DEFINITION OF ACTIVATED THROMBOCYTE NUMBER WITH ANTIBODIES FOR ACTIVATED FIBRINOGEN AND P-SELECTIN IN PATIENTS WITH ESSENTIAL THROMBOCYTHEMIA AND ANTIAGGREGATION DRUG EFFECT
Abstract
Background. Essential thrombocythemia (ET) is a chronic myeloproliferative disease with a platelet count within the range of 400–2000 × 109/L. Higher percentage of platelets in the circulation of patients with ET express also activation markers on their membranes. Two of such markers are P-selectin and activated fibrinogen on platelet membranes. Because of frequent thrombembolic and also bleeding related complications, treatment of ET is mandatory. Patients whose platelet count is less than 1000 × 109/L and who did not suffer any thrombembolic complication during the course of the disease, are ussually treated with an antiaggregation drug, acetylsalicylic acid 100 mg/daily orally. Clopidogrel is an adenosyn-di-phosphate (ADP) receptor antagonist in platelets. There is no routine clinical data about clopidogrel treatment in the patients with ET and only sporadic case reports can be find in the literature.
Patients and methods. In our clinical study we compared antiaggregational effects of acetylsalicylic acid and clopidogrel, by measuring the P-selectin level and activated fibrinogen expression on platelet membranes.
There were 35 ET patients included, within the age range between 21 and 78 years and with platelet counts within 451–952 × 109/L. None of the patients did suffer any thrombembolic complication during the course of the disease. During the sequential 14 day periods, patients received acetylsalicylic acid 100 mg/daily orally, followed by clopidogrel 75 mg/daily orally and ultimativelly, together acetylsalicylic acid 100 mg/daily orally plus clopidogrel 75 mg/daily orally. After each fourteen days period the level of P-selectin and activated fibrinogen activated platelets were determined with monoclonal antibodies on flow cytometer. Statistical evaluation was calculated on the difference of average values between the two small, independent pair groups with the t-test.
Results. When the patients stopped with acetylsalicylic acid and began with clopidogrel, the percentage of P-selectin exposure on platelet membranes was statistically significant lower (t-value 1.99; p < 0.05). We also noticed statistically significant lower P-selectin exposure in the period, during which patients received acetylsalicylic acid plus clopidogrel, versus the period, during which they received acetylsalicylic acid only (t-value 2.11; p < 0.05). But there was no statistically significant difference in P-selectin exposure within the periods, during which patients received clopidogrel versus acetylsalicylic acid plus clopidogrel (t-value 0.19; p > 0.05). Percentages of activated fibrinogen exposures on platelet membranes were in all clinical study periods comparable and no statistically significant differences between them were noticed (for each pair-relation p > 0.05).
Conclusions. In patients with ET clopidogrel statistically significant (p < 0.05) lowers the percentage of P-selectin exposure on platelet membranes. Acetylsalicylic acid has no influence on P-selectin expression and also the combination of acetylsalicylic acid and clopidogrel, does not have higher P-selectin lowering efficacy, than clopidogrel itself. Acetylsalicylic acid and clopidogrel alone, nor in combination don’t have any influence on the expression level of activated fibrinogen on platelet membranes. To conclude, that clopidogrel may be an alternative to acetylsalicylic acid in patients with ET, who can not tolerate acetysalicylic acid because of it’s side-effects.
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References
Kutti J, Wadenvik H. Diagnostic and differential criteria of essential thrombocythemia and reactive thrombocytosis. Leuk Lymph 1996; 22: Suppl. 1: 41–6.
Frojmovic MM. Flow cytometric analysis of plateled activation and fibrinogen binding. Platelets 1996; 7: 9–21.
Griesshammer M, Beneke H, Nussbaumer B. Increased plateled surface expression of P-selectin and thrombospodin as markers of plateled activation in essential thrombocythaemia. Thromb Res 1999; 96: 191–6.
Cortelazzo S, Viero P, Finazzi G et al. Incidence and risk factors for thrombotic complications in a historical cohort of 100 patients with essential thrombocythemia. J Clin Oncol 1990; 8: 555–62.
Colombi M, Radaelli F, Zocchi L et al. Thrombotic and hemorrhagic complications in essential thrombocythemia. Cancer 1991; 67: 2926–30.
Van Genderen PJJ, Michielis JJ. Erythromelalgia: a patognomonic microvascular thrombotic complication in essential thrombocythemia and polycythemia vera. Semin Thromb Haemost 1997; 23: 357–64.
Tefferi A. Risk based management in essential thrombocythemia. Hematology; ASH education program book 1999: 172–7.
Podbregar M, Černelč P. Zapleti in zdravljenje bolnikov z ET. Zdrav Vestn 1999; 68: 353–6.
Savi P, Herbert JM, Pharmacology of ticlopidin and clopidogrel. Haematologica 2000; 85: 66–72.
Defreyn G, Gachet C, Savi P et al. Ticlopidin and clopidogrel selectively neutralize ADP inhibition of PGE1-activated plateled adenylate cyclase in rats and rabbits. Thromb Haemost 1991; 65: 186–90.
Storey RF, Judge HM, Wilcox RG. Inhibition of ADP-induced P-selectin expression and plateled leukocyte conjugate formation by clopidogrel and the P2Y12 receptor antagonist AR-C69931MX but not aspirin. Thromb Haemost 2002; 88: 488–94.
Kanapuli SP. Functional characterization of plateled ADP receptors. Platelets 1998; 9: 343–51.
Reimers H. Adenine nucleotides in blood platelets. In: Longenecker G ed. The platelets: physiology and pharmacology. Orlando: Academic Press, 1985: 85–98.
Weiss HJ. Inherited abnormalities of plateled granules and signal transduction. In: Colman RW, Hirsh J, Marder VJ, Salzman EW eds. Hemostasis and thrombosis. Basic principles and clinical practice. 3rd ed. Philadelphia: Lippincott, 1994: 673–84.
Macffarlane DE. Agonists and receptors: adenosine diphosphate. In: Holmsen H ed. Plateled responses and metabolism. Boca Raton CRC Press, 1987: 19–36.
Lanza F, Beretz A, Stierle A et al. Epinephrine potentiates human plateled activation but is not an aggregating agent. Am J Physiol 1988; 255: H1276– H1288.
Clementson KJ, Clementson JM, Proudfoot AE et al. Functional expression of CCR1, CCR3, CCR4 and CXCR4 chemokine receptors on human platelets. Blood 2000; 96: 4046–54.
Savi P, Artcanuthurry V, Bornia J et al. Effect of clopidogrel treatment on ADPinduced phosphorylation in rats platelets. Br J Haematol 1997; 97: 185–91.
Geiger J, Brich J, Honig-Liedl P et al. Specific impairment of human plateled P2Y(AC) ADP receptor mediated signalling by the antiplateled drug clopidogrel. Arterioscler Thromb Vasc Biol 1999; 19: 2007–11.
Mills DC, Puri R, Hu CJ et al. Clopidogrel inhibits the binding of ADP analogues to the receptor mediating inhibition of plateled adenylate cyclase. Arterioscler Thromb 1992; 12: 430–6.
Furie B, Furie BC, Flaumenhaft R. A journey with plateled P-selectin: the molecular basis of granule secretion, signalling and cell adhesion. Thromb Haemost 2001; 86: 214–21.
Ruf A, Patscheke H. Flow cytometric detection of activated platelets: comparison of determining shape change, fibrinogen binding and P-selectin expression. Semin Thromb Haemost 1995; 21: 146–51.
The clopidogrel in unstable angina to prevent recurrent events trial investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345: 494–502.
Harding SA, Boon NA, Flapan AD. Antiplateled treatment in unstable angina: aspirin, clopidogrel, glycoprotein IIb/IIIa antagonist or all three? Heart 2002; 88: 11–4.
Bertrand ME, Rupprecht HJ, Urban P et al. Double blind study of the safety of clopidogrel with and without a loading dose in combination with aspirin compared with ticlopidine in combination with aspirin after coronary stenting (CLASSICS). Circulation 2000; 102: 624–9.
McGregor JL. Adhesion molecules and platelets. Educational sessions of the second EHA 1996; 134–8.
Azar RR, Waters DD. The inflamatory etiology of unstable angina pectoris. Am Heart J 1996; 132: 1106–16.
Klinkhardt U, Bauersachs R, Adams J et al. Clopidogrel but not aspirin reduces P-selectin expression a formation of plateled-leukocyte aggregates in patients with atherosclerotic vascular disease. Clin Pharm Ther 2003; 73: 232–41.
Jaremo P, Lindahl TL, Fransson SG et al. Individual variations of plateled inhibition after loading doses of clopidogrel. J Intern Med 2002; 252: 233–8.
Žontar D, Černelč P. Uporaba pretočne citometrije v klinični hematologiji. Zdrav Vestn 1993; 62: 393–5.
Mesa RA, Silverstein MN, Jacobsen SJ et al. Population based incidence and survival figures in essential thrombocythemia and agnogenic myeloid metaplasia: an Olmsted County study; 1976–1995. Am J Hematol 1996; 61: 10–5.
Modic M. Kronične mieloproliferativne bolezni. In: Kocijančič A, Mrevlje F eds. Interna medicina. Ljubljana: EWO, 1998: 1088–94.
Laszlo J. Myeloproliferative disorders (MPD): myelofibrosis, myelosclerosis, extramedullary hematopoesis, undifferentiated MPD and hemorrhagic thrombocythemia. Semin Hematol 1975; 12: 409–32.
Berlin NI. Diagnosis and classification of the polycythemias. Semin Hematol 1975; 12: 339–51.
Michelis JJ, Juvonen E. Proposal for revised diagnostic criteria of essential thrombocythemia and polycythemia vera by the Thrombocythemia Vera Study Group. Semin Thromb Hemost 1997; 23: 339–47.
Schafer AI. Bleeding and thrombosis in myeloproliferative disorders. Blood 1984; 64: 1–10.
Schafer AI. Essential thrombocythemia. In: Beutler E, Lichtman MA Coller BS, Kipps TJ eds. Williams Hematology. New York: McGraw Hill 2001: 1541–49.
Cortelazzo S, Finazzi G, Ruggeri M et al. Hydroxyurea in the treatment of patients with essential thrombocythemia at high risk thrombosis: a prospective randomised trial. N Eng J Med 1995; 332: 1132–6.
Lofvenberg E, Wahlin A. Management of polycythemia vera, essential thrombocythemia and myelofibrosis with hydroxyurea. Eur J Haematol 1988; 41: 375–81.
Solberg LA, Tefferi A, Oles A et al. The effects of anagrelide on human megakaryopoesis. Br J Haematol 1997; 99: 174–9.
Elliot MA, Tefferi A. Interpheron alpha therapy in polycythemia vera and essential thrombocythemia. Semin Thromb Hemost 1997; 23: 463–71.
Van Genderen PJJ, Michelis JJ Van Stirk R et al. Plateled consumption in thrombocythemia complicated by erythromelalgia: reversal by aspirin. Thromb Hemost 1995; 73: 210–5.
Michelis JJ. Normal life expectancy and thrombosis free survival in aspirin treated essential thrombocythemia. Clin Appl Thromb/Hemost 1999; 23: 335–8.
Villmow T, Kemkes-Matthes B, Matzdorff AC. Markers of plateled activation and plateled-leukocyte interaction in patients with myeloproliferative syndromes. Thromb Res 2002; 108: 139–45.
Gruppo Italiano Studio Polycythemia Vera: Low dose aspirin in polycythemia vera: a pilot study. Br J Haematol 1997; 97: 453–7.
Willoughby S, Pearson TC. The use of aspirin in polycythaemia vera and primary thrombocythaemia. Blood Rev 1998; 12: 12–22.
Klinzing P, Markert UR, Liesaus K et al. Case report: successful pregnancy and delivery after myocardial infarction and essential thrombocythemia treated with clopidogrel. Clin Exp Obstet Gynecol 2001; 28: 215–6.
Caprie Steering Committee. A randomiced, blinded trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). Lancet 1996; 348: 1329–39.
Gurbel PA, Cummings CC, Bell CR et al. Onset and extent of plateled inhibition by clopidogrel loading in patients undergoing elective coronary stenting: The Plavix Ň reduction of new thrombus occurrence (PRONTO) trial. Am Heart J 2003; 145: 239–47.
McEver RP. Adhesive interactions of leukocytes, platelets and the vessel wall during hemostasis and inflammation. Thromb Haemost 2001; 86: 746–56.
Burger PC, Wagner DD. Plateled P-selectin facilitates atherosclerotic lesion developement. Blood 2003; 101: 2661–7.
Vestweber D, Blanks JE. Mechanisms that regulate the functions of the selectins and their ligands. Physiol Rev 1999; 79: 181–213.
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