Comparison of different prothrombin complex concentrates - in vitro and in vivo studies

doi:10.1016/0049-3848(90)90340-I

Thrombosis Research

Volume 60, Issue 1, 1 October 1990, Pages 63-70

https://doi.org/10.1016/0049-3848(90)90340-I Get rights and content

Abstract

The potency and tests for thrombogenicity were studied prospectively in 7 different (two lots of each brand, A - G) prothrombin complex concentrates (PCC). Human albumine (H) and a factor IX concentrate (I), served as controls. The potency of coagulation factors and inhibitors varied considerably. Two brands (E, F) contained no protein S, additionally one brand contained no protein C. Two preparations exhibited high amidolytic activities, especially towards the thrombin-sensitive chromogenic substrate S-2238, in vitro. These activities could be quenched in part by the addition of hirudin or antithrombin III. The heparin and antithrombin III content of the PCCs was significantly different, and, after addition of antithrombin III an increase of thrombin-antithrombin III complexes in 2 preparations (B, D) was observed in vitro. Additionally, three brands (B, D, F) caused more severe cardio-pulmonary reactions in rabbits, associated with an increase of fibrin split products for brands B and D. We conclude that the use of these preparations in patients, in whom an acquired protein C or S defect, or a hypercoagulable state, can be suspected, cannot be recommended.

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Cited by (31)

Detection and differentiation of active and inactive isoforms of coagulation factors II, VII, IX, and X in prothrombin complex concentrate by mass spectrometry
2022, Journal of Pharmaceutical and Biomedical Analysis
Citation Excerpt :
Despite of their well-known benefits in several clinical situations, they can carry a small but important risk for severe complications, such as unwanted thromboembolic events. One of the major reported reasons for those complications is the undesired transformation of the coagulation factor zymogens into an active state [1–4]. The presence of activated states defines the quality of coagulation factor preparations with important indications, like the antihaemophilic factor VIII (FVIII; hemophilia A treatment), the Christmas factor (FIX; hemophilia B treatment) and PCCs (vitamin K antagonist reversal and restoration of the international normalized ratio) [5–7].
Prothrombin complex concentrates (PCCs) are plasma products containing a mixture of four inactive/proactive coagulation factors. The activated forms of human coagulation factors, like Thrombin (FIIa), Convertin (FVIIa), activated Christmas factor (FIXa) and the activated Stuart-Prower factor (FXa), are impurities in PCCs. Until now no valid assay exists to differentiate the non activated proform (inactive) from active coagulation factor isoforms in PCCs in one measurement. Therefore, the aim of this study was to establish a mass spectrometry (LC-MS/MS)-based assay to address this issue in the ready to use medicinal product.
Bottom-up proteomics combining double digestion (Glu-C & Lys-C) and LC-MS/MS, was used to differentiate the inactive and active forms of the coagulation factors Prothrombin (FII), Proconvertin (FVII), Christmas factor (FIX) and the Stuart-Prower-factor (FX) in PCCs.
A targeted pseudo-multiple reaction monitoring (pMRM-LC-MS/MS)-assay was developed for the specific detection of four different coagulation factors in PCCs. Proteotypic peptides for the inactive/active isoforms (zymogen) of the four coagulation factors were identified and validated by the investigation of six investigational and one commercially available PCCs.
In conclusion, the semi-quantitative determination and the distinction between the active and the inactive isoform of the respective coagulation factors were possible in one liquid chromatography tandem mass spectrometry (LC-MS/MS) run.
Heparin supplement counteracts the prohemostatic effect of prothrombin complex concentrate and factor IX concentrate: An in vitro evaluation
2016, Thrombosis Research
Citation Excerpt :
Thrombogenicity has been attributed to the presence of procoagulant phospholipid contaminant and activated coagulation factors in the product [9–13]. Thromboembolic complications associated with PCC treatment may also be related to zymogen overload in the circulation, particularly that of prothrombin, and to relatively low levels of the anticoagulant proteins C and S [12, 14]. To minimize thrombogenicity, heparin and antithrombin were advised as supplements in PCC together with a balanced clotting factor composition mimicking relative in vivo molar ratios [15].
Coagulation factor concentrates like factor IX (FIX) and prothrombin complex concentrate (PCC) can contain anticoagulant substances that may hamper their procoagulant effectiveness in the treatment of hemophilia B or reversal of oral anticoagulation, as well as the laboratory assessment thereof. The aim of the present study was to evaluate the influence of anticoagulant heparin supplement on the prohemostatic potential of different PCCs and FIX concentrates.
Prohemostatic potential was evaluated in vitro employing PT/aPTT, thrombography (TGA) and thromboelastography (TEG) with FIX deficient plasma, vitamin K antagonist (VKA)-anticoagulated plasma and plasma anticoagulated with rivaroxaban.
Most PCCs contained heparin, while heparin was detected in 1 out of 4 examined FIX concentrates. All heparin-containing clotting factor concentrates showed severely hampered prohemostatic effects when therapeutic doses were added to anticoagulated plasmas. Upon heparin removal, comparable prohemostatic effects were observed. Of importance is the notion that the anticoagulant effect of heparin was enhanced by rivaroxaban, resulting in a 7 fold increased PT sensitivity towards heparin in the presence of 500 μg/L rivaroxaban.
Compositional differences between clotting factor concentrates should be taken into account. Therapeutic levels of heparin may be co-infused when treating emergency bleeds with high prohemostatic drug doses, particularly those recommended in the reversal of non-VKA anticoagulants such as rivaroxaban by PCC. Given the relative short half-life of heparin compared to vitamin K-dependent clotting factors, an anticoagulant heparin effect shortly after concentrate infusion should be considered clinically and while interpreting laboratory coagulation parameters.
Thrombogenicity of prothrombin complex concentrates
1999, Thrombosis Research
Thrombogenicity of factor IX complex or prothrombin complex concentrates (PCC) is a well-acknowledged problem. The exact incidence is unknown but has decreased with the improvement of the quality of coagulation factor concentrates and a more judicious use of these products. The clinical spectrum of thrombogenicity ranges from superficial thrombophlebitis, deep-vein thrombosis and pulmonary embolism, and arterial thrombosis to disseminated intravascular coagulation. Several risk factors have been identified: (a) predisposing clinical factors (underlying disease and clinical condition), (b) therapy factors (dosing, concomitant therapy and drug interactions), and (c) quality of the PCC used. It is generally assumed that the risk of thromboembolic adverse effects is greater in patients with acquired disorders of hemostasis than in patients with inherited coagulation factor deficiencies. In hemophilia B, clinical conditions with an increased risk include large muscle hematomas, immobilization, surgery (especially orthopedic surgery), and liver disease. In acquired disorders of hemostasis, a prethrombotic state can be assumed in all patients where an indication for PCC concentrates is considered. Liver disease and/or antithrombin deficiency are considered as major risk factors. Therapy factors with an increased risk include large, repetitive doses of PCC. It is assumed that heparin and, in the case of antithrombin deficiency, antithrombin substitution decrease the incidence of thromboembolic adverse effects. Heparin neutralisation with protamine and aprotinin therapy may be additional risk factors. The declining incidence and the recent cluster of fatal thromboembolic adverse events in Germany with one brand of PCC is strong evidence for the crucial role of the quality of PCC in the occurrence of thromboembolic adverse effects.
Replacement of coagulation factors in liver or multiple organ dysfunction
1999, Thrombosis Research
Due to the complexity of alterations in hemostasis, replacement therapy in multiple organ dysfunction is a domain for nonspecific replacement therapy by means of fresh frozen plasma. Refined methods of virus inactivation as well as the consequent declaration of the major components of plasma derivatives have led to an increasing use of high-purity blood coagulation factor concentrates. Furthermore, the problem of activated factors and their inherent thrombogenic effect is meanwhile considerably attenuated. In the future, the availability of high-purity blood coagulation factor concentrates with a defined amount and quality of their factor content will enable a specific replacement therapy in single or multiple organ dysfunction in addition to unspecific replacement therapy by fresh frozen plasma.
Rational, high quality laboratory monitoring before, during, and after infusion of prothrombin complex concentrates
1999, Thrombosis Research
Prothrombin complex concentrates (PCCs) have been used for over thirty years to treat or prevent bleeding due to hemophilia B, vitamin K deficiency, warfarin overdose, liver disease, or deficiency of one of the prothrombin complex factors. This article tries to answer the questions of which profile of laboratory assays is required for the establishment of the diagnosis; what are indications of replacement therapy with PCCs; how to monitor the therapeutic effect; and how to monitor a possible prethrombotic state after PCC infusion. After proposing basic, standard, and optimal profiles of hemostaseological assays, the basic principal characteristics of a quality management satisfying the requirements of good laboratory practice are discussed.
Production and composition of prothrombin complex concentrates: Correlation between composition and therapeutic efficiency
1999, Thrombosis Research

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PaperComparison of different prothrombin complex concentrates - in vitro and in vivo studies

Abstract

Lancet

Lancet

Thromb Res

Thromb Res

Blood

Blood

Homozygoter Säugling in einer Sippe mit erblichem Protein C-Mangel

Klin Wschr

Ways to reduce the risk of transmission of viral infections by plasma and plasma products

Single-dose pharmacokinetics of factor IX evaluated by model-independent methods

Eur J Haematol

In vivo recovery and half-life of a steam-treated factor IX concentrate in haemophilia B patients

Blut

Factor VII half-life after transfusion of a steam-treated prothrombin complex concentrate in a patient with homozygous factor VII deficiency (letter)

Vox Sang

In vitro spontaneous thrombin generation in human factor-IX concentrates

Br J Haematol

Paper
Comparison of different prothrombin complex concentrates - in vitro and in vivo studies