Intrinsic Pathway Of Blood Coagulation Research Articles

Current state of research on intrinsic pathway of blood coagulation ; Factor XII, factor XI and high-molecular-weight kininogen deficient mice

Current state of research on intrinsic pathway of blood coagulation ; Factor XII, factor XI and high-molecular-weight kininogen deficient mice

Incremental Improvement in Bioengineering of Coagulation Factor VIII for Efficient Expression: Elimination of a Dispensable Disulfide Loop Enhances Secretion

Coagulation factor VIII (FVIII), a glycoprotein cofactor, performs a critical function in the intrinsic blood coagulation pathway and a quantitative or qualitative deficiency of this protein results in Hemophilia A. The primary obstacle to producing low cost replacement therapy is the inherent limitation of commercial recombinant FVIII (rFVIII) production since its expression is 2 to 3 orders of magnitude lower than that of other comparably sized proteins. Inefficient mRNA expression, protein misfolding & chaperone mediated retention and the requirement for facilitated transport from the Endoplasmic Reticulum (ER) to Golgi have been identified as the major bottlenecks to efficient expression of rFVIII. Bioengineering strategies aimed at clearing each of these hurdles have resulted in the generation of several rFVIII variants with more efficient expression. This study focused on the effect of each of FVIII's eight disulfide bonds on its secretion efficiency and functionality. Elimination of specific disulfide loops has previously been shown to confer a secretion advantage in certain proteins, e.g. lysozyme and human chorionic gonadotropin (hCG). The FVIII disulfide bonds were eliminated by replacing the corresponding cysteine residues with glycine residues by a PCR-based site-directed mutagenesis protocol using mutagenic primers. The disulfide mutants were created both in the full length FVIII as well as a previously bioengineered FVIII variant (226/N6) with enhanced (5–10 fold) secretion efficiency. All the mutants were characterized by restriction enzyme digestion and DNA sequencing. The secretion efficiency of all the mutants was studied by transient transfection in Chinese Hamster Ovary (CHO) and COS-1 cells. FVIII activity was measured by one-stage and two-stage clotting assays and the antigen levels were quantified by anti-FVIII light chain sandwich enzyme-linked immunosorbent assay. Seven of the eight disulfide bonds in factor VIII were found to be indispensable for the correct folding and secretion since all these disulfide mutants were retained intracellularly. A single mutant with substitution of glycine for cysteine at position 2326 in the C2 domain resulted in secretion of a functionally inactive protein. Elimination of the disulfide loop between cysteine residues at positions 1899 and 1903 in the A3 domain resulted in a 1.5- to 2-fold increase in secretion of both the full length FVIII and the already efficiently expressed 226/N6 rFVIII variant. This enhanced secretion was reflected in both the antigen levels and the activity of the protein. Also, incorporation of these mutations in 226/N6 F309S, yet another efficiently secreted rFVIII variant, further improved secretion with a synergistic effect, resulting overall in a 25- to 30-fold higher expression than full length FVIII in CHO and COS-1 cells. Interestingly, coagulation factor V (FV), that shares considerable homology with FVIII and is secreted much more efficiently, lacks a disulfide loop in the homologous position to the 1899–1903 bridge with FVIII. The other seven disulfide bonds are conserved between these two proteins. Such combined targeted bioengineering strategies may facilitate more efficient production of rFVIII toward lower cost replacement therapy.

Pharmacological regulation of factor XII activation may be a new target to control pathological coagulation

FXII was identified 50 years ago as a coagulation protein in the intrinsic pathway of blood coagulation as FXII deficient patients had marked prolongation of the in vitro surface-activated coagulation time. However, series of investigations have convincingly shown that FXII has no role in normal hemostasis. Recently, experimentally induced thrombosis in factor XII-knockout mice has provided evidence that factor XII (FXII) deficient mice are protected against ischemic brain injury after obstructive clot formation. Based on these experiments it has, therefore, been suggested, that blocking of FXII could be a unique target to prevent obstructive clot formation in arterial thrombosis without side effect of increased bleeding. FXII deficiency has, however, not convincingly been shown to protect against arterial thrombosis in humans. The target mentioned above may either be an inhibition of FXII activation or an inhibition of its proteolytic activity. FXII is a zymogen of the proteolytic enzyme, FXIIa, the substrates of which are factor XI and prekallikrein. Thus, FXIIa is not only involved in the activation of the coagulation system, but is also associated with the kallikrein/kinin system. The activation of the latter is deeply involved in inflammation and pain sensation. Furthermore, FXIIa binds to endothelial cells and to the extracellular matrix, indicating a role in vascular repair. Therefore, a complete evaluation of all these properties of FXII and FXIIa has to be considered when formulating a strategy for blocking FXII activation.

Metal Oxide Surface Charge Mediated Hemostasis

Blood coagulates faster upon contact with polar glasslike surfaces than on nonpolar plastic surfaces; this phenomenon is commonly termed the glass effect. However, the variable hemostatic response that we report here for contact-activated coagulation by different metal oxides, all of which are polar substrates, requires a refinement of this simple polarity model of how inorganic metal oxides activate the intrinsic pathway of blood coagulation. To our knowledge, the role of metal oxide surface charge as determined at the physiological pH and Ca2+ concentration of blood has not been previously investigated. We find that basic oxides with an isoelectric point above the pH of blood are anticoagulant while acidic oxides with an isoelectric point below the pH of blood are procoagulant. Using a thromboelastograph, we find that the onset time for coagulation and rate of coagulation post-initiation depend on both the sign and the magnitude of the initial surface charge density of the metal oxide. This work presents a useful strategy based on a quantifiable material parameter to select metal oxides to elicit a predictable and tunable biological response when they are in contact with blood.

Influence of coagulation factors on intrinsic thrombin generation

The intrinsic coagulation activity assay (INCA) is a new thrombin-generation test that imitates the intrinsic pathway of blood coagulation. The aim of the present study was to investigate the influence of the main coagulation factors on the INCA. The INCA was performed with citrated plasma samples supplemented with different amounts of fibrinogen. The INCA and activated partial thromboplastin time determination were performed with factor-depleted plasmas and with mixtures of depleted plasmas with normal plasma. Supplemented purified fibrinogen resulted in a decrease of intrinsic thrombin generation (50% inhibitory concentration = 0.8 g/l). The INCA depends on the intrinsic factors (factors VIII, IX, XI and XII) and on the factors of the common pathway (factors II, V and X): for normal thrombin generation, at least about 50% of normal factor II is necessary. For the majority of factors, the sensitivity of the INCA appears to be approximately one order of magnitude better than that of the activated partial thromboplastin time. The INCA allows one to diagnose defects in the intrinsic coagulation system and might be a useful test to support development and characterization of new drugs targeted at the intrinsic generation of thrombin.

Biological Activity of Asp-hemolysin as a Regulation Factor to Atherogenic Effect by Oxidized Low-Density Lipoprotein

Oxidatively modified low-density lipoprotein (OxLDL) is present in atherosclerotic lesions and has been proposed to play an important role in atherogenesis. Asp-hemolysin, a hemolytic toxin from Aspergillus fumigatus, is a binding protein for OxLDL. This study was undertaken to clarify the biological activity of OxLDL and the potentially of Asp-hemolysin as a regulation factor to atherogenic effect by OxLDL. We first analyzed the interaction between OxLDL and blood coagulation factors, which are involved in the blood coagulation pathway. OxLDL caused prolongation of activated partial thromboplastin time (APTT) as a parameter of the intrinsic pathway of blood coagulation in a dose- and oxidation time-dependent manner. In addition, OxLDL significantly inhibited blood coagulation factor VIII, IX, and XI activity. Furthermore, we demonstrated that factor VIII binds to OxLDL. These results indicate that the binding of factor VIII to OxLDL affects the intrinsic pathway of the blood coagulation cascade. Next, to clarify the structure-function relationship of Asp-hemolysin, we expressed Asp-hemolysin in Escherichia coli as a fusion protein with a maltose-binding protein (MBP) and purified it by affinity chromatography. The purified recombinant Asp-hemolysin showed an immunoreactivity with the anti-Asp-hemolysin antibody. In addition, MBP-Asp-hemolysin fusion protein exhibited binding activity to Ox-LDL as did native Asp-hemolysin. Furthermore, to investigate the effect of the Asp-hemolysin-related peptide (P-21), a synthetic peptide derived from a region of Asp-hemolysin that is rich in positive charges, on macrophage proliferation induced by OxLDL. P-21 inhibited OxLDL-induced macrophage proliferation in a dose-dependent manner. In addition, the binding analysis of P-21 to OxLDL indicated that P-21 binds to OxLDL. These results indicate that P-21 inhibits the OxLDL-induced macrophage proliferation through binding of P-21 to OxLDL. In conclusion, we have shown that OxLDL affects the intrinsic pathway of blood coagulation, and its mechanism is dependent on the binding of factor VIII to OxLDL. Furthermore, we indicate the possibility that Asp-hemolysin is a useful tool to investigate the pathophysiological significance of OxLDL. In particular, since the P-21, an Asp-hemolysin-related peptide, inhibits the OxLDL-induced macrophage proliferation through binding of P-21 to OxLDL, further study on the binding mechanism between Asp-hemolysin-related peptide and OxLDL may provide important information on the prevention and treatment of atherosclerosis.

Ceruloplasmin prevents hemostatic disorders during experimental hyperammonemia

Experimental hyperammonemia in rats was accompanied by hemostatic disorders manifesting in coagulopathy (activation of the intrinsic pathway of blood coagulation) and suppression of platelet function. Ceruloplasmin in a total dose of 60 mg/kg effectively normalized coagulation hemostasis and functional activity of platelets by improving secretory processes in platelets and increasing aggregation rate.

Anticoagulant effect of Naja naja venom 5′nucleotidase: Demonstration through the use of novel specific inhibitor, vanillic acid

The snake venom proteins affect hemostasis by either advancing/delaying blood coagulation. Apart from proteases and phospholipase A(2)s (PLA(2)s), 5'nucleotidase is known to affect hemostasis by inhibiting platelet aggregation. In this study, the possible involvement of Naja naja venom 5'nucleotidase in mediating anticoagulant affect is evaluated. Vanillic acid selectively and specifically inhibited 5'nucleotidase activity among other enzymes present in N. naja venom. It is a competitive inhibitor as evident of inhibition relieving upon increased substrate concentration. Vanillic acid dose dependently inhibited the anticoagulant effect of N. naja venom up to 40%. This partial involvement of 5'nucleotidase in mediating anticoagulant effect is substantiated by concanavalin-A (Con-A) inhibition studies. Con-A, competitively inhibited in vitro protease and 5'nucleotidase activity up to 100%. However, it did not exhibit inhibitory activity on PLA(2). The complete inhibition of anticoagulant effect by Con-A upon recalcification time suggests the participation of both 5'nucleotidase and protease in mediating anticoagulant effect of N. naja venom. Vanillic acid and Con-A inhibition studies together suggest that probably 5'nucleotidase interacts with one or more factors of intrinsic pathway of blood coagulation to bring about anticoagulant effect. Thus, this study for the first time demonstrates the involvement of 5'nucleotidase in mediating N. naja venom anticoagulant effect.

Structural and Mutational Analyses of the Molecular Interactions between the Catalytic Domain of Factor XIa and the Kunitz Protease Inhibitor Domain of Protease Nexin 2

Factor XIa (FXIa) is a serine protease important for initiating the intrinsic pathway of blood coagulation. Protease nexin 2 (PN2) is a Kunitz-type protease inhibitor secreted by activated platelets and a physiologically important inhibitor of FXIa. Inhibition of FXIa by PN2 requires interactions between the two proteins that are confined to the catalytic domain of the enzyme and the Kunitz protease inhibitor (KPI) domain of PN2. Recombinant PN2KPI and a mutant form of the FXI catalytic domain (FXIac) were expressed in yeast, purified to homogeneity, co-crystallized, and the structure of the complex was solved at 2.6 angstroms (Protein Data Bank code 1ZJD). In this complex, PN2KPI has a characteristic, disulfide-stabilized double loop structure that fits into the FXIac active site. To determine the contributions of residues within PN2KPI to its inhibitory activity, selected point mutations in PN2KPI loop 1 11TGPCRAMISR20 and loop 2 34FYGGC38 were tested for their ability to inhibit FXIa. The P1 site mutation R15A completely abolished its ability to inhibit FXIa. IC50 values for the wild type protein and the remaining mutants were as follows: PN2KPI WT, 1.28 nM; P13A, 5.92 nM; M17A, 1.62 nM; S19A, 1.86 nM; R20A, 5.67 nM; F34A, 9.85 nM. The IC50 values for the M17A and S19A mutants were not significantly different from those obtained with wild type PN2KPI. These functional studies and activated partial thromboplastin time analysis validate predictions made from the PN2KPI-FXIac co-crystal structure and implicate PN2KPI residues, in descending order of importance, Arg15, Phe34, Pro13, and Arg20 in FXIa inhibition by PN2KPI.

Factor XI deficiency database: an interactive web database of mutations, phenotypes, and structural analysis tools

Factor XI (FXI) is the zymogen of a serine protease enzyme in the intrinsic pathway of blood coagulation and is an important factor in the creation of a stable fibrin clot. Deficiency of FXI leads to an injury-related bleeding disorder and is remarkable for the lack of correlation between bleeding symptoms and FXI coagulant activity (FXI:C). The FXI protein is composed of five domains: four tandem repeat domains of approximately 80 residues known as Apple (Ap) domains, and the catalytic serine protease (Sp) domain. A total of 65 mutations throughout the FXI gene (F11) have been reported in FXI deficient patients. An interactive web database of these mutations has been created (www.FactorXI.org) that integrates the phenotypic data with genetic data and structural homology models for the five FXI domains. The database provides a central repository for all reported genetic alterations within F11. With the use of recently developed visualization tools, each mutation can be highlighted on the structural models of the FXI domains together with an appropriate survey of patient data, such as FXI:C levels and FXI antigen levels. The database also enables new F11 mutations to be interpreted. The interactive design of this database will lead to a more comprehensive comparative understanding of the genetic factors that influence bleeding risk.

Inhibition of Plasma Coagulation through Interaction between Oxidized Low-Density Lipoprotein and Blood Coagulation Factor VIII

Oxidatively modified low-density lipoprotein (OxLDL) is present in atherosclerotic lesions and has been proposed to play an important role in atherogenesis. Thrombosis is the major mechanism underlying acute complications of atherosclerosis. In the present study, we analyzed the interaction between OxLDL and blood coagulation factors, which are involved in the blood coagulation pathway. We investigated the effect of OxLDL on plasma coagulation by measuring prothrombin time (PT) as a parameter of the extrinsic pathway of blood coagulation and activated partial thromboplastin time (APTT) as a parameter of the intrinsic pathway of blood coagulation following the addition of OxLDL to plasma. OxLDL, but not native LDL, caused prolongation of APTT in a dose- and oxidation time-dependent manner. In addition, the oxidatively modified product of acetylated LDL (AcLDL), but not AcLDL, also caused prolongation of APTT. The inhibition of lysophosphatidylcholine production in OxLDL by phenylmethylsulfonyl fluoride or Pefabloc pretreatment of LDL resulted in a prolongation of APTT, which was equivalent to the effect of OxLDL. Moreover, OxLDL significantly inhibited blood coagulation factor VIII, IX, and XI activity. Furthermore, we demonstrated that recombinant factor VIII binds to OxLDL and that factor VIII associated with OxLDL is detected in the incubation mixture of OxLDL and plasma. These results indicate that the binding of factor VIII to OxLDL affects the intrinsic pathway of the blood coagulation cascade. The present study suggests that the interaction between OxLDL and factor VIII may provide important information on the initiation and progression of atherosclerosis.

DNA Extraction from Bovine Mummified Fetuses and Detection of Factor XI Gene Deficiency in the Mummies

Genomic DNA extracted from bovine mummified tissue is valuable material for detection of some genes that may contribute to fetal abnormalities. In this study bovine genomic DNA was extracted from the hardened tissue samples of ten bovine mummified fetuses. The amount of genomic DNA extracted from 2 g of the mummified tissues by the phenol/chloroform-ethanol method was low (less than 4 microg/ml) for all samples. The extracted DNA was then amplified by the GenomiPhi DNA amplification system. After amplification, the amount of DNA was increased to more than 100 microg/ml for all samples. This amplification system was shown to be a good tool for amplifying the genomic DNA of the mummified fetuses. The amplified genomic DNA was used for testing the mummies for Factor XI gene deficiency, an autosomal recessive deficiency involved in the early stages of the intrinsic blood coagulation pathway. Exon 12 of the Factor XI gene of the mummies was amplified by PCR. Two of the ten mummified fetuses were heterozygous for the Factor XI gene as indicated by the presence of two amplified DNA fragments of 320 bp and 244 bp. Factor XI deficiency has already been described in Holstein cattle. However, no report is available for bovine fetus. In this study, DNA was extracted and amplified from the bovine mummified fetuses, and the samples were successfully tested for Factor XI gene deficiency in the mummies.

Fish Protein Stimulated the Fibrinolysis in Rats

Objective: We hypothesized that fish protein affects blood coagulation and/or fibrinolysis, and compared the activity and amounts of factors involved in blood coagulation and fibrinolysis in rats fed the fish protein, which was treated to remove water-soluble and ethanol-soluble elements, from sardine (sardine protein). Methods: In the first experiment, rats were fed for 21 days an AIN-93G-based control diet, and diets in which the casein of the control diet was exchanged for sardine protein at 5, 10 and 20% levels. In the second experiment, rats were fed an AIN-93G control diet and diets containing 5% fish oil, 10% sardine protein or both (5% fish oil + 10% sardine protein) for 21 days. At the end of the experiments, blood coagulation time, hemostatic parameters and fibrinolysis parameters were measured. Results: The activated partial thromboplastin time (APTT), which is an assay for blood coagulation time in the intrinsic blood coagulation pathway, of rats fed the 20% sardine protein diet was significantly prolonged compared to that of rats fed the control diet. The prolonged APTT by dietary sardine protein was due to a significant decrease of the activities of plasma blood coagulation factors VIII, IX, XI and XII. On the other hand, dietary sardine protein significantly increased the activity of tissue-type plasminogen activator, and the amount of plasma plasmin–α₂-plasmin inhibitor complex, which are markers of activated plasmin. Moreover, we observed that the 20% sardine protein diet increased the amount of plasma D-dimer, which is a degraded product of the fibrin polymer by plasmin. In the second experiment, the APTT and PT of rats fed the F diet were prolonged compared to those of rats fed the control diet, however the concentration and amount of fibrinolytic parameters in the plasma were almost the same as those of rats fed the control diet. In contrast, the F+S diet not only prolonged APTT and PT, but also increased the concentration and amount of fibrinolytic parameters in plasma. Conclusions: We consider that the beneficial effects to health and amelioration of cardiovascular and cerebrovascular diseases by fish consumption are caused by a combination of the suppressing effect on blood coagulation of n–3 polyunsaturated fatty acids and the promoting effect on fibrinolysis of fish protein.

Bioengineering of coagulation factor VIII for improved secretion

AbstractFactor VIII (FVIII) functions as a cofactor within the intrinsic pathway of blood coagulation. Quantitative or qualitative deficiencies of FVIII result in the inherited bleeding disorder hemophilia A. Expression of FVIII (domain structure A1-A2-B-A3-C1-C2) in heterologous mammalian systems is 2 to 3 orders of magnitude less efficient compared with other proteins of similar size compromising recombinant FVIII production and gene therapy strategies. FVIII expression is limited by unstable mRNA, interaction with endoplasmic reticulum (ER) chaperones, and a requirement for facilitated ER to Golgi transport through interaction with the mannose-binding lectin LMAN1. Bioengineering strategies can overcome each of these limitations. B-domain-deleted (BDD)-FVIII yields higher mRNA levels, and targeted point mutations within the A1 domain reduce interaction with the ER chaperone immunoglobulin-binding protein. In order to increase ER to Golgi transport we engineered several asparagine-linked oligosaccharides within a short B-domain spacer within BDD-FVIII. A bioengineered FVIII incorporating all of these elements was secreted 15- to 25-fold more efficiently than full-length FVIII both in vitro and in vivo. FVIII bioengineered for improved secretion will significantly increase potential for success in gene therapy strategies for hemophilia A as well as improve recombinant FVIII production in cell culture manufacturing or transgenic animals. (Blood. 2004;103: 3412-3419)

Roles of factor XI, platelets and tissue factor-initiated blood coagulation

Roles of factor XI, platelets and tissue factor-initiated blood coagulation

Optimization of factor VIII replacement therapy: can structural studies help in evading antibody inhibitors?

Optimization of factor VIII replacement therapy: can structural studies help in evading antibody inhibitors?

Recurrent reproductive wastage and immunologic factors.

The causes of recurrent reproductive wastage are varied and complex. The present study was designed to focus on the role of immunologic factors in cases where other causes were not evident. Over 20 years, more than 1500 couples were evaluated in our clinic because of recurrent spontaneous abortion. Women were tested for anti-phospholipid antibodies and plasma contact proteins of the intrinsic pathway of blood coagulation after endocrine, organic, infectious and genetic etiologies of miscarriages were excluded. Anti-phosphatidylethanolamine antibodies, anti-annexin antibodies, and factor XII deficiency were more common factors in recurrent spontaneous abortion patients than were anti-cardiolipin antibodies in terms of induction of recurrent pregnancy losses. Paternal leukocyte immunotherapy of patients without such abnormalities was associated with a significantly improved success rate. Recurrent reproductive wastage can be minimized by individualized therapy based on comprehensive evaluation of immunologic factors, including several anti-phospholipid antibodies.

Intrinsic pathway of blood coagulation contributes to thrombogenicity of atherosclerotic plaque

Thrombosis is the major mechanism underlying acute complications of atherosclerosis. Although thrombogenicity of atherosclerotic plaques has been ascribed to activation of the extrinsic pathway of blood coagulation, in the present study we investigated contribution of the intrinsic factor VIII (fVIII)-dependent pathway. We found that in vitro exposure of human macrophages and smooth muscle cells (SMCs) to atherogenic oxidized low-density lipoprotein (oxLDL) enhances their ability to support activity of 2 major complexes of the intrinsic pathway, Xase and prothrombinase, leading to a 20- and 10-fold increase in thrombin formation, respectively. In contrast, human aortic endothelial cells were less responsive to oxLDL. The increase in the intrinsic procoagulant activity was related to formation of additional fVIII binding sites due to enhanced translocation of phosphatidylserine to the outer surface of oxLDL-treated cells and a 5-fold higher affinity of interaction between components of the Xase complex, activated factors VIII and IX. Processes occurring at early apoptotic stages, including changes in the cell membrane induced by free radicals, may be related to activation of the intrinsic pathway as suggested by effects of inhibitors of early apoptosis on thrombin formation. Immunohistochemical studies on human atherectomy specimens revealed the presence of fVIII in the vicinity of macrophages and SMCs in atheromatous regions with massive deposits of oxLDL, supporting the possible involvement of the intrinsic pathway in thrombus formation in vivo. Our data predict that the intrinsic pathway significantly enhances thrombogenicity of atherosclerotic lesions after removal of the endothelial layer and exposure of SMCs and macrophages to blood flow.

Hemophilia A-From Basic Science to Clinical Practice

This article summarizes achievements of basic research and their implementation in clinical treatment of one of the most common inherited bleeding disorders hemophilia A, which is caused by genetic deficiency of coagulation factor VIII (FVIII). We discuss the structure of FVIII, its major interactions in the intrinsic pathway of blood coagulation, and the catabolism of FVIII. We also discuss achievements in the contemporary clinical practice of treatment of hemophilia A. Replacement therapy has substantially improved by development of purification and virus inactivation procedures, allowing preparation of safe and effective therapeutic plasma-derived FVIII concentrates. We give special attention to the principles used in the development of contemporary recombinant FVIII products, which do not inherit a potential risk for viral or prion transmission. Development of FVIII inhibitory antibodies is the major complication of FVIII replacement therapy. We summarize the accumulated knowledge regarding epitopes of FVIII inhibitors and mechanisms by which they inactivate FVIII and discuss approaches to overcome the effects of inhibitors and to prevent their formation by induction of immunotolerance. We also analyze the main concepts and scientific priorities in the gene-therapeutic approach for treatment of hemophilia A.

Haemophilia A: effects of inhibitory antibodies on factor VIII functional interactions and approaches to prevent their action.

Factor VIII (FVIII) is an essential component of the intrinsic pathway of blood coagulation. Normal functioning of FVIII requires its interactions with other components of the coagulation cascade. In the circulation, it exists as a complex with von Willebrand factor (vWF). Upon activation by thrombin or activated factor X (FXa), activated FVIII (FVIIIa) functions as a cofactor for the serine protease factor IXa. Their complex assembled on the phospholipid surface activates FX to FXa, which consequently participates in formation of thrombin, the key protease of the coagulation cascade. Genetic deficiency in FVIII results in a coagulation disorder haemophilia A, which is treated by infusions of FVIII products. Approximately 25-30% of patients develop antibodies inhibiting FVIII activity (FVIII inhibitors). The major epitopes of inhibitors are located within the A2, C2 and A3 domains of the FVIII molecule. The inhibitory effects of antibodies are manifested at various stages of the FVIII functional pathway, including FVIII binding to vWF, activation of FVIII by thrombin, and FVIIIa incorporation into the Xase complex. We summarize the current knowledge of the FVIII sites involved in interaction with its physiological ligands and different classes of inhibitory antibodies and describe their inhibitory mechanisms. We outline the strategies aimed to overcome the effects of inhibitory antibodies such as development of human/porcine FVIII molecules, resistant to inhibitors. We also discuss approaches to modulate the antibody response, as well as efforts to develop a long-term immunotolerance to FVIII protein.