Article

Effects of antithrombin and gabexate mesilate on disseminated intravascular coagulation: a preliminary study

Unlabelled imageAmerican Journal of Emergency Medicine (2012) 30, 1219-1223

Brief Report

Effects of antithrombin and gabexate mesilate on disseminated intravascular coagulation: a preliminary study

Tomoki Nishiyama MD, PhD?, Yumiko Kohno MD, Keiko Koishi MD

Department of Anesthesiology and Critical Care, Higashi Omiya General Hospital, 5-18 Higashi Omiya Minuma-ku, Saitama-shi, Saitama, 337-0051, Japan

Received 30 April 2011; revised 30 May 2011; accepted 1 June 2011

Abstract

Purpose: We hypothesized that antithrombin is more effective for disseminated intravascular coagulation than is gabexate mesilate, which is a protease inhibitor, suggested from the previous studies. Initially, we compared the effects of antithrombin and gabexate mesilate for treating infection- related DIC.

Methods: Sixteen adult patients with a diagnosis of DIC with infection who were assessed with an acute DIC score 4 or higher at the admission to the intensive care unit were divided into antithrombin- treated and gabexate mesilate-treated groups. White blood cell counts, C-reactive protein, platelet counts, antithrombin, fibrin and fibrinogen degradation product, D-dimer, fibrinogen, thrombin antithrombin complex, plasmin plasminogen complex, prothrombin time, and activated partial thrombin time were measured on the day of admission and on days 1, 3, 5, and 7 thereafter. Mortality over 28 days was also compared.

Results: Platelet counts and antithrombin were significantly higher in the antithrombin group on day 7 and on days 5 and 7, respectively. Antithrombin increased to the normal level on day 1 in the antithrombin group but on day 7 in the gabexate mesilate group. C-reactive protein, fibrinogen degradation product, D-dimer, thrombin antithrombin complex, plasmin plasminogen complex, and prothrombin time were lower in the antithrombin group; but the differences were not significant. The 28-day mortality was 2 of 8 in the antithrombin group and 3 of 8 in the gabexate mesilate group, but they were not significantly different.

Conclusions: Antithrombin may be a more effective treatment for coagulation and fibrinolysis disorders than gabexate mesilate in infection-related DIC, but there was no difference in 28-day mortality.

(C) 2012

Introduction

disseminated intravascular coagulation is a severe complication in critically ill patients with, for example, sepsis, major trauma, obstetric emergencies. Treatment of the initial disease is of prime importance, but improvement of

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E-mail address: [email protected] (T. Nishiyama).

coagulation and fibrinolysis disorders is also an important goal in the treatment of DIC. In Japan, many clinicians use the protease inhibitor gabexate mesilate to treat DIC; but only a few studies have been published in peer-reviewed journals [1,2]. In addition, these published studies [1,2] had no control groups but concluded that gabexate mesilate was effective. From these studies, therefore, we are not able to know with certainty whether gabexate mesilate was effective. In contrast, we showed that gabexate mesilate at

0735-6757/$ – see front matter (C) 2012 doi:10.1016/j.ajem.2011.06.003

2 mg/kg per hour did not improve coagulation, fibrinolysis, DIC score, and mortality in pre-DIC, compared with the control group in a prospective randomized study [3].

Antithrombin has been enthusiastically investigated for treatment of sepsis [4,5]. In the KyberSept Trial, a Large dose of antithrombin (30 000 U in 4 days) did not improve 28-day mortality for sepsis; but antithrombin used without heparin did improve 90-day mortality [6]. Recently, antithrombin was also shown to be effective for septic DIC [7]. In the expert consensus for the treatment of DIC in Japan [8], gabexate mesilate is classified in B2 (treatment does not have high-quality evidence of efficacy but has few deleterious effects and is clinically used), whereas antithrombin is in B1 (treatment has moderately high-quality evidence or high- quality evidence but the clinical usefulness is not significant) for treatment of DIC with organ failure.

From this evidence, we hypothesized that antithrombin is more effective for DIC than gabexate mesilate, especially for septic DIC or DIC with organ failure. There have been no previous comparative studies; and we, therefore, performed a randomized prospective study to compare the effects of antithrombin and gabexate mesilate on infection-related DIC.

Materials and methods

Patients

A prospective, randomized, controlled, and single-blind study was conducted. The study was approved by the review boards of Kagawa Central Hospital and Kochi Medical School Hospital, and informed consent was obtained from the families of the patients. Sixteen adult patients, diagnosed as having DIC with infection assessed with an acute DIC score [9] 4 or higher at admission to the intensive care unit, were enrolled. Those who had Hematologic diseases, liver cirrhosis classified as Child-Pugh grade C, burn, or obstetric diseases or who had received anticancer agents, radiation, or anticoagulant were excluded from the study.

Protocol

The patients were divided into 2 groups, the antithrombin group and the gabexate mesilate group, at random using an envelope method. The antithrombin group received anti- thrombin (Neuart; Mitsubishi Tanabe Pharm, Co, Ltd, Osaka, Japan) as a 1500-U infusion for 30 min/d for 5 days, and the gabexate mesilate group received gabexate mesilate (FOY; Ono Pharm, Co, Ltd, Osaka, Japan) as a 2000-mg infusion for 24 h/d for 5 days. Antibiotics, red blood cells, plasma protein products, sedatives, catechol-

Measurements

White blood cell counts, C-reactive protein (CRP), platelet counts, antithrombin, fibrin and fibrinogen degrada- tion product (FDP), D-dimer, fibrinogen, thrombin anti- thrombin complex (TAT), plasmin plasminogen complex (PIC), prothrombin time, activated partial thrombin time (aPTT), as ordinally measurable parameters of inflammation, coagulation, and fibrinolysis, were monitored, as our previous study [3] on the day of intensive care unit admission and on days 1, 3, 5, and 7 thereafter. The measurements were performed at the central laboratory of our hospital. Mortality over 28 days was also compared between the groups.

Statistics

For statistical analysis, the ?2 test was performed for sex, DIC score, disease, and mortality. Factorial analysis of variance (ANOVA) was used for age, body weight, height, and Sequential Organ Failure Assessment score. Repeated measures ANOVA followed by the Student- Newman-Keuls test was used for measured parameters. P b .05 was considered to be statistically significant. Post hoc power analysis was performed for repeated measures ANOVA and ?2 test with ? = .05 using G Power software (University Mannheim, Germany).

Results

Demographic data, SOFA score, and DIC score were not significantly different between the 2 groups (Table 1). The power of this study was 0.674 for repeated measures ANOVA and 0.123 for the ?2 test.

Platelet counts and antithrombin were significantly higher in the antithrombin group on day 7 and on days 5 and 7, respectively. However, both groups had platelet counts below the reference range until day 7. Antithrombin increased to the normal level on day 1 in the antithrombin group but on day 7 in the gabexate mesilate group. Prothrombin time decreased significantly to normal levels

amines, and H2 blocker were administered according to the

Table 1 Background of the patients

Antithrombin group

Gabexate mesilate group

Age (y)

69 (30-85)

72 (62-83)

Male/female

5/3

6/2

Body weight (kg)

53 (42-62)

49 (36-60)

Height (cm)

159 (143-171)

162 (150-181)

DIC score (4/5)

4/4

3/5

SOFA score

7 (5-9)

7 (5-10)

Disease panperitonitis

5

7

Abscess

3

1

Mean and range (parenthesis) or number of the patients is shown.

patient’s status. Fresh frozen plasma; platelet concentrate; ?-lglobulin; and coagulation and fibrinolysis agents, such as heparin, steroid, and ulinastatin, were not administered.

in the antithrombin group on day 7, whereas aPTT and PIC increased significantly in the gabexate mesilate group on days 3 and 7, respectively. C-reactive protein, FDP, D-dimer, TAT, PIC, and prothrombin time were lower in the antithrombin group than in the gabexate mesilate group; but the differences were not significant. Prothrombin time in the antithrombin group improved to the normal levels on day 7 (Table 2). The 28-day mortality was 2 of 8 in the antithrombin group and 3 of 8 in the gabexate mesilate group, but this difference was not significant.

Discussion

This study directly compared the effects of antithrombin and gabexate mesilate on infection-related DIC and showed that antithrombin may be more effective for improving coagulation and fibrinolysis disorders than gabexate mesilate, whereas 28-day mortality was not significantly different.

The power to detect significant differences in the measured parameters was 0.674, and platelet counts and antithrombin showed significant differences between the groups. If the number of patients had been larger, possible differences between the 2 groups could have been detected for CRP, FDP, D-dimer, TAT, PIC, and prothrombin time. The mortality was not significantly different between the groups, but the power was quite low (0.123) due to the small

Table 2 Results

number of patients. Therefore, a future prospective study with a large number of patients is necessary; 220 patients would be required for a power of 0.95. This study was performed single blinded, which was a limitation; but the presented results were mortality and parameters that were measured. Therefore, bias should not be a factor.

We used the acute DIC score [9] to diagnose DIC, whereas in the previous study, we used the criteria by the Japanese Ministry Health and Welfare [3]. However, it has been reported that the platelet counts, prothrombin time, FDP, and fibrinogen were important for diagnosis of DIC; and the acute DIC score was more sensitive for DIC than were other criteria [10]. Therefore, the acute DIC score was judged suitable for diagnosis of DIC.

coagulation disorders are mediated by inflammatory activity [11]. Gabexate mesilate directly inhibits serine protease independent of antithrombin [12], inhibits leuko- cyte activation [13], and inhibits endotoxin-induced increase in Proinflammatory cytokine [14]. Ohno et al [12] also showed experimentally that gabexate mesilate inhibited clotting activity of thrombin more strongly than the fibrinolytic activity of plasmin. In a clinical study, gabexate mesilate at 2 mg/kg per hour increased platelet counts and decreased FDP compared with heparin in DIC associated with decreased antithrombin [15]. However, the same dose of gabexate mesilate did not improve any parameters of coagulation and fibrinolysis in DIC in our previous study [3]. Hsu et al [16] reported that gabexate mesilate did not

Parameter

Group

0

1

3

5

7

Platelet counts

AT

4.0 (1.0)

8.1 (3.0) ?

8.5 (3.5) ?

9.6 (4.5) ?

12.6 (5.8) ??, ?

(15-34 x 104/uL)

GM

4.8 (2.3)

5.9 (2.0)

6.7 (1.4)

8.2 (2.4) ?

9.7 (2.5) ?

Antithrombin

AT

47 (25)

78 (26) ?

89 (27) ?

110 (27) ??, ?

104 (28) ??, ?

(80%-120%)

GM

46 (16)

57 (10)

66 (6)

72 (8)

80 (13) ?

Prothrombin time

AT

16.2 (3.5)

15.1 (2.8)

14.8 (2.5)

13.1 (2.7)

11.3 (2.1) ?

(9.5-12 s)

GM

16.6 (4.2)

15.6 (3.4)

15.2 (3.5)

14.6 (2.4)

13.4 (3.1)

aPTT

AT

45 (15)

47 (15)

52 (12)

64 (19)

64 (22)

(25-37 s)

GM

45 (7)

49 (7)

57 (9) ?

63 (8) ?

61 (14) ?

PIC

AT

1.1 (0.8)

1.3 (1.3)

1.8 (1.8)

1.8 (1.7)

1.5 (1.0)

(<=0.8 ug/mL)

GM

1.1 (0.3)

1.3 (0.6)

1.6 (0.7)

2.2 (1.0)

3.0 (1.7) ?

CRP

AT

1.5 (0.9)

1.4 (0.9)

1.3 (0.5)

0.9 (0.4)

0.8 (0.5)

(b0.03 mg/L)

GM

1.5 (0.8)

1.8 (0.8)

1.7 (0.7)

1.3 (0.4)

1.2 (0.4)

FDP

AT

103 (109)

91 (110)

55 (57)

42 (36)

26 (21)

(<=10 ug/mL)

GM

92 (112)

93 (115)

75 (81)

51 (55)

42 (36)

D-dimer

AT

9.4 (7.6)

8.2 (7.8)

6.9 (8.3)

6.8 (8.4)

7.3 (8.5)

(b1.0 ug/mL)

GM

10.0 (7.4)

9.1 (7.5)

10.1 (6.9)

9.4 (7.2)

9.6 (7.4)

TAT

AT

28 (22)

23 (18)

16 (18)

10 (5)

9 (8)

(<=3.0 ng/mL)

GM

28 (18)

22 (19)

22 (18)

19 (17)

20 (13)

White blood cell counts

AT

8.0 (5.9)

9.1 (4.2)

9.2 (4.2)

7.6 (2.2)

8.6 (3.4)

(4-8 x 103/uL)

GM

7.7 (5.6)

8.7 (2.3)

8.2 (2.4)

7.8 (2.0)

9.4 (1.5)

Fibrinogen

AT

22.0 (16.5)

31.1 (22.9)

38.4 (24.3)

37.2 (14.6)

36.9 (10.5)

(17-30 mg/L)

GM

29.6 (23.4)

31.5 (16.3)

32.8 (13.4)

36.1 (12.4)

39.2 (12.0)

Mean and SD (parenthesis). AT indicates antithrombin group; GM, gabexate mesilate group.

* P b .05 vs day 0.

?? P b .05 vs gabexate mesilate group.

improve mortality but reduced the severity of infection- induced DIC in patients after abdominal surgery.

Kaneider et al [17] reported that antithrombin directly affected platelets, which elicit anti-inflammatory effects. Antithrombin decreased the release of proinflammatory cytokines [18,19] that could reduce endothelial activation and leukocyte adhesion. Antithrombin also induced endothe- lial prostacyclin synthesis by binding to endothelium [20]. This limits leukocyte adhesion to the Endothelial cells [21] and reduces platelet aggregation. In our previous study of major vascular surgery, antithrombin decreased polymorphonuclear leukocyte elastase, which may contribute to the inhibition of hypercoagulability [22]. Antithrombin attenuated proinflam- matory cytokines but not anti-inflammatory cytokines [23]. Thus, antithrombin decreased both hypercoagulation and inflammatory activation significantly, as shown in our previous study, in which, however, the dose of antithrombin was double that of the present study [22]. We did not measure cytokines and polymorphonuclear leukocyte elastase in the present study; but CRP, FDP, D-dimer, TAT, PIC, and prothrombin time were lower in the antithrombin group than in the gabexate mesilate group, although the differences were not significant. These results suggest that antithrombin, compared with gabexate mesilate, may decrease both hypercoagulation and the inflammatory response.

We did not coadminister heparin. Heparin prevents antithrombin from binding to the endothelium [24], which inhibits decrease in platelet aggregation and decrease in proinflammatory cytokine production. Antithrombin without heparin significantly decreased mortality of septic patients with DIC [25]. In sepsis, low-antithrombin plasma activities correlated with high mortality [26,27]. The prognoses were better in patients with DIC with antithrombin 70% or higher than in those with antithrombin less than 70% [28]. In addition, an initial increase of less than 60% after administration of antithrombin may be associated with high mortality in critically ill patients [27]. Initially, antithrombin in our cases was less than 70%; but it increased more than 60% in the antithrombin group. The mortality was not different from that in the gabexate mesilate group, however, possibly due to the small number of patients.

Administration of high doses of antithrombin that maintained activity over 150% to 200% maximized aggravation of bleeding tendency in septic patients with DIC [5,29]. We administered antithrombin at 1500 U once per day for 5 days, which was the maximum dose available due to the insurance regulations in Japan; and antithrombin was increased over 100% only on day 5. Administration of antithrombin at 1 U/kg should increase antithrombin activity 1% [30]. However, the increase was smaller than expected on days 3 to 5 in the present study. The half-life of administered antithrombin was significantly shorter in patients with DIC than in patients without DIC [31]. Increased vascular permeability may play a major role in antithrombin reduction during DIC [7]. In sepsis, antithrom- bin is consumed by thrombin generation, shortened half-life,

enhanced degeneration by polymorphonuclear leukocyte elastase, and decreased hepatic synthesis [32]. Antithrombin administration of 500 U every 8 hours maintained plasma antithrombin activity higher than that of 1500 U once per day [33]. Therefore, we should increase the administration dose of antithrombin or divide the dose for administration every

8 hours to produce significant effects. Antithrombin of 1500 U once per day for 2 to 3 days decreased D-dimer, fibrin monomer, and DIC score in our previous study [34].

In conclusion, antithrombin may be a more effective treatment for coagulation and fibrinolysis disorders than gabexate mesilate in infection-related DIC.

References

  1. Okamura T, Niho Y, Itoga T, et al. Treatment of disseminated intravascular coagulation and its prodromal stage with gabexate mesilate (FOY): a multi-center trial. Acta Haematol 1993;90:120-4.
  2. Tamaki S, Wada H, Hiyoyama K, et al. Treatment of disseminated intravascular coagulation with gabexate mesilate. Clin Ther 1993;15: 1076-84.
  3. Nishiyama T, Matsukawa T, Hanaoka K. Is protease inhibitor a choice for the treatment of pre- or mild disseminated intravascular coagulation? Crit Care Med 2000;28:1419-22.
  4. Inthorn D, Hoffmann JN, Harti WH, et al. Effect of antithrombin III supplementation on inflammatory response in patients with severe sepsis. Shock 1998;20:90-6.
  5. Ilias W, List W, Decruyenaere J, et al. Antithrombin III in patients with severe sepsis: a pharmacokinetic study. Intensive Care Med 2000;26: 704-15.
  6. Warren BL, Singer P, Pillay SS, et al. High-dose antithrombin III in severe sepsis. A randomized controlled trial. JAMA 2001;286:1869-78.
  7. Aibiki M, Fukuoka N, Umakoshi K, et al. serum albumin levels anticipate antithrombin III (AT) activities before and after AT agent in critical patients with disseminated intravascular coagulation. Shock 2007;27:139-44.
  8. Wada H, Asakura H, Okamoto K, et al. Expert consensus for the treatment of disseminated intravascular coagulation in Japan. Thromb Res 2010;125:6-11.
  9. Okabayashi K, Wada H, Ohta S, et al. Hemostatic markers and the Sepsis-related Organ Failure Assessment score in patients with disseminated intravascular coagulation in an intensive care unit. Am J Hematol 2004;76:225-9.
  10. Takemitsu T, Wada H, Hatada T, et al. Prospective evaluation of three different diagnostic criteria for disseminated intravascular coagulation. Thromb Haemost 2011;105:40-4.
  11. Levi M, van der Poll T. Inflammation and coagulation. Crit Care Med 2010;38:S26-34.
  12. Ohno H, Kosaki G, Kambayashi J. FOY: [Ethyl p-(6-guanidino hexanoyloxy) benzoate] methanesulfonate as a serine protease inhibitor. I. Inhibition of thrombin and factor Xa in vitro. Thromb Res 1980;19:579-88.
  13. Harada N, Okajima K, Kushimoto S. Gabexate mesilate, a synthetic protease inhibitor, reduces ischemia/reperfusion injury of rat liver by inhibiting leukocyte activation. Crit Care Med 1999;27:1958-64.
  14. Murakami K, Okajima K, Uchiba M, et al. Gabexate mesilate, a synthetic protease inhibitor, attenuates endotoxin-induced pulmonary Vascular injury by inhibiting tumor necrosis factor production by monocytes. Crit Care Med 1996;24:1047-53.
  15. Taenaka N, Shimada Y, Hirata T, et al. Gabexate mesilate (FOY) therapy of disseminated intravascular coagulation due to sepsis. Crit Care Med 1983;11:735-8.
  16. Hsu JT, Chen HM, Chiu DF, et al. Efficacy of gabexate mesilate on disseminated intravascular coagulation as a complication of infection developing after abdominal surgery. J Formos Med Assoc 2004;103: 678-84.
  17. Kaneider NC, Feistritzer C, Gritti D, et al. Expression and function of syndecan-4 in human platelets. Thromb Haemost 2005;93:1120-7.
  18. Fourrier F, Jourdain M, Tournoys A, et al. Effects of a combined antithrombin III and protain C supplementation in porcine acute endotoxic shock. Shock 1998;10:364-70.
  19. Gray E, Thomas S, Mistry Y, et al. Inhibition of tissue factor and cytokine release. Haemostasis 1996;26:92-5.
  20. Horie S, Ishii H, Kazama M. Heparin-like glycosaminoglycan is a receptor for antithrombin III-dependent but not for thrombin- dependent prostacyclin production in human endothelial cells. Thromb Res 1990;59:895-904.
  21. Uchiba M, Okajima K, Murakami K, et al. Attenuation of endotoxin- induced pulmonary vascular injury by antithrombin III. Am J Physiol 1996;270:L921-30.
  22. Nishiyama T. Antithrombin can modulate coagulation, cytokine production, and expression of adhesion molecules in Abdominal aortic aneurysm repair surgery. Anesth Analg 2006;102:1007-11.
  23. Taniguchi T, Mizukoshi Y, Saito S, et al. Early effect of antithrombin

III supplementation on Cytokine response in septic patients with disseminated intravascular coagulation. Med Postgrad 2003;41: 126-30.

  1. Pulletz S, Lehmann C, Volk T, et al. Influence of heparin and hirudin on endothelial binding of antithrombin in experimental thrombinemia. Crit Care Med 2000;28:2881-6.
  2. Kienast J, Jures M, Wiedermann CJ, et al. Treatments effects of high- dose antithrombin without concomitant heparin in patients with severe sepsis with or without disseminated intravascular coagulation. J Thromb Haemost 2006;4:90-7.
  3. Wilson RF, Farag A, Mammen EF, et al. Sepsis and antithrombin III, prekallikrein, and fibronectin levels in surgical patients. Am Surg 1989;55:450-6.
  4. Gando S, Sawamura A, Hayakawa M, et al. First day dynamic changes in antithrombin III activity after supplementation have a predictive values in critically ill patients. Am J Hematol 2006;81:907-14.
  5. Nishiyama T, Hanaoka K. Antithrombin III is useful factor in disseminated intravascular coagulation. Med Postgrad 1995;33:242-7.
  6. Fourrier F, Joudain M, Toumoys A. Clinical trial results with antithrombin III in sepsis. Crit Care Med 2000;28:S38-43.
  7. Blauhut B, Kramar H, Vinazzer H, et al. Substitution of antithrombin III in shock and DIC: a randomized study. Thromb Res 1985;39:81-9.
  8. Blauhut B, Necek S, Vinazzer H, et al. Substitution therapy with an antithrombin III concentrate in shock and DIC. Thromb Res 1982;27: 271-8.
  9. Levi M, ten Cate H, van der Poll T. Disseminated intravascular coagulation: state of the art. Thromb Haemost 1999;82:695-705.
  10. Aibiki M, Fukuoka N, Nishiyama T, et al. Differences in antithrombin

III activities by administration method in critical patients with disseminated intravascular coagulation: a pharmacokinetic study. Shock 2007;28:141-7.

  1. Nishiyama T, Hanaoka K. Can antithrombin attenuate the severity of disseminated intravascular coagulation ? Med Postgrad 2001;39: 390-5.

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