Potent inhibition of thrombin with a monoclonal

European Heart Journal (2005) 26, 682–688
doi:10.1093/eurheartj/ehi094
Clinical research
Potent inhibition of thrombin with a monoclonal
antibody against tissue factor (Sunol-cH36): results
of the PROXIMATE-TIMI 27 trial
David A. Morrow1*, Sabina A. Murphy1, Carolyn H. McCabe1, Nigel Mackman2,
Hing C. Wong3, and Elliott M. Antman1 on behalf of the PROXIMATE-TIMI 27
Investigators
1
TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, 75 Francis
Street, Boston, MA 02115, USA
2
Scripps Research Institute, La Jolla, CA, USA
3
Sunol Molecular Corp., Miramar, FL, USA
KEYWORDS
Clinical trials;
Antithrombins;
Coronary artery disease;
Tissue factor
Aims Exposure of tissue factor (TF) is a critical proximal step in the pathogenesis of
acute coronary syndromes. Sunol-cH36, a chimaeric monoclonal antibody to TF,
blocks binding of factor X to the TF:VIIa complex. This report describes the first completed trial of Sunol-cH36 in humans.
Methods and results We assessed the safety and pharmacokinetics of Sunol-cH36 in an
open-label, dose-escalating trial among subjects with stable coronary artery disease.
The safety analysis included all adverse events with a focus on overt or occult bleeding. Five doses of Sunol-cH36 (0.03, 0.06, 0.08, 0.1, 0.3 mg/kg) were administered as
a single intravenous bolus to 26 subjects (three to eight subjects per dose tier). No
major bleeding (2 g/dL haemoglobin decline) occurred. Spontaneous minor bleeding
was observed with a dose-related pattern. Notably, the majority of spontaneous
bleeding episodes were clinically consistent with platelet-mediated bleeding (e.g.
gum, tongue) without thrombocytopenia. The median terminal half-life was 72.2
(25th, 75th: 28.4, 72.5) h.
Conclusion Sunol-cH36 exhibited dose-dependent anticoagulant effects. We postulate
that the mucosal bleeding observed with this potent inhibitor of thrombin generation
may reflect antiplatelet effects resulting from networking between the coagulation
cascade and platelet pathways that could prove clinically relevant with this novel
class of anticoagulants.
Introduction
Rupture of vulnerable or high-risk atherosclerotic plaque,
the most frequent inciting event for an acute coronary
syndrome, exposes the highly pro-coagulant contents of
* Corresponding author. Tel: þ1 6172780145; fax: þ1 6177347329.
E-mail address: [email protected]
the atheroma core, resulting in concomitant activation
of circulating coagulation proteins and platelets. The
exposure of tissue factor (TF) is the predominant contributor to activation of the extrinsic coagulation pathway
and initiation of thrombus formation.1,2 When in
contact with circulating blood, TF binds to Factor VII to
initiate the extrinsic pathway and generate activated
Factor X (Xa).3,4 Factor Xa converts pro-thrombin (PT)
& The European Society of Cardiology 2005. All rights reserved. For Permissions, please e-mail: [email protected]
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Received 23 May 2004; revised 25 October 2004; accepted 25 November 2004; online publish-ahead-of-print 31 January 2005
PROXIMATE-TIMI 27 results
to thrombin (Factor IIa), the key enzyme that generates
fibrin. In addition to generating fibrin, thrombin promotes platelet activation and aggregation, and exerts
positive feedback within the coagulation cascade.2 At
each branch in this pathway, one molecule of activated
enzyme is able to activate many molecules of its substrate protein, thereby amplifying each step in the
cascade. In addition, extensive networking between
coagulation and platelet pathways magnifies the activity
of each.5 As such, inhibition of TF, which constitutes the
most proximal component of the coagulation cascade,
quenches the multiplier effect of downstream amplification, and presents an attractive potential strategy for
potent inhibition of coronary thrombosis.
Recently, a chimaeric mouse/human monoclonal antibody to TF (Sunol-cH36) has been developed. This antibody binds specifically to human TF at the Factor X
binding site, preventing formation of the TF:VIIa–Factor
X (or Factor IX) complex (Figure 1 ). Sunol-cH36 thereby
inhibits formation of thrombin by blocking the production
of Factors Xa and IXa. The PROXimal Inhibition of Coagulation using a Monoclonal Antibody to TissuE Factor
(PROXIMATE)-TIMI 27 trial was designed to assess the
safety and pharmacokinetics of Sunol-cH36 in an openlabel, dose-escalating trial among subjects with stable
coronary artery disease treated with aspirin.
Study population
Patient enrolment occurred between 1 April 2002 and 13 August
2003 in four centres in the United States. Eligible participants
were men and non-pregnant women, aged 21–65 years, with
stable coronary artery disease treated with aspirin. Patients
with changes in their cardiovascular medications in the prior 2
weeks, hospitalization in the prior 2 months, coronary artery
bypass grafting in the prior 3 months, or percutaneous coronary
revascularization in the prior 6 months were excluded.
Additional exclusion criteria included any history of
cerebrovascular disease, poorly controlled hypertension (systolic
pressure .160 mmHg or diastolic pressure .90 mmHg), estimated creatinine clearance 40 mL/min, known or suspected
liver disease, prior treatment with murine antibodies, treatment
with anticoagulant or antiplatelet medication other than aspirin,
or indicators of increased risk of bleeding. The latter included
known bleeding diathesis, anaemia (haemoglobin ,11 g/dL),
thrombocytopenia (platelet count ,100 000/mm3), history of
clinically significant bleeding in the previous year, recent
trauma or surgery, documented peptic ulcer disease,
haemorrhagic retinopathy, or intracranial pathology.
The protocol was approved by the Institutional Review Board
at each participating centre and all patients provided written
informed consent prior to the performance of study procedures.
Study protocol
The trial was an open-label, dose-escalation study of a single
intravenous bolus of Sunol-cH36. The trial design included four
planned dose tiers (0.03, 0.3, 1.0, and 3.0 mg/kg) with seven
patients in each dose group and, provided that enrolment
could be modified, or additional dose tiers were added, based
upon review by the Safety Committee. Such decisions were
based upon deliberation by the Committee after assessment of
all available clinical and safety data. There was no formal stopping rule. After enrolment of seven subjects at 0.03 mg/kg and
four subjects in the 0.3 mg/kg dose tier, the Safety Committee
recommended termination of recruitment in the 0.3 mg/kg
dose group, and modification of the planned dose tiers to eliminate doses higher than 0.3 mg/kg and to introduce additional
lower dose groups (0.06, 0.1, 0.15, and 0.2 mg/kg) enrolling
four patients (with an extension to seven patients at the highest
dose level). After review of seven subjects at 0.1 mg/kg, the
Safety Committee recommended elimination of doses higher
than 0.1 mg/kg and study of one additional lower dose group
(0.08 mg/kg).
All participants were treated with aspirin 81–325 mg once
daily. The assigned dose of Sunol-cH36 was administered in
100 mL of normal saline delivered intravenously as a bolus over
15 min. Patients were observed for 8 h after administration of
the bolus, and returned for follow-up evaluations at 24 h, 48 h,
72 h, 7 days, 10 days, 2 weeks, 4 weeks, and 7 weeks. One
subject enrolled in the 0.3 mg/kg dose cohort, received
0.03 mg/kg through a dosing error, and was analysed according
to the actual dose received.
Clinical procedures
Figure 1 Mechanism of TF pathway inhibition by Sunol-cH36. FVIIa,
activated Factor VII; FX, Factor X. FX binds to the TF:FVIIa complex and
is subsequently activated to form FXa.
Blood was sampled prior to administration of the study drug and
at 15 min, 30 min, 1 h, 2 h, 4 h, 8 h, and each study visit thereafter for measurement of the plasma level of Sunol-cH36. A
complete blood count and serum chemistries were performed
pre-dose, at 2 h and 8 h after the bolus dose, and at each subsequent study visit. Coagulation parameters [PT, activated
partial thromboplastin time (aPTT)] were determined at each
of these time points, as well as at 30 min and 4 h post-dose.
Bleeding times were not performed. Serum samples for detection of human antichimaeric antibodies (HACAs) were obtained
pre-dose and at the 4 and 7 week follow-up visits. Testing of
HACAs to Sunol-cH36 was performed using a double-antigen
radiometric assay employing Sunol-cH36-coated polystyrene
beads and 125I-Sunol-cH36.6 Surveillance for occult gastrointestinal bleeding was accomplished by guiaic testing at the 24-h,
48-h, 2-week, and 4-week visits. Urinalysis for microscopic
haematuria was performed at 4 h after study drug and at each
subsequent study visit.
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Methods
683
684
Endpoints and statistical analysis
The principal objectives of this study were to assess the safety
profile and pharmacokinetics of increasing doses of Sunol-cH36
in patients with stable coronary artery disease taking aspirin.
Major bleeding was defined as clinically overt or occult bleeding
resulting in a 2 g/dL decline in haemoglobin and requiring
transfusion, or retroperitoneal, intra-cranial or intra-ocular
haemorrhage, or haemorrhage associated with hypotension or
death. Minor bleeding events were defined broadly, as clinically
overt or occult bleeding not meeting the criteria for major
bleeding.
All patients who received any dose of study drug were
included in the safety analysis. Patients were categorized
according to the dose received. Testing for an association
between the dose of Sunol-cH36 and bleeding was performed
using a x2 test for trend. Analyses were performed using
STATA v7-intercooled (STATA Corp., College Station, TX, USA).
P-values of ,0.05 (two-sided) were considered to indicate statistical significance. Non-compartmental methods were used to
determine the pharmacokinetic parameters. The maximum
measured concentration (Cmax) was evaluated for each
patient. The area under the plasma concentration curve, elimination rate constant (ke), and terminal half-life (t1/2 ¼ ln 2/ke)
were calculated using WinNonlin Pro (Pharsight Inc., Mountain
View, CA, USA).
In a separate study, two experiments were performed on blood
from healthy volunteers. In the first experiment, blood samples
(n ¼ 5 subjects) were drawn and treated with corn trypsin
inhibitor (Haematologic Technologies Inc., Essex Junction, VT,
USA) and immediately pre-incubated with or without 13 nM
(2 mg/mL) final concentration of Sunol-cH36 antibody for
1 min. Recombinant human TF was added to a final concentration of 40 pM and samples incubated at 378C. Clotting was
stopped at 0, 3, 6, and 9 min by the addition of the anticoagulant solution provided in the FPA ELISA kit. Samples were then
placed on ice and centrifuged at 2000 g for 15 min. Plasma was
removed and stored at 2808C. Plasma samples were analysed
for Fibrinopeptide A levels using ELISA kits (DiaPharma Group
Inc., West Chester, OH, USA). In the second experiment, subjects (n ¼ 5) had blood drawn on Day 1 and were given
325 mg aspirin orally on Days 1 and 2 and on Day 3 blood was
again drawn. Samples were incubated with or without SunolcH36.
Results
A total of 26 patients were enrolled in the trial.
Follow-up through 7 weeks was complete for all
patients enrolled. The baseline characteristics of the
study population are described in Table 1. By design,
the median age was lower than that expected for a
community-based population with established coronary
artery disease. The proportion of patients receiving
aspirin 325 mg daily was 75, 50, 75, 83, and 0% in
the 0.03, 0.06, 0.08, 0.1, and 0.3 mg/kg dose tiers,
respectively. The remainder received 81 mg daily with
the exception of one patient in the 0.06 mg/kg dose
tier (162 mg qd).
Table 1 Baseline characteristics (n ¼ 26)
Demographics
Age, years
Female
Caucasian
Medical history
Tobacco use
Active
Past
Diabetes
History of hypertension
Prior acute coronary syndrome
Prior revascularization
55 (53, 60)
7 (26.9)
15 (57.7)
4 (15.4)
15 (60.0)
8 (30.8)
22 (84.6)
20 (76.9)
20 (76.9)
Data are shown as n (%) for dichotomous variables and median
(25th, 75th percentile) for continuous variables.
Bleeding and other safety events
The doses administered and incidence of bleeding are
detailed in Table 2. There were no major bleeding
events. Spontaneous minor bleeding occurred in 14
patients, with a graded rise in the frequency of bleeding with increasing dose of study drug (P ¼ 0.03). The
majority (66.7%) of the bleeding events occurred
within the first 3 days after receiving study drug,
with all of the events occurring by Day 12 of followup. Notably, 8 of the 14 patients with minor haemorrhage experienced oral mucosal bleeding, spontaneous
tongue haematomas, or cutaneous bleeding consistent
with platelet-mediated bleeding (Table 3 ). These
minor bleeding episodes occurred in the absence of significant changes in the platelet count or prolongation
of the aPTT (Figure 2A and B ). The PT in the highest
dose group was modestly prolonged as anticipated
due to the recognized interaction between Sunol-cH36
and human TF-based assays for measurement of PT
(Figure 2C ).
There were no serious adverse events judged as
related to study medication by the local investigators.
Five patients experienced non-serious (non-bleeding)
adverse events reported as possibly or probably
related to the study drug (Table 4 ). These non-serious
adverse events included headache, fatigue, and asthenia. No clinically significant abnormalities of liver
chemistry, creatinine, or electrolytes were observed.
Nine patients developed detectable HACAs by 7 weeks
of follow-up.
Pharmacokinetics
Maximum plasma concentrations were observed after the
intravenous bolus with subsequent decline in an apparently bi-exponential manner (Figure 3 ). Median Cmax
(0.69, 1.52, 2.13, 3.0, 10.1 mg/mL) and AUClast values
increased in nearly linear fashion over the five doses
studied. The median apparent terminal half-life (t1/2)
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Analysis of clot formation in minimally altered
whole blood
D.A. Morrow et al.
PROXIMATE-TIMI 27 results
685
Table 2 Incidence of bleeding
Dose Sunol-cH36 (mg/kg)
Enrolled, n
Major bleeding (patients)
Minor bleeding (patients)
Spontaneous
Provoked
Any minora
(Exact 95% CI)
0.03
0.06
0.08
0.10
0.30
8
0
4
0
4
0
7
0
3
0
1 (13)
2 (25)
2 (25)
(3, 65)
2 (50)
1 (25)
3 (75)
(19, 99)
2 (50)
0
2 (50)
(7, 93)
6 (86)
1 (14)
6 (86)
(44, 100)
3 (100)
1 (33)
3 (100)
(29, 100)
Data are shown as n (%).
CI, confidence intervals.
a
Individual patients may be classified as having both a spontaneous and provoked episode of bleeding. Provoked bleeds were those that occurred at
the site of iv insertion or as the result of minor trauma; all others were classified as spontaneous.
Discussion
Table 3 Site of minor bleeding
Dose Sunol-cH36 (mg/kg)
0.03
1a
0.08
0.10
0.30
1
4
2
3
1
3
1
1
1
1
1
1
1
2
1
Data are shown as the number of patients with each bleed location.
All bleeding sites are reported. Individual patients may have more
than one site of bleeding.
a
Evident pre-dose.
was 72.2 (25th, 75th: 28.4–72.5) h over the 7 weeks
covered by this study.
Effects on coagulation in whole blood
The potency of Sunol-cH36 was evaluated using the minimally altered whole blood assay.7 Whole blood was drawn
from five healthy subjects before and after administration of aspirin. Clot formation was initiated with
40 pM of recombinant human TF. As shown in Figure 4,
the addition of Sunol-cH36 at a final concentration of
13 nM (2 mg/mL), similar to the Cmax achieved with the
0.08 mg/kg infusion of Sunol-cH36 in PROXIMATE,
delayed clot formation. When added to the whole blood
assay in the absence of aspirin, Sunol-cH36 was associated with significant inhibition of thrombin generation
(Figure 5A, P , 0.03). Moreover, when tested in combination with aspirin, both the antithrombotic effect of
Sunol-cH36 measured by clotting time (Figure 4 ) and
the degree of inhibition of thrombin generation
(Figure 5B, P , 0.03) were more pronounced compared
with Sunol-cH36 alone.
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Spontaneous
Oral
Haematuria (gross)
Haematuria (micro)
Haemoccult
Other
Provoked
Iv insertion site
Cutaneous (trauma)
0.06
In this first completed trial of Sunol-cH36 in humans,
this monoclonal antibody against TF exhibited dosedependent anticoagulant effects. The safety profile from
this preliminary experience is encouraging for future
investigation. The observation that the bleeding episodes
were minor but clinically consistent with plateletmediated bleeding, including tongue haematomas
characteristic of disorders of primary haemostasis such
as Glanzmann’s thrombasthenia [absence of the glycoprotein (GP) IIb/IIIa receptor], is intriguing.
Human TF is a 263 amino acid transmembrane glycoprotein with an extracellular domain that binds to
Factor VIIa as well as its inactive zymogen, Factor
VII. This cell surface protein is expressed by endothelial
cells, monocytes, and smooth muscle cells and is upregulated in response to a variety of stimuli, including
vascular endothelial injury.3 Although TF is primarily a
membrane bound protein, it is detectable in circulating
plasma at low concentrations (0.0067 nM) in healthy
individuals and at modestly but detectably higher concentrations in patients presenting with unstable angina
(0.01 nM),8 as well as among patients with angiographic
no-reflow during percutaneous coronary intervention.9
TF is also found more abundantly in atherosclerotic
plaque from patients with unstable compared with
stable angina.10 In addition to initiating the extrinsic
and intrinsic (via IXa) coagulation pathways, TF has
been implicated in short- and long-term adverse
effects mediated through inflammatory pathways.11,12
Inhibitors of TF thus have the potential to modulate
both thrombotic and inflammatory effects of the
protein. Moreover, by virtue of the critical initiating
role of TF in the coagulation cascade, upstream of multiple pathways of forward and feedback amplification,
inhibitors of this protein may impede thrombin generation and activity more effectively than antithrombins
acting primarily downstream at the level of Factor Xa
or thrombin itself.13
The clinical observation from PROXIMATE-TIMI 27 of an
unanticipated, dose-related incidence of mucosal
686
D.A. Morrow et al.
Table 4 Adverse events (non-bleeding)
Dose Sunol-cH36 (mg/kg)
Serious
Relateda
Unrelatedb
Non-serious
Relateda
Unrelatedb
0.03
0.06
0.08
0.10
0.30
0
1
0
0
0
1
0
1
0
0
0
8
0
1
0
3
4
2
1
4
Data are shown as the number of events in each group.
a
Possibly, probably, or definitely.
b
None or unlikely. Individual patients may experience more than
one event. The three serious adverse events were recurrent subclavian stenosis, toe infection, and left arm discomfort 1 month
after receiving Sunol-cH36.
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Figure 3 Mean concentration of Sunol-cH36 (ng/mL) as a function of
time from dosing to 72 h post-dose.
Figure 2 Coagulation testing and platelet count categorized by dose
group. (A ) Median aPTT. (B ) Median platelet count. (C ) Median PT.
bleeding characteristic of disruption of primary haemostasis, points towards possible important effects of
Sunol-cH36 on platelets. Confirmatory measurements of
platelet function are not available from the PROXIMATE
trial; however, the results raise a plausible hypothesis
to be addressed in future investigations. Moreover, the
results of our testing in whole blood point towards possible synergistic effects between Sunol-cH36 and aspirin
on inhibition of clot formation and thrombin generation.
Interactions between the coagulation and platelet
pathways are multifaceted and central to maintaining
haemostasis. The links between these two pathways,
and the impact of therapies directed at one pathway or
the other have taken on particular importance as the
combined clinical use of more potent antithrombins and
antiplatelet agents has increased in the management of
acute coronary syndromes. The influence of platelets
on thrombin generation has attracted intense interest,
as agents which bind to the GP IIb/IIIa receptor on platelets have been shown to inhibit production of thrombin,
possibly by interrupting binding of PT to platelet
surface integrins and reducing the platelet surface area
acting as a platform for the pro-thrombinase
complex.5,14 In turn, thrombin promotes platelet activation and aggregation, both through binding of its byproduct fibrin to integrins on the platelet surface, and
PROXIMATE-TIMI 27 results
Figure 4 Delay of clot formation in minimally altered whole blood by
Sunol-cH36 and aspirin. Blood samples collected before and after administration of aspirin (ASA) for 2 days were pre-incubated with or without
Sunol-cH36. Clotting times were recorded in minutes. With the exception
of blood from one subject (Donor 3), ASA alone did not prolong the time
to clot formation. In contrast, a consistent pattern of prolonged time
to clot formation was evident with the addition of Sunol-cH36, with a
tendency towards greater effect after treatment with ASA.
as a direct agonist via the G-protein-coupled receptor
family known as protease-activated receptors (PARs),
and possibly GP Ib.15,16 Through G-protein-coupled signalling, thrombin activates phospholipase C, thereby
increasing the cytosolic concentration of Ca2þ, and inducing changes in platelet shape.15 As such, thrombin is
believed to play an important role in extension of the
platelet plug during primary haemostasis and to contribute to initiation of platelet activation. TF and/or the
TF:VIIa complex may also play a direct role in platelet
activation and/or aggregation.17,18 Specifically, TF has
been shown to act as a cofactor for the activation of
both PAR2 (endothelial cells) and PAR1 (platelets).17,19
Moreover, TF accumulation in the developing thrombus
through a mechanism involving P-selectin on the platelet
surface has been demonstrated.18,20 We postulate that
possibly through interruption of key TF–platelet interactions and/or ultra-potent inhibition of thrombin generation, Sunol-cH36 may modify their contributions to
platelet activation and aggregation, and thus act synergistically with aspirin to exert significant direct antiplatelet effects.
Notably, studies of other antithrombins have also
demonstrated inhibition of thrombin-induced platelet
activation.21 At least one direct antithrombin, bivalirudin, has been proposed to reduce or obviate the need
for GP IIb/IIIa antagonists in selected groups of
patients.22 Should future mechanistic studies in humans
support relevant antiplatelet actions of Sunol-cH36,
study of the agent as an alternative to combined use of
anticoagulant and antiplatelet drugs may be
appropriate.
There are limitations to this study. By virtue of the
small sample size, the confidence limits around our estimates of rates of minor bleeding are necessarily wide. By
design, the trial excluded patients receiving other antithrombins or antiplatelet therapy more potent than
aspirin. As such, study in larger trials and in combination
with such agents will be important in defining the safety
of Sunol-cH36 in the context of contemporary care for
patients with unstable coronary syndromes. Also important to the future study of this agent will be the assessment of biochemical measures of the clinical effect in
humans. As demonstrated in this study, standard
measures such as the PT using human TF are subject to
‘interference’ by binding of Sunol-cH36 to the test
reagent and modest elevation of the PT at concentrations
that manifest a clinical effect. In the absence of comprehensive testing of platelet function, our observations
must be viewed as hypothesis generating and as a basis
for additional investigation.
Conclusion
Administration of a chimaeric antibody against TF offers a
novel approach to anticoagulation, with the potential to
be more effective than agents acting principally at the
level of Factors Xa and IIa. We postulate that the
mucosal bleeding observed with this potent inhibitor of
thrombin generation may reflect antiplatelet effects
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Figure 5 Inhibition of thrombin generation in whole blood. The thrombin activity generated was measured by analysing the level of fibrinopeptide A at 0, 3, 6, and 9 min after initiation of clotting by TF. (A ) In
experiment 1, samples from subjects taking no anticoagulant or antiplatelet agents were incubated with or without Sunol-cH36. (B) In experiment 2, samples were drawn before and after aspirin for 2 days and
incubated with Sunol-cH36. The inhibition of thrombin generation by
Sunol-cH36 was more profound in the setting of pre-treatment with
aspirin (P , 0.03).
687
688
resulting from important networking between the coagulation cascade and platelet pathways that could prove
clinically relevant with this novel class of anticoagulants.
Acknowledgement
PROXIMATE-TIMI 27 was supported by Sunol Molecular.
Appendix
Enrolling centres (number enrolled)
Brigham and Women’s Hospital, Boston, MA, USA (4);
Investigators: David A. Morrow, Howard A. Cooper,
Benjamin S. Scirica.
Minneapolis Heart Instititute Foundation, Minneapolis,
MN, USA (5); Investigator: Timothy D. Henry.
University of Miami/Jackson Memorial Hospital,
Miami, FL, USA (7); Investigators: Raphael Sequeira,
S. Medrano.
SFBC International, Miami, FL, USA (10); Investigator:
Lawrence Galitz.
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