plasmin from
plasminogen. These drugs create a generalized lytic state when administered intravenously,
causing both protective hemostatic thrombi and target thromboemboli to break down.
Streptokinase is a protein that combines with proactivator plasminogen to catalyze the
conversion of inactive plasminogen to activate plasmin. Urokinase is an enzyme that directly
converts plasminogen to activate plasmin. Anistreplase consists of a complex of purified human
plasminogen and bacterial streptokinase to protect the enzyme’s active site. On intravenous
injection, it hydrolyzes activated streptokinase-proactivator complex that results in increased
thrombolytic activity.
 Plasminogen can also be activated endogenously through tissue plasminogen activators
(t-PA). Activated plasminogen that is bound to fibrin confines fibrinolysis to the formed
thrombus and avoids systemic activation. t-PA are manufactured as Alteplase, Reteplase and
Tenecteplase. Alteplase is human t-PA manufactured through DNA recombinant technology.
Reteplase is also recombinant human t-PA with several amino acid sequences deleted causing it
to be economically more affordable but less fibrin binding compared to Alteplase. Tenecteplase
is a mutant form of t-PA that has longer half-life and more fibrin specific than t-PA.
Indications of fibrinolytic drugs are pulmonary embolism with hemodynamic instability,
severe deep venous thrombosis andascending thrombophlebitis. Fibrinolytic drugs are
administered intravenously or intra-arterial for peripheral vascular diseases. Fibrinolytic drugs
are very expensive.

Drug Loading Dose Maintenance Dose

Streptokinase 250.000 IU 100.000 IU/h for 24-72h
Urokinase 300.000 IU first 10min 300.000 IU/h for 12h
Alteplase 60mg first hour 40mg at 20mg/h
Reteplase 2 x 10 IU, 30min separate -
Tenecteplase 0.5mg/kg -

Reference:
1. Sherwood L. Human Physiology From Cells to System, 7th Edition. Canada: Brooks/Cole
Cengage learning, 2010. Pg.406-411
2. Lilly L. Pathophysiology of Heart Disease, 5th Edition. China: Lippincott Williams &
Wilkins, 2011. Pg 422-430
3. Katzung B. Basic and Clinical Pharmacology, 10th Edition. Singapore: McGrawHill,
2007. Pg 542-554