1
BLOOD
INFLUENCING OF BLOOD
COAGULABILITY
ANTICOAGULANTS
COMPOUNDS BINDING CALCIUM IONS
Ions of calcium Ca2+ are for coagulation necessary. Their
„scavenging“ for example by binding to citrate or EDTA prevents
blood coagulation. Possibility to manage this in vitro only. Used
for taking of blood.
HEPARINS (heparin inhibits the factors of blood coagulation)
COUMARINE DERIVATIVES (block synthesis of blood
coagulation factors)
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HEPARINUM CALCIUM, HEPARINUM NATRIUM (ČL 2005)
Heparin calcium salt, Heparin natrium salt
Natrium or calcium salt of sulphated glucosaminoglycane
MW 15.000-20.000
Source: lungs of beef cattle, intestinal mucose of beef cattle, pigs or sheep
Almost white moderately hygroscopic powder, easily soluble in water
Mechanism of effect: activation of the body's own glycoprotein
antithrombine III
Hydrolysis:
• D-glucosamine
• D-glucuronic acid
• L-iduronic acid (epimer of glucuronic acid)
• Sulphuric acid
• Acetic acid
STRUCTURE OF HEPARIN
O
OH
OSO3H
O O
O
CH2OSO3H
OH
NHSO3H
O
O
OH
OH
O
O
CH2OSO3H
OH
NHCOCH3
O
COOH COOH
sulphatated and acetyled
glucosamine
glucuronic acid
basic unit
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HEPARIN USAGE
• Prophylaxis of thromboses
• Therapy of thromboses, it means prevention of further growth of
thrombus
• Consumption coagulopathy
• Emboli
• Myocardial infarction
Parenteral application, in organism rapid decomposition (repeated administration
necessary)
Side effects:
• Bleeding in high doses (antidote protamin)
• Allergic reactions
• Thrombocytopenia
• Osteoporosis, reversible hair loss (long-termed application)
LOW-MOLECULAR HEPARIN
(fragments of heparin)
Prepared by directed cleavage of native heparin
MW cca 5000
Usage:
Prophylaxis of thromboses (benefit is long-termed effect)
Side effects:
• Bleeding
• Thrombocytopenia - rare
• More difficult antagonisation with protamine
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HEPARINOIDS
Polyesters of saccharides with sulphuric acid, lowing coagulability
MW cca 7000
Source: low-molecular residues after heparin production or natural
polysaccharides (dextrans, xylans, cellulose, starch, pectin,
chitin)
Anticoagulation effect in comparison to heparin weaker,
heparinoids are more toxic
Usage:
Local in ointments for treatment of inflammatory diseases and
hematomas
HIRUDIN
Source: Hirudo medicinalis L., bloodsucker; ambidextrous worm
from sub-class of annelids. Hirudin is protein with MW 16 000, it
is present in oral glands
Hirudin reacts directly with thrombin, with cooperation with
antitrombin III, inactivates thrombin and prohibits the blood
coagulation
Relatively difficult obtain from bloodsucker; possible usage of gene
engineering
Usage: for patients with increased risk of thrombocytopenia;
necessary clinical trials for real comparison of effect with
heparin
Bloodsuckers in pharmacies: usage has strong impact and posseses strong
psychotherapeutic potential
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COUMARINS
Cattle feeded by fermented hey with rich content of common
melilot suffered by increased bleeding
Link 1941 – effect triggered by dicoumarol (from coumarins)
Source: Meliloti herba (ČL 2005) – common melilot herb
Melilotus officinalis (L.) LAM. – common melilot (Fabaceae)
Dicoumarol introduced into practise – lead compound for synthesis
→ Pelentan
Mechanism of effect – competitive antagonism with vitamine K
COUMARIN BIOSYNTHESIS
O O
O Glc
H
H
COOH
OH
H
H
COOH
OH
H
COOH
H
O O OH
COOH
COOH
O
O OH
coumarin
melilotoside
hydrolyse
o-coumaric acid (trans)
o-coumaric acid (cis)
+ D-Glc
melilotin melilotic acid ester of coumaric and melilotic acid
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DICOUMAROL, PELENTAN
OO O
OH OH
O OO O
OH OH
O
CO
OC2H5
dicoumarol
Pelentan
COUMARINS – ANTAGONISTS OF VITAMIN K
H
CH3
O
O CH3
CH3 H CH3 H
O O
OH
C
H
C
H2
COCH3
vitamin K1, phytomenadion
2-methyl-3-phytyl-1,4-naphtoquinon
warfarin
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FIBRINOLYTICS
• Disolve fresh thrombes
• Support conversion of body´s own plasminogen to plasmin,
which as protease cleave fibrin to soluble cleavage products
Usage: myocardial infarction, pulmonary embolia, deep venose
thromboses
The mechanism of effect shows the possibility of increased
bleeding
Antidote during bleeding: inhibitors of plasmine, for example
p-aminomethylbenzoic acid (PAMBA)
STREPTOKINASI SOLUTIO AD PRAEPARATIONEM (ČL 2005)
Streptokinase concentrated solution
Protein obtained from filtrate of cultured hemolytic
streptococci group C; Mr 47000, it is not enzyme
Effect: It is binded to plasminogen and formed complex
changes further free plasminogen molecules to
plasmin, which acts as fibrinolytic
Intravenous application
Side effects: intolerance - tremor, headache, joint pain,
feeling of weakness. Do not administer repeatedly –
risk of allergy development
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UROKINASUM ČL 2005
Urokinase
Enzyme obtained from human urine, composed of forms
• low-molecular (MW 33 000)
• high-molecular (MW 54 000), prevalent
From immunologic point of view better than streptokinases
Can be obtained from cultured human kidney tissues
Supports the conversion of plasminogen to plasmin
Physiologic importance
• dissolution of fibrin clots formed in urinary tract
• Staying of menstruation blood in liquid state
STREPTOKINASE + STREPTODORNASE
for local application
Source: hemolytic streptococci
Streptodornase (enzyme) cleaves nucleoproteins to a purine bases
and pyrimidine nucleosides → liquefaction of pus
Usage:
• dissolving of fibrinose or purulent exsudates in body cavities and
necrotic tissues of wounds
• Application local only, for example into pleural cavity, into lumbal
space, into joint cavities, onto superficial wound
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ANKROD
Fraction from poison of malaysian
rattlesnake Agkistrodon
rhodostoma , malayan pit
viper
Glycoprotein MW cca 38 000
Acts as thrombin, lowers the level
of fibrinogen in blood, and
therefore lowers blood
viscosity and blood
coagulability
Usage: myocardial infarction,
venous thromboses
BAXOTROBIN
Fraction of poison of south
American snake Bothrops
atrox, common lancehead
Decreases the effect of
fibrinogen on coagulation
process
Ankrod and batroxobin can be
interchanged during
immunological problems.
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LINOLENIC ACID
Nutritient, essential fatty acid (as triglycerid in many drying oils)
Occurrence: Oleum rapae – colza oil obtained from Brassica
oleracea var. arvensis – turnip mustard (Brassicaceae)
Lowers increased adhesivity of thrombocytes
CH3
C
H2
C
H
C
H
C
H2
C
H
C
H
C
H2
C
H
C
H
C
H2
C
H2
C
H2
C
H2
C
H2
C
H2
C
H2
C
O
OH
191012131516
LOCAL FIBRINOLYTICS
Peptidhydrolases
• Chymotrypsinum (ČL 2005)
• Trypsinum (ČL 2005)
Cleavage of proteins at certain locations of chain. Reactive group
of active centre of both enzymes is hydroxyl group of serin.
Chymotrypsin prefers cleavage bonds of carboxylic groups of Phe,
Tyr, Trp a ester bonds
Trypsin cleavages lysyl and arginyl bonds of peptides.
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DRUGS LOWERING INCREASED
READINESS TO BLEEDING
Blood factors of coagulation
• thrombin
• fibrinogen
Vitamins K
Antifibrinolytics
• Protamin sulphate (during overdose of heparin)
Other drugs causing
• vasoconstriction
• astringent effect
THROMBINUM HUMANUM (ČL 2005 zkoumadla)
Human thrombin
Enzyme preparation, which changes human fibrinogen on fibrin.
• Obtained from liquid human blood plasma by precipitation with
suitable salts and organic solvents with controlled pH a
temperature
• Protein obtained by conversion of prothrombin with
thromboplastin
Usage:
• Bleeding from open wounds which is not possible to close by
stitching
• To stop capillary bleeding
Application exclusively local or superficial
Never parenterally!!
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PROTHROMBINUM MULTIPLEX HUMANUM (ČL 2005)
Human prothrombin complex
Lyophilized fraction of plasmatic proteins containing coagulation
factor IX together with fluctuating amount of of cagulation
factors II, VII and X.
Obtained by fractionation of human plasma.
FIBRINOGENUM HUMANUM ČL 2005
Human fibrinogen
Protein from human plasma, essential for proces of blood
coagulation.
Obtained by ethanol fractionation of human plasma, further
fractionation and lyophilisation.
Usage:
• During disorders of blood coagulation in case of missing, low
content or malfunction of fibrinogen in plasma.
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FIBRINI GLUTINUM (ČL 2005)
Fibrin adhesive
Composed from two components
1. Fibrinogen concentrate
2. Human thrombin
Fibrin coagulum is formed after mixing of defrozen or reconstituted
components
Fibrin foam – carrier is gelatin – foamy mass strongly hygroscopic,
after soaking is produced plastic pad
Usage: Bleeding from parenchymatic organs, during surgery in
cavities
VITAMIN K GROUP
• Two biogenic derivatives of naphtoquinone
• Synthetic naphtoquinones
Important for syntheis of coagulation factors (prothrombin (factor II) and factors
VII, IX and X.
Biogenic compounds = vitamin K1 (in green plants), vitamin K2 – menaquinone,
(synthetised by many bacterial strains including gut microflora)
Phytomenadionum – Phytomenadione (ČL 2005)
Mixture of trans-phytomenadione (at least 75 %), cis-phytomenadione and
maximally 4 % of trans-2,3-epoxyphytomenadione
Source: Medicago sativa L., alfalafa (Fabaceae)
Usage: insufficiency of natural vitamin K (diseases of liver and biliar tract,
hypoprothrombinemia of newborns, after destruction of intestinal microflora by
broad spectral antibiotic therapy, functional disorders of gut)
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PHYTOMENADIONUM – PHYTOMENADIONE (ČL 2005)
CH3
O
O
R
H
CH3
O
O CH3
H CH3
CH3
CH3
CH3
H
vitamin K1
vitamin K1 R = 4 isoprene units (phytyl-)
vitamin K2 R = 6 isoprene units (difarnesyl-)
vitamin K3 R = H (2-methyl-1,4-naphtoquinone)
2
3
ANTIFIBRINOLYTICS
Drugs preventing excessive fibrinolysis as a case of excessive
activity of plasmin.
• Aprotininum
• Protamin
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APROTININUM ČL (2005)
Aprotinine
APROTININI SOLUTIO CONCENTRATA (ČL 2005)
Aprotinin concentrated solution
• Basic polypeptid MW 6511
• Composed of 58 aminoacids
• Contains 3 disulphide bridges
Polyvalent inhibitor of proteolytic enzymes, for example
chymotrypsin, kalikrein, plasmin and trypsin.
Source: beef lungs
Usage:
• Hyperfibrinolytic bleeding after/during surgery
• Chronic joint inflammation
PROTAMINI HYDROCHLORIDUM (ČL 2005)
Protamin hydrochloride
PROTAMINI SULFAS (ČL 2005)
Protamin sulphate
Mixture of hydrochlorides or sulphates of basic peptides
Source is milt or spawn of fishes (usually from families Salmonidae
and Clupeidae)
Mostly often from milt of herrings (Clupea pallasii). Milt – pair
formation oblong shape brownish color. After opening of
abdominal cavity of males is taken and conserved by freezing.
Isolated by extraction with acidic solutions.
Usage: antidote of heparin. In solution it is bonded to heparin with
inhibiting of its anticoagulant effect.
Synonym: Klupein
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LOCAL HEMOSTATICS
During bleeding from limited area of tissues or organs
Injuries, radical surgical therapy, physiologic delivery (afterdelivery
(postnatal) bleeding)
Substances
• Interfering with mechanism of blood coagulation (fibrin foam)
• Acting mechanically is carriers of active substances (gelatin
sponge)
• Acting as astringents (tannins)
Postnatal bleeding – uterotonics, sympatolytics
TRANSFUSION LIQUIDS
Used during lowered volume and disorder of composition of circulating
liquid.
• Blood - Sanquis
• Plasma – Plasma humanum ad separationem (ČL 2005) – liquid part of
human blood after separation of cellular elements. From plasma can be
obtained: (fibrinogen, γ-globulin (carrier of antibody properties,
increase and mediates immunity against infections) , β-globulins
(preparation of thrombin), α- and β-globulins, albumin
• Albumin – Albumini humani solutio (ČL 2005)
It possesses the biggest portion of colloid-osmotic pressure of blood
plasma.
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TO BODY STRANGE SUBSTITUTES OF BLOOD
PLASMA
DEXTRANS
Dextrans – high molecular polysaccharides of mucilage-like
consistence, MW 30 000 to 30 000 000. Basic building block is
α-D-glucopyranose, connected to other glucopyranose units via
glycosidic bonds prevalently at position 1→6, less 1→3 and
1→4.
Saccharose + enzymes at the surface of Leuconostoc
mesenteroides NRRL B-15 bacteria, or relative species.
Hydrolysis and condensation of glucose units. Two days
cultivation, precipitation of dextran with methanol at lowered
temperature, washing of material and hydrochloric acid
hydrolysis at 100-105 0C, neutralization and isolation of fraction
with demanded molecular weight. Mixture isomaltooligosades.
PART OF DEXTRANE MOLECULE
O
C
H2
OH
O
O
O
C
H2
O
OH
OH
O O
O
CH2
OH
OH
OH
O
CH2OH
OH
OH
OH
O
C
H2
OH
OH
O
n
O
CH2
OH
OH
OH
OH
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DEXTRANS IN PHARMACOPOEIA ČL 2005
• Dextranum 1 pro iniectione (low molecular fraction of dextran)
Average relative molecular weight is 1 000
• Dextranum 40 pro iniectione
Average relative molecular weight is 40 000.
• Dextranum 60 pro iniectione
Average relative molecular weight is 60 000.
• Dextranum 70 pro iniectione
Average relative molecular weight is 70 000.
Usage: Infusion with specific influence on capillary circulation