Argatroban Inhibits Human Factor Xa at Therapeutic Drug Levels: An Explanation for Its Prolongation of the INR.

Abstract

Three direct thrombin inhibitors (DTIs) differ in their ability to increase the International Normalized Ratio (INR) for a given prolongation of the activated partial thromboplastin time (APTT), as follows: argatroban > bivalirudin > lepirudin. This phenomenon is clinically-relevant, as it can complicate the transition to coumarin therapy (a risk factor for venous limb ischemia in patients with heparin-induced thrombocytopenia and deep-vein thrombosis, i.e., a clinical situation in which a DTI may be given). Since this observed order of INR prolongation by DTIs is the reverse of that expected based on their known relative affinities for human thrombin (see Table), we tested whether these DTIs (as well as the small-molecule thrombin inhibitor, D-Phe-Pro-ArgCH2Cl [PPACK]) also inhibit free and/or prothrombinase-bound factor Xa (FXa). Prothrombinase-bound FXa was assembled on rabbit brain phospholipids supplemented with human plasma factor X-depleted plasma, to which human FXa (0.5 nM, final) was added. We found that argatroban inhibited free human FXa, i.e., FXa in the fluid-phase (IC50 = 5 μM), whereas it inhibited bovine FXa much less effectively (IC50 = 110 μM). In contrast, only supratherapeutic concentrations of bivalirudin inhibited human and bovine FXa, whereas lepirudin had no effect (see Table). Neither therapeutic nor supratherapeutic concentrations of the three DTIs inhibited prothrombinase-bound FXa.Comparison of DTIs on INR, APTT, IIa, and Inhibition of Human and Bovine FxaPPACKArgatrobanBivalirudinLepirudinEffect on INRN.D.GreatestIntermediateLeast[DTI] doubling APTTN.D.1 μM0.25 μM0.06 μMKi for human thrombin*~40 nM~2 nM~0.0001 nMIC50 human FXa3 μM5 μM1,700 μM>10,000 μMIC50 bovine FXa5 μM110 μM2,900 μM>10,000 μM* published valuesCONCLUSION: Compared with the other two DTIs, argatroban effectively inhibits human FXa at concentrations (IC50 = 5 μM) within the order of magnitude of the usual therapeutic drug levels (about 1 to 2 μM). Inhibition of free FXa is a plausible reason why argatroban prolongs the INR more effectively than the other two DTIs.