HK1060525A - Use of activated coagulation factor vii for treating thrombolytic therapy-induced major bleedings - Google Patents

Description

Treatment of thrombolytic therapy-induced major bleedings with activated factor VII

Background

The hemostatic system, including platelet, blood clotting and fibrinolysis, plays a critical role in maintaining blood flow and limiting blood loss upon vascular injury. Upon vascular injury, platelets adhere to the vessel wall, aggregate and form a plug (plug) which results in the solidification of the fibrin network formed by the activation of factor VII, factor X and prothrombin upon activation of blood coagulation. After blood loss ceases, healing of the wound begins, after which the fibrinolytic system dissipates the blood clot through tissue plasminogen activator (t-PA) -induced production of plasmin.

In pathological situations, such as in cardiovascular disease, the system escapes normal physiologic regulation, causing a complete blockage of the vessel, as observed after the atherosclerotic plaque has sloughed off. To treat the blockage of the thrombus formation and restore blood flow, thrombolytic therapy is often applied (reference 1).

Thrombolytic therapy includes combination therapy of antiplatelet agents (e.g., acetylsalicylic acid), anticoagulants (e.g., heparin) and fibrinolytic agents (e.g., tissue plasminogen activator, streptokinase, staphylokinase, urokinase or derivatives thereof). The combined use of these agents, while very therapeutically effective, still presents a significant risk of causing bleeding complications, including hemorrhagic shock (references 2, 3). Many of the patients receiving thrombolytic therapy experience severe bleeding. According to the most recent clinical trials of thrombolytic therapy (i.e., the Assent-2 trial involving 16949 patients), it was found that tenecteplase (a derivative of tissue plasminogen activator (t-PA) treated patients had an incidence of intracranial hemorrhage of 0.93%, alteplase (also a derivative of t-PA)) treated patients had an incidence of intracranial hemorrhage of 0.94%, and that the incidence of non-cerebral hemorrhage complications was 26.43% and 28.95% for tenecteplase and alteplase, respectively. Transfusions were required in 4.25% and 5.49% of people. Mortality or non-lethal shock rates at 30 days were 7.11% and 7.04%, respectively, with treatment with either Tenecteplase or alteplase (reference 3).

Therefore, it is necessary to provide the physician with an antidote in addition to the thrombolytic drug used to reverse the massive hemorrhage resulting from this thrombolytic therapy.

Brief description of the invention

It is an object of the present invention to provide compositions and methods for treating thrombolytic/fibrinolytic therapy-induced major bleeding (hemorrhaging) in a subject, such as a human or an animal.

The present invention is based on the finding that the above object can be achieved by using activated factor vii (viia).

Factor VII is a vitamin K-dependent glycoprotein that is physiologically synthesized by hepatocytes and secreted into the blood as a single-chain molecule consisting of 406 amino acid residues. The process of factor VII activation to factor VIIa involves hydrolysis of a single peptide bond between arginine at position 152 and isoleucine at position 153, forming a double-stranded molecule formed by a light chain of 152 amino acid residues and a heavy chain of 254 amino acid residues held together by a disulfide bond. This protein, in its activated form, functions as a serine protease and is involved in an alternative pathway of the coagulation cascade (extrinsic pathway). Upon exposure to Tissue Factor (TF), the damaged vascular wall site forms a complex with factor VII, resulting in activated factor VII (factor VIIa), which activates factor X to Xa, which in turn converts prothrombin to thrombin. Thrombin plays a key role in blood coagulation and wound healing. In the initial stage of vascular injury, it induces platelet aggregation and induces fibrin formation, followed by stimulation of cell growth to promote repair of damaged blood vessels (reference 1).

Transfection of baby hamster kidney cells with human DNA encoding factor VII allows the expression of recombinant factor VII (rFVII), which can be converted during purification into activated factor VII (rFVIIa) (reference 4). Commercially available recombinant factor VIIa is NovoSeven  (Novo Nordisk, Bagsvaerd, Denmark), which has been increasingly used for the treatment of bleeding episodes in a wide variety of bleeding disorders, especially hemophilia patients with inhibitors of factor VII or IX but who otherwise would not be effective (references 5-10).

Although 13 years of experience has accumulated with the use of this drug, major bleeding episodes resulting from factor VIIa reverse thrombolytic therapy have never been proposed or studied.

Detailed Description

In a first aspect, the present invention relates to the use of activated factor vii (viia) or a functional derivative thereof for the manufacture of a medicament for the treatment of major bleedings, including intracranial haemorrhages, caused by thrombolytic/fibrinolytic therapy.

In a second aspect, the present invention relates to a method of treating major bleedings, including intracranial bleedings, caused by thrombolytic/fibrinolytic therapy, which method comprises administering to a subject suffering from said bleedings an effective amount of activated factor vii (viia) or a functional derivative thereof. The method is particularly useful for treating mammals, including humans.

Purified factor VIIa suitable for use in humans of the invention may be isolated from natural sources or preferably prepared by recombinant DNA techniques, for example as described in reference 20. Factor VIIa, prepared by recombinant techniques, may be substantially identical to native factor VIIa, as is the product NovoSeven  from NovoNordisk. The term "functional derivative" refers to a modified derivative of factor VIIa having substantially the same desired biological activity. Such functional derivatives of factor VIIa may be prepared as follows: modified recombinant proteins having an amino acid sequence which differs from the native amino acid sequence by one or more amino acid residues are produced, for example, by site-directed mutagenesis of a nucleic acid sequence encoding factor VII. The modification may comprise, for example, an amino acid substitution, insertion, addition, substitution, inversion or deletion. In addition, useful post-translational modifications, such as removal or alteration of glycosylation patterns, can also be made.

Thrombolytic/fibrinolytic agents for thrombolytic/fibrinolytic therapy may comprise any form of natural or recombinant tissue plasminogen activator, such as alteplase, reteplase, duteplase, saroplase, recombinant DSPA α 1(BAT PA), streptokinase, anistrepplase, staphylokinase including pegylated staphylokinase and mutants of staphylokinase with no or reduced immunogenicity, urokinase, single chain urokinase, any third generation thrombolytic agent known in the art, such as amedipase, tenecteplase, monteplase, lanoteplase, pamiteplase (references 2, 3, 11-15, 19), or a therapeutically acceptable derivative of the above.

Preferably, the medicament or pharmaceutical composition comprising factor VIIa is administered by intravenous bolus injection or by intermittent or continuous intravenous infusion. Additionally, it may be beneficial to re-infuse factor VIIa intravenously after a single intravenous bolus injection.

Suitable pharmaceutical formulations for injection or infusion purposes include sterile aqueous solutions and sterile powders for the preparation of sterile injectable or infusible solutions for use. Typically, the final solution also contains appropriate salts and other adjuvants known in the art. For example, a reconstituted aqueous solution of NovoSeven , prepared and sold by Novo Nordisk, contains 3mg/ml sodium chloride, 1.5mg/ml calcium chloride dihydrate, 1.3mg/ml N-glycylglycine, 0.1mg/ml polysorbate 80 and 30mg/ml mannitol.

The dosage of factor VIIa administered may vary depending on, for example, the age and physical condition of the particular subject, the severity of the bleeding complications being treated, and the route of administration chosen. Appropriate dosages can be readily determined by one skilled in the art.

In general, a suitable dosage range for intravenous bolus injection of factor VIIa is about 3000-6000IU (International units; in accordance with the first International Standard relating to factor VIIa 89/688), which corresponds to about 60-120 μ g of recombinant factor VIIa per kg of body weight. Preferably, the dosage range for intravenous bolus injection is about 4500-. Since the systemic half-life of recombinant factor VIIa is typically only about 2-3 hours, it may be necessary to repeat intravenous bolus injections at relatively short intervals, preferably at intervals of 2-3 hours, more preferably at intervals of 2 hours. The initial time interval during the treatment may be extended to, for example, 4, 6, 8, 12 hours, as appropriate.

When therapeutically needed, administration can be by intravenous bolus injection within about 2-5 minutes.

A suitable dosage regimen for intermittent infusion of factor VIIa may be about 4500-6000IU per kg body weight per 2-6 hours.

A suitable dose for continuous infusion of factor VIIa may be about 500-1500IU/kg/h, which corresponds to about 10-30. mu.g rFVIIa/kg/h. Where appropriate, a bolus injection of about 4500-6000IU per kg body weight may be given prior to continuous infusion of factor VIIa. The results of prior studies with continuous infusion of recombinant factor VIIa (references 17, 18) suggest that the total amount of drug required to achieve efficacy with continuous infusion of factor VIIa is lower compared to bolus injections.

To date, the known use of factor VIIa has low incidence of side effects and biochemical signs suggest that thrombosis or wasting coagulopathy does not occur, so it is expected that the major bleedings associated with thrombolytic therapy can be effectively reversed by activated factor VIIa without significant damage to the subject.

Reference to the literature

1.Stassen JM，Nystrm ANGSTROM.A historical review on thrombosisand hemostasis.Ann Plast Surgery 1997；39：317-329。

2.The GUSTO investigators.An international randomized trial comparingfour thrombolytic strategies for acute myocardial infarction.N Engl J Med.1993Sep 2；329(10)：673-82。

3.Assent-2.Single-bolus tenecteplase compared with front-loaded alteplasein acute myocardial infarction：the ASSENT-2 double-blind randomised trial.Assessment of the Safety and Efficacy of a New Thrombolytic Investigators.Lancet 1999 Aug 28；354(9180)：716-22。

4.Thim L，Bioem S，Christensen M，Nicolaisen EM，Lund-Hansen T，Pedersen AH，Hedner U.Amino acid sequence and posttranslationalmodifications of human factor VIIa from plasma and transfected baby hamsterkidney cells.Biochemistry.1988；27：7785-93。

5.Macik BG，Hohneker J，Roberts HR，Griffin AM.Use of recombinantactivated factor VII for treatment of a retropharyngeal hemorrhage in ahemophilic patient with a high titer inhibitor.Am J Hematol.1989；32：232-4。

6.Kenet G，Walden R，Eldad A，Martinowitz U.Treatment of traumaticbleeding with recombinant factor VIIa.Lancet 1999；354：1879。

7.White B，McHale J，Ravi N，Reynolds J，Stephens R，Moriarty J，SmithOP.Successful use of recombinant FVIIa(NovoSeven TM)in the managementof intractable post-surgical intra-abdominal haemorrhage.Br J Haematol1999；107：677-8。

8.Al Douri M，Shafi T，Al Khudairi D，Al Bokhari E，Black L，Akinwale N，Osmann Musa M，Al Homaidhi A，Al Fagih M，Borum Andreasen R.Effect of theadministration of recombinant activated factor VII(rFVIIa；NovoSeven TM)inthe management of severe uncontrolled bleeding in patients undergoing heartvalve replacement surgery.Blood Coagul Fibrinolysis.2000 Suppl 1：S121-7。

9.Negrier C，Lienhart A，Overall experience with NovoSeven TM.BloodCoagul Fibrinolysis 2000 Suppl 1：S19-24。

10.Wong WY，Huang WC，Miller R，McGinty K，Whisnant JK Clinicalefficacy and recovery levels of recombinant FVIIa(NovoSeven TM)in thetreatment of intracranial haemorrhage in severe neonatal FVII deficiency.Haemophilia 2000；6：50-4。

11.Gissi International Study Group.In-hospital mortality and clinical courseof 20,891 patients with suspected acute myocardial infarction randomisedbetween alteplase and streptokinase with or without heparin.The Lancet.1990；336：71-5。

12.The Global Use of Strategies to Open Occluded Coronary Arteries(GUSTO III)Investigators.A comparison of reteplase with alteplase for acutemyocardial infarction.N Engl J Med.1997；337：1118-2。

13.Van de Werf F，Cannon CP，Luyten A，Houbracken K，McCabe CH，Berioli S，Bluhmki E，Sarelin H，Wang-Clow F，Fox NL，Braunwald E.Safetyassessment of single-bolus administration of TNK tissue-plasminogen activatorin acute myocardial infarction：the ASSENT-1 trial.The ASSENT-1Investigators.Am Heart J.1999；137：786-91。

14.Collen D，Sinnaeve P，Demarsin E，Moreau H，De Maeyer M，Jespers L，Laroche Y，Van De Werf F.polyethylene glycol-derivatized cystein-substitutionvariants of recombinant staphylokinase for single-bolus treatment of acutemyocardial infarction.Circulation.2000；102：1766-72。

15.Laroche Y，Heymans S，Capaert S，De Cock F，Demarsin E，Collen D.Recombinant staphylokinase variants with reduced antigenicity due toelimination of B-lymphocyte epitopes.Blood.2000；96：1425-32。

16.Hedner U.Dosing and Monitoring NovoSeven TM treatment，Haemostasis 1996；26(suppl 1)：102-108。

17.Schulman S，Bech Jensen M，Varon D，Keller N，Gitel S，Horoszowski H，Heim M，Martinowitz U.Feasibility of using recombinant factor VIIa incontinuous infusion.Thromb Haemost.1996 Mar；75(3)：432-6。

18.Baudo F，Redaelli R，Caimi TM，Mostarda G，Somaini G，de Cataldo F.The continuous infusion of recombinant activated factor VIIa(rFVIIa)in patientswith factor VIII inhibitors activates the coagulation and fibrinolytic systemswithout clinical complications.Thromb Res.2000；99：21-4。

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Claims (10)

1. Use of activated factor vii (viia) or a functional derivative thereof for the manufacture of a medicament for the treatment of major bleedings caused by thrombolytic/fibrinolytic therapy.

2. Use according to claim 1, wherein the bleeding is caused by thrombolytic/fibrinolytic therapy using any form of natural or recombinant tissue plasminogen activator, such as alteplase, reteplase, duteplase, saroplase, recombinant DSPA α 1(BAT PA), streptokinase, staphylokinase including pegilated staphylokinase and mutants of staphylokinase without or with reduced immunogenicity, urokinase, single-chain urokinase, third generation thrombolytic agents, or therapeutically acceptable derivatives of the aforementioned.

3. The use of claim 1 or 2, wherein the hemorrhage is an intracranial hemorrhage.

4. The use according to any of claims 1-3, wherein the medicament is adapted for administration of an effective amount of factor VIIa or a functional derivative thereof by intravenous bolus injection or intravenous infusion.

5. The use according to claim 4, wherein the effective amount of factor VIIa or functional derivative thereof comprises one or more single intravenous bolus injections at a dose of about 3000-6000IU per kg body weight, corresponding to about 60-120 μ g of recombinant factor VIIa, and/or an intravenous infusion at a dose of about 500-1500IU per kg body weight per hour, corresponding to about 10-30 μ g of recombinant factor VIIa.

6. The use of claim 4 or 5, wherein the effective amount of factor VIIa or functional derivative thereof is administered in multiple intravenous bolus injections at about 2 hour intervals.

7. A method of treating major bleedings, including intracranial bleedings, caused by thrombolytic/fibrinolytic therapy, which method comprises administering to a subject suffering from said bleedings an effective amount of activated factor vii (viia) or a functional derivative thereof.

8. The method of claim 7, wherein the bleeding is caused by thrombolytic/fibrinolytic therapy using any form of natural or recombinant tissue plasminogen activator, such as alteplase, reteplase, duteplase, saroplase, recombinant DSPA alpha 1(BAT PA), streptokinase, staphylokinase including pegilated staphylokinase and mutants of staphylokinase with no or reduced immunogenicity, urokinase, single-chain urokinase, third generation thrombolytic agents, or therapeutically acceptable derivatives of the foregoing.

9. The method of claim 7 or 8, wherein the effective amount of factor VIIa or functional derivative thereof is administered by intravenous bolus injection or intravenous infusion, preferably by multiple intravenous bolus injections spaced apart by about 2 hours.

10. The method of claim 9, wherein the effective amount of factor vila or a functional derivative thereof comprises one or more single bolus injections and/or intravenous infusions, wherein the single bolus injection dose is about 3000-6000IU per kg body weight, corresponding to about 60-120 μ g of recombinant factor vila, and the intravenous infusion dose is about 500-1500IU per kg body weight, corresponding to about 10-30 μ g of recombinant factor vila per hour.