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was offered by acontinuous IV infusion 1 h prior to the induction ofthrombosis or cuticle incision.Antithrombotic studiesApixaban exhibited strong antithrombotic ALK Inhibitor activity in therabbit models of AV-ST, ECAT and DVT, which comparedwell with standard antithrombotic agents. For instance, apixaban, the direct FXa inhibitorrivaroxaban, the direct thrombin inhibitor dabigatran andthe oral anticoagulant warfarin showed similar efficacy inthe prevention model of DVT. In the preventionmodel of ECAT, apixaban was as efficacious as theantiplatelet agent clopidogrel and warfarin. Doses and plasma concentrations of apixaban for 50%thrombus reduction ranged from 0.07 to 0.27 mg/kg/h and0.065 to 0.36 lM, respectively. The 1 mg/kg/h dose was related with approximately 80% antithromboticefficacy in these models.
Interestingly, thepotency of apixaban in arterial and venous thrombosisprevention models was broadly equivalent. Apixaban alsoeffectively ALK Inhibitor inhibited the growth of a pre-formed intravascularthrombus CDK inhibitors inside a treatment model of DVT, suggestingthat apixaban shows potential for the treatment of establishedthrombosis.Bleeding time studiesThe bleeding potential of apixaban was compared withthose of rivaroxaban, dabigatran and warfarin in the rabbitcuticle bleeding time model. At the highest effectivedoses studied, warfarin increased bleeding timealmost six-fold, whereas apixaban, rivaroxaban and dabigatranprolonged bleeding time 1.13-, 1.9 and 4.4-fold,respectively. As shown in Fig. 3, the antithromboticefficacy and bleeding profiles of warfarin anddabigatran were less favorable than those of apixaban andrivaroxaban.
It really should be noted; however, that extrapolationof pre-clinical bleeding time data to humans requirescaution. Provoked bleeding measured in anaesthetizedhealthy animals may not directly translate into spontaneousbleeding observed in the clinical setting, where complicationsof cardiovascular disease and polypharmacy are oftenpresent. Nevertheless, PARP pre-clinical bleeding time studies arestill beneficial for generating hypotheses for clinical investigation,by way of example by allowing the anti-haemostatic profilesof experimental agents to be ranked and comparedwith those of established agents such as warfarin. The preclinicalcomparison of these agents’ therapeutic windows,as summarized in Fig. 3, remains a hypothesis, and headto-head clinical studies are essential to validate theseresults.
Combination therapyDual antiplatelet therapy with clopidogrel and aspirincurrently represents the standard of care for the reductionof CDK inhibitors atherothrombotic events inside a broad range of individuals. Tounderstand the benefit-risk ratio of apixaban therapy incombination with standard antiplatelet therapy, apixabanwas evaluated in combination with clinically relevant dosesof aspirin and/or clopidogrel for the prevention of arterialthrombosis in rabbit models. These evaluationsshowed that the triple combination of apixaban, aspirin andclopidogrel resulted in improved antithrombotic activityversus mono-therapies, without excessively increasingbleeding time in rabbits. Such data suggest that intensiveantithrombotic therapy with apixaban, aspirin and clopidogrelmay be a viable option for enhancing antithromboticefficacy without unacceptable increases in bleeding.
This hypothesis was tested inside a big phase III study,APPRAISE-2, in high-risk individuals with recent ACS treatedwith apixaban or placebo moreover to monoor dual antiplatelettherapy. Veryrecently, the trial was discontinued according to ‘‘evidence ALK Inhibitor of aclinically significant boost in bleeding among patientsrandomized to apixaban, and this boost in bleeding wasnot offset by clinically meaningful reductions in ischemicevents’’. The investigators with the APPRAISE-2 trialwill continue to review the readily available data to superior understandthe effects of apixaban in this ACS patient populationand will publish the results.As discussed above, the translatability of preclinicalbleeding models to safety in clinical settings requirescaution.
It appears that the preclinical CDK inhibitors cuticle bleedingeffect of apixaban in combination with dual antiplatelettherapy in rabbits does not translate directly into spontaneousbleeding observed in the APPRAISE-2 trial. Theunderlying causes for this disconnect are not known, butmay be related to species differences, bleeding time versusspontaneous bleeding, vascular bed differences, and thefact that unlike animal bleeding models, the APPRAISE-2patients had the highest tendency to bleed due to advancedage, diabetes, complications of cardiovascular disease,other comorbidities and also the additive hazards of combinationantiplatelet treatment. Finally, the APPRAISE-2 findingdoes not mean that apixaban can't benefit otherpatient populations, as recent phase III clinical trials ofapixaban have demonstrated promising final results in patientswith venous thromboembolismandatrial fibrillation.Ex vivo coagulation markersThe conventional clotting time tests for adjusting anticoagulantdoses of heparinand warfarina