Hemostasis

Presenter-
Dr. Sonu
 Normal hemostasis is a consequence
of tightly regulated processes that
maintain blood in a fluid state in
normal vessels, yet also permit the
rapid formation of a hemostatic clot
at the site of a vascular injury.
 NORMAL HEMOSTASIS
After initial injury there is a
brief period of arteriolar
vasoconstriction mediated
by reflex neurogenic
mechanisms and
augmented by the local
secretion of factors such as
endothelin (a potent
endothelium-derived
vasoconstrictor). The effect
is transient, however, and
bleeding would resume if
not for activation of the
platelet and coagulation After vascular injury local
systems. neurohumoral factors induce a
transient vasoconstriction
 Endothelial injury exposes
highly thrombogenic
subendothelial
extracellular matrix (ECM),
facilitating platelet
adherence and activation.
Activation of platelets
results in a dramatic shape
change (from small
rounded discs to flat plates
with markedly increased
surface area), as well as Platelets bind via glycoprotein Ib
the release of secretory (GpIb) receptors to von Willebrand
granules. Within minutes factor (vWF) on exposed
the secreted products extracellular matrix (ECM) and are
activated, undergoing a shape
recruit additional platelets change and granule release.
(aggregation) to form a Released adenosine diphosphate
hemostatic plug; this (ADP) and thromboxane A2 (TxA2)
process is referred to as induce additional platelet
primary hemostasis. aggregation through platelet GpIIb-
IIIa receptor binding to fibrinogen,
 Tissue factor is also exposed
at the site of injury. Also
known as factor III and
thromboplastin, tissue factor
is a membrane-bound
procoagulant glycoprotein
synthesized by endothelial
cells. It acts in conjunction
with factor VII as the major
in vivo initiator of the
coagulation cascade, Local activation of the
eventually culminating in coagulation cascade
(involving tissue factor and
thrombin generation. platelet phospholipids)
Thrombin cleaves circulating results in fibrin
fibrinogen into insoluble polymerization, cementing
the platelets into a definitive
fibrin, creating a fibrin secondary hemostatic plug
meshwork, and also induces
additional platelet
 Polymerized fibrin and
platelet aggregates
form a solid,
permanent plug to
prevent any further
hemorrhage. At this
stage, counter-
regulatory
mechanisms (e.g.,
tissue plasminogen Counter-regulatory mechanisms,
activator, t-PA) are set mediated by tissue plasminogen
into motion to limit activator (t-PA, a fibrinolytic product) and
the hemostatic plug thrombomodulin, confine the hemostatic
process to the site of injury
to the site of injury.
 Role of Endothelium
Endothelial cells are key players in the regulation
of homeostasis, as the balance between the anti-
and prothrombotic activities of endothelium
determines whether thrombus formation,
propagation, or dissolution occurs.
Normally, endothelial cells exhibit antiplatelet,
anticoagulant, and fibrinolytic properties;
however, after injury or activation they acquire
numerous procoagulant activities.
Besides trauma, endothelium can be activated by
infectious agents, hemodynamic forces, plasma
mediators, and cytokines.
 Anti- and procoagulant activities of endothelium. NO, nitric oxide; PGI 2,
prostacyclin; t-PA, tissue plasminogen activator; vWF, von Willebrand
factor. The thrombin receptor is also called a protease-activated receptor
(PAR).
 Antithrombotic Properties
Under normal circumstances endothelial cells
actively prevent thrombosis by producing factors
that variously block platelet adhesion and
aggregation, inhibit coagulation, and lyse clots.
 Antiplatelet effects
Intact endothelium prevents platelets (and
plasma coagulation factors) from engaging the
highly thrombogenic subendothelial ECM.
Nonactivated platelets do not adhere to
endothelial cells, and even if platelets are
activated, prostacyclin (PGI2) and nitric oxide
produced by the endothelial cells impede platelet
adhesion.
Both of these mediators are potent vasodilators
and inhibitors of platelet aggregation; their
synthesis by the endothelium is stimulated by
several factors produced during coagulation (e.g.,
thrombin and cytokines).
Endothelial cells also elaborate adenosine
 Anticoagulant effects
These effects are mediated by endothelial membrane-
associated heparin-like molecules, thrombomodulin, and tissue
factor pathway inhibitor.
The heparin-like molecules act indirectly; they are cofactors
that greatly enhance the inactivation of thrombin and several
other coagulation factors by the plasma protein antithrombin
III.
Thrombomodulin binds to thrombin and converts it from a
procoagulant into an anticoagulant via its ability to activate
protein C, which inhibits clotting by inactivating factors Va and
VIIIa.
Endothelium also produces protein S, a co-factor for protein C,
and tissue factor pathway inhibitor (TFPI), a cell surface
protein that directly inhibits tissue factorfactor VIIa and factor
Xa activities.
 Fibrinolytic effects
Endothelial cells synthesize tissue-type
plasminogen activator (t-PA), a protease that
cleaves plasminogen to form plasmin; plasmin, in
turn, cleaves fibrin to degrade thrombi.
 Prothrombotic Properties
While normal endothelial cells limit clotting,
trauma and inflammation of endothelial cells
induce a prothrombotic state that alters the
activities of platelets, coagulation proteins, and
the fibrinolytic system.
 Platelet effects
Endothelial injury allows platelets to contact the
underlying extracellular matrix; subsequent
adhesion occurs through interactions with von
Willebrand factor (vWF), which is a product of
normal endothelial cells and an essential cofactor
for platelet binding to matrix elements.
 Procoagulant effects
In response to cytokines (e.g., tumor necrosis
factor [TNF] or interleukin-1 [IL-1]) or bacterial
endotoxin, endothelial cells synthesize tissue
factor, the major activator of the extrinsic clotting
cascade.
In addition, activated endothelial cells augment
the catalytic function of activated coagulation
factors IXa and Xa.
 Antifibrinolytic effects
Endothelial cells secrete inhibitors of plasminogen
activator (PAIs), which limit fibrinolysis and tend
to favor thrombosis.
Platelet adhesion and aggregation. Von Willebrand factor functions as an adhesion bridge between
subendothelial collagen and the glycoprotein Ib (GpIb) platelet receptor. Aggregation is accomplished
by fibrinogen bridging GpIIb-IIIa receptors on different platelets. Congenital deficiencies in the various
receptors or bridging molecules lead to the diseases indicated in the colored boxes. ADP, adenosine
diphosphate.
 In summary, intact, nonactivated endothelial cells
inhibit platelet adhesion and blood clotting.
Endothelial injury or activation, however, results
in a procoagulant phenotype that enhances
thrombus formation.
 Role of Platelets
Platelets are disc-shaped, anucleate cell fragments
that are shed from megakaryocytes in the bone
marrow into the blood stream.
They play a critical role in normal hemostasis, by
forming the hemostatic plug that initially seals
vascular defects, and by providing a surface that
recruits and concentrates activated coagulation
factors.
Their function depends on several glycoprotein
receptors, a contractile cytoskeleton, and two
types of cytoplasmic granules.
-Granules have the adhesion molecule P-selectin
on their membranes and contain fibrinogen,
fibronectin, factors V and VIII, platelet factor 4 (a
heparin-binding chemokine), platelet-derived
 Dense (or ) granules contain ADP and ATP,
ionized calcium, histamine, serotonin, and
epinephrine.
After vascular injury, platelets encounter ECM
constituents such as collagen and the adhesive
glycoprotein vWF.
On contact with these proteins, platelets undergo:
(1) adhesion and shape change,
(2) secretion (release reaction), and
(3) aggregation.
 Platelet adhesion to ECM is mediated
largely via interactions with vWF, which acts as a
bridge between platelet surface receptors (e.g.,
glycoprotein Ib [GpIb]) and exposed collagen.
Although platelets can also adhere to other
components of the ECM (e.g., fibronectin), vWF-
GpIb associations are necessary to overcome the
high shear forces of flowing blood. Reflecting the
importance of these interactions, genetic
deficiencies of vWF (von Willebrand disease; ) or its
receptor (Bernard-Soulier syndrome) result in
bleeding disorders.
 Secretion (release reaction) of both
granule types occurs soon after adhesion. Various
agonists can bind platelet surface receptors and
initiate an intracellular protein phosphorylation
cascade ultimately leading to degranulation.
Release of the contents of dense-bodies is
especially important, since calcium is required in
the coagulation cascade, and ADP is a potent
activator of platelet aggregation. ADP also begets
additional ADP release, amplifying the
aggregation process. Finally, platelet activation
leads to the appearance of negatively charged
phospholipids (particularly phosphatidylserine) on
their surfaces. These phospholipids bind calcium
and serve as critical nucleation sites for the
assembly of complexes containing the various
 Platelet aggregation follows adhesion
and granule release. In addition to ADP, the
vasoconstrictor thromboxane A2 is an important
platelet-derived stimulus that amplifies platelet
aggregation, which leads to the formation of the
primary hemostatic plug. Although this initial
wave of aggregation is reversible, concurrent
activation of the coagulation cascade generates
thrombin, which stabilizes the platelet plug via
two mechanisms.
First, thrombin binds to a protease-activated
receptor on the platelet membrane and in concert
with ADP and TxA2 causes further platelet
aggregation. This is followed by platelet
contraction, an event that is dependent on the
platelet cytoskeleton that creates an irreversibly
fused mass of platelets, which constitutes the
definitive secondary hemostatic plug.
 Noncleaved fibrinogen is also an important
component of platelet aggregation. Platelet
activation by ADP triggers a conformational
change in the platelet GpIIb-IIIa receptors that
induces binding to fibrinogen, a large protein that
forms bridging interactions between platelets that
promote platelet aggregation. Predictably,
inherited deficiency of GpIIb-IIIa results in a
bleeding disorder (Glanzmann thrombasthenia).
 Red cells and leukocytes are also found in
hemostatic plugs. Leukocytes adhere to platelets
via P-selectin and to endothelium using several
adhesion receptors ; they contribute to the
inflammation that accompanies thrombosis.
Thrombin also drives thrombus-associated
inflammation by directly stimulating neutrophil
and monocyte adhesion and by generating
chemotactic fibrin split products during fibrinogen
cleavage.
 Platelet-Endothelial Cell Interactions
The interplay of platelets and endothelium has a profound impact
on clot formation. The endothelial cell-derived prostaglandin PGI 2
(prostacyclin) inhibits platelet aggregation and is a potent
vasodilator; conversely, the platelet-derived prostaglandin TxA 2
activates platelet aggregation and is a vasoconstrictor. Effects
mediated by PGI2 and TxA2 are exquisitely balanced to effectively
modulate platelet and vascular wall function: at baseline, platelet
aggregation is prevented, whereas endothelial injury promotes
hemostatic plug formation. The clinical utility of aspirin (an
irreversible cyclooxygenase inhibitor) in persons at risk for coronary
thrombosis resides in its ability to permanently block platelet TxA 2
synthesis. Although endothelial PGI2 production is also inhibited by
aspirin, endothelial cells can resynthesize active cyclooxygenase
and thereby overcome the blockade. In a manner similar to PGI 2,
endothelial-derived nitric oxide also acts as a vasodilator and
inhibitor of platelet aggregation.
 Coagulation Cascade
The coagulation cascade is the third arm of the
hemostatic process.
The coagulation cascade is essentially an
amplifying series of enzymatic conversions; each
step proteolytically cleaves an inactive
proenzyme into an activated enzyme, culminating
in thrombin formation. Thrombin is the most
important coagulation factor, and indeed can act
at numerous stages in the process. At the
conclusion of the proteolytic cascade, thrombin
converts the soluble plasma protein fibrinogen
into fibrin monomers that polymerize into an
insoluble gel. The fibrin gel encases platelets and
other circulating cells in the definitive secondary
hemostatic plug, and the fibrin polymers are
 Each reaction in the pathway results from the
assembly of a complex composed of an enzyme
(activated coagulation factor), a substrate
(proenzyme form of coagulation factor), and a
cofactor (reaction accelerator). These
components are typically assembled on a
phospholipid surface and held together by
calcium ions (as an aside, the clotting of blood is
prevented by the presence of calcium chelators).
The requirement that coagulation factors be
brought close together ensures that clotting is
normally localized to the surface of activated
platelets or endothelium, it can be likened to a
dance of complexes, in which coagulation
factors are passed successfully from one partner
to the next. Parenthetically, the binding of
coagulation factors II, XII, IX, and X to calcium
depends on the addition of -carboxyl groups to
Schematic illustration of the conversion of factor X to factor Xa via
the extrinsic pathway, which in turn converts factor II (prothrombin)
to factor IIa (thrombin). The initial reaction complex consists of a
proteolytic enzyme (factor VIIa), a substrate (factor X), and a
reaction accelerator (tissue factor), all assembled on a platelet
phospholipid surface. Calcium ions hold the assembled components
together and are essential for the reaction. Activated factor Xa
becomes the protease for the second adjacent complex in the
coagulation cascade, converting prothrombin substrate (II) to
 Blood coagulation is traditionally classified into
extrinsic and intrinsic pathways that converge on
the activation of factor X . The extrinsic pathway
was so designated because it required the
addition of an exogenous trigger (originally
provided by tissue extracts); the intrinsic pathway
only required exposing factor XII (Hageman
factor) to thrombogenic surfaces.
The extrinsic pathway is the most physiologically
relevant pathway for coagulation occurring when
vascular damage has occurred; it is activated by
tissue factor (also known as thromboplastin or
factor III), a membrane-bound lipoprotein
expressed at sites of injury.
 Clinical laboratories assess the function of the two arms of the
coagulation pathway through two standard assays:
prothrombin time (PT) and partial thromboplastin time (PTT).
The PT assay assesses the function of the proteins in the
extrinsic pathway (factors VII, X, II, V, and fibrinogen). This is
accomplished by adding tissue factor and phospholipids to
citrated plasma (sodium citrate chelates calcium and prevents
spontaneous clotting). Coagulation is initiated by the addition
of exogenous calcium and the time for a fibrin clot to form is
recorded.
The partial thromboplastin time (PTT) screens for the function
of the proteins in the intrinsic pathway (factors XII, XI, IX, VIII,
X, V, II, and fibrinogen). In this assay, clotting is initiated
through the addition of negative charged particles (e.g.,
ground glass), which activates factor XII (Hageman factor),
phospholipids, and calcium, and the time to fibrin clot
formation is recorded.
 In addition to catalyzing the final steps in the
coagulation cascade, thrombin exerts a wide
variety of proinflammatory effects. Most of these
effects of thrombin occur through its activation of
a family of protease activated receptors (PARs)
that belong to the seven-transmembrane G
proteincoupled receptor family. PARs are
expressed on endothelium, monocytes, dendritic
cells, T lymphocytes, and other cell types.
Receptor activation is initiated by cleavage of the
extracellular end of the PAR; this generates a
tethered peptide that binds to the clipped
receptor, causing a conformational change that
triggers signaling.
Role of thrombin in hemostasis and cellular activation. Thrombin
plays a critical role in generating cross-linked fibrin (by cleaving
fibrinogen to fibrin, and by activating factor XIII), as well as
activating several other coagulation factors. Through protease-
activated receptors (PARs), thrombin also modulates several cellular
activities. It directly induces platelet aggregation and TxA 2
production, and activates ECs to express adhesion molecules, and a
variety of fibrinolytic (t-PA), vasoactive (NO, PGI2), and cytokine
mediators (e.g., PDGF). Thrombin also directly activates leukocytes.
ECM, extracellular matrix; NO, nitric oxide; PDGF, platelet-derived
growth factor; PGI2, prostacyclin; TxA2, thromboxane A2; t-PA, tissue
 Once activated, the coagulation cascade must be
restricted to the site of vascular injury to prevent
runaway clotting of the entire vascular tree.
Besides restricting factor activation to sites of
exposed phospholipids, three categories of
endogenous anticoagulants also control clotting.
(1) Antithrombins (e.g., antithrombin III) inhibit the
activity of thrombin and other serine proteases,
including factors IXa, Xa, XIa, and XIIa.
Antithrombin III is activated by binding to
heparin-like molecules on endothelial cells; hence
the clinical usefulness of administering heparin to
minimize thrombosis.
(2) Proteins C and S are vitamin Kdependent
proteins that act in a complex that proteolytically
inactivates factors Va and VIIIa.
(3) TFPI is a protein produced by endothelium (and
Activation of the coagulation cascade also sets into
motion a fibrinolytic cascade that moderates the size
of the ultimate clot. Fibrinolysis is largely
accomplished through the enzymatic activity of
plasmin, which breaks down fibrin and interferes with
its polymerization. The resulting fibrin split products
(FSPs or fibrin degradation products) can also act as
weak anticoagulants. Elevated levels of FSPs (most
notably fibrin-derived D-dimers) can be used in
diagnosing abnormal thrombotic states including
disseminated intravascular coagulation (DIC), deep
venous thrombosis, or pulmonary embolism. Plasmin
is generated by enzymatic catabolism of the inactive
circulating precursor plasminogen, either by a factor
XIIdependent pathway or by plasminogen activators.
 The most important of the PAs is t-PA; it is synthesized
principally by endothelium and is most active when
bound to fibrin. The affinity for fibrin makes t-PA a
useful therapeutic agent, since it largely confines
fibrinolytic activity to sites of recent thrombosis.
Urokinase-like PA (u-PA) is another PA present in
plasma and in various tissues; it can activate plasmin
in the fluid phase. Finally, plasminogen can be cleaved
to plasmin by the bacterial enzyme streptokinase, an
activity that may be clinically significant in certain
bacterial infections. As with any potent regulator,
plasmin activity is tightly restricted. To prevent excess
plasmin from lysing thrombi indiscriminately
elsewhere in the body, free plasmin is rapidly
inactivated by 2-plasmin inhibitor.
The fibrinolytic system, illustrating various plasminogen activators
and inhibitors
 Endothelial cells also fine-tune the
coagulation/anticoagulation balance by releasing
plasminogen activator inhibitor (PAI); it blocks
fibrinolysis by inhibiting t-PA binding to fibrin and
confers an overall procoagulant effect . PAI
production is increased by thrombin as well as
certain cytokines, and probably plays a role in the
intravascular thrombosis accompanying severe
inflammation.
 Anticoagulants

Hirudo medicinalis produce Hirudin that inhibits Thrombin

 Although tissue breakdown and platelets
destruction are normal events in the absence of
trauma, intravascular clotting does not usually
occur because:
- the amounts of procoagulants released are
very small
- natural anticoagulants are present
(Antithrombin III, Heparin, Antithromboplastin,
Protein C and S)
 Natural anticoagulants
Antithrombin III inhibits factor X and thrombin

Heparin from basophils and mast cells potentiates

effects of antithrombin III (together they inhibit
IX, X, XI, XII and thrombin)

Antithromboplastin (inhibits tissue factors

tissue thromboplastins)

Protein C and S activated by thrombin; degrade

factor Va and VIIIa
 HEPARIN
McLean, a medical student, discovered in 1916
that liver contains a powerful anticoagulant.
Howell and Holt (1918) named it 'heparin'
because it was obtained from liver.
However, it could be used clinically only in 1937
when sufficient degree of purification was
achieved.
 Heparin is a powerful and instantaneously acting
anticoagulant, effective both in vivo and in vitro.
It acts indirectly by activating plasma
antithrombin III (AT III, a serine proteinase
inhibitor) and may be other similar cofactors.
The heparin-AT III complex then binds to clotting
factors of the intrinsic and common pathways
(Xa, Ila, IXa, XIa, XIla and XIIIa) and inactivates
them but not factor VIla operative in the extrinsic
pathway.
At low concentrations of heparin, factor Xa
mediated conversion of prothrombin to thrombin
is selectively affected.
 The anticoagulant action is exerted mainly by
inhibition of factor Xa as well as thrombin (lIa)
mediated conversion of fibrinogen to fibrin.
Heparin in higher doses inhibits platelet
aggregation and prolongs bleeding time.
 After i.v. injection of doses < 100 U /kg, the t1/2
averages 1 hr. Beyond this, dose-dependent
inactivation is seen and t1/2 is prolonged to 1-4
hrs.
The t1/2 is longer in cirrhotics and kidney failure
patients, and shorter in patients with pulmonary
embolism.
 Unitage and administration
:Because of variable molecular size, heparin is
standardized only by bioassay: 1 U is the amount
of heparin that will prevent 1 ml of citrated sheep
plasma from clotting for 1 hour after the addition
of 0.2 ml of 1% calcium chloride, solution.
Heparin sod. 1 mg has 120-140 U of activity.
HEPARIN SOD., BEPARlNE, NUPARIN 1000 and
5000 U/ml in 5 ml vials for injection.
 Heparin should not be mixed with penicillin,
tetracyclines and hydrocortisone in the same
syringe or infusion bottle.
Heparinized blood is not suitable for blood counts
(alters the shape of RBCs and WBCs), fragility
testing and complement fixation tests.
 Dosage: Heparin is conventionally given i.v. in
bolus doses of 5,000-10,000 U (children 50-100
U/kg) every 4- 6 hours, or the initial bolus dose is
followed by continuous infusion of 750-1000 U per
hr which may reduce the total dose needed and
the incidence of bleeding.
The dose and frequency is controlled by aPTT
measurement which is kept at 50-80 sec. or 1.5-
2.5 times the patient's pretreatment value.
If this test is not available, whole blood clotting
time should be measured and kept at 2 times the
normal value.
Deep s.c. injection of 10,000-20,000 U every 8-12
hrs can be given if repeated i.v. injection or
infusion is not possible.
Needle used should be fine and trauma should be
 Low dose (s.c.) regimen 5000 U is injected s.c.
every 8-12 hours, started before surgery and
continued for 7-10 days or till the patient starts
moving about.
This regimen has been found to prevent
postoperative deep vein thrombosis without
increasing surgical bleeding.
It also does not prolong aPTT or clotting time.
However, it should not be used in case of
neurosurgery or when spinal anaesthesia is to be
given.
The patients should not be receiving aspirin or
oral anticoagulants.
 ADVERSE EFFECTS
1. Bleeding due to overdose is the most serious complication
of heparin therapy. Haematuria is generally the first sign.
With proper monitoring, serious bleeding is reported in 1-3%
patients.
2. TIrrombocytopenia is another common problem. Generally it
is mild and transient; occurs due to aggregation of platelets.
Occasionally serious thromboembolic events result. In some
patients antibodies are formed to the heparin-platelet
complex and marked depletion of platelets occurs heparin
should be discontinued. Even LMW heparins are not safe in
such patients.
3. Transient and reversible alopecia is infrequent. Serum
transaminase levels may rise.
4. Osteoporosis may develop on long-term use of relatively
high doses.
5. Hypersensitivity reactions are rare-urticaria, rigor, fever and
anaphylaxis. Patients with allergic diathesis are more liable .
 Low molecular weight (LMW) heparins

Heparin has been fractionated into LMW forms (MW

3000-7000) by different techniques.
LMW heparins have a different anticoagulant profile;
selectively inhibit factor Xa with little effect on IIa.
They act only by inducing conformational change in
AT III and not by bringing together AT III and thrombin.
As a result, LMW heparins have smaller effect on aPTT
and whole blood clotting time than unfractionated
heparin (UFH) relative to antifactor Xa activity.
Also, they appear to have lesser antiplatelet action-
less interference with haemostasis.
TIrrombocytopenia is less frequent.
 The more important advantages of LMW heparins
are pharmacokinetic:
Better subcutaneous bioavailability (70-90%)
compared to unfractionated heparin (20-30%):
Variability in response is minimized.
Longer and more consistent monoexponential
t1/2: once daily s.c. administration.
Since aPTT / clotting times are not prolonged,
laboratory monitoring is not needed; dose is
calculated on body weight basis.
 Indications of LMW heparins are:
1. Prophylaxis of deep vein thrombosis and
pulmonary embolism in high-risk patients
undergoing surgery; stroke or other immobilized
patients.
2. Treatment of established deep vein thrombosis.
3. Unstable angina.
4. To maintain patency of cannulae and shunts in
dialysis patients, and in extracorporeal
circulation.
 A number of LMW heparins have been marketed.
They differ in composition, pharmacokinetics and
dosage.
Enoxaparin: CLEXANE 20 mg (0.2 mI) and 40 mg
(0.4mI) prefilled syringes; 20-40 mg OD, s.c.
(start 2 hour before surgery).
Reviparin: CLIV ARINE 13.8 mg (eq. to 1432 anti
Xa IU) in 0.25 mI prefilled syringe; 0.25 mI s.c.
once daily for 5-10 days.
Nadroparin: FRAXIPARINE 3075 IU (0.3 mI) and
4100 IU (0.4 mI) inj., CARDIOPARIN 4000 anti Xa
IU/0.4 mI, 6000 anti Xa IU/0.6 mI, 100, 000 anti
Xa IU/l0 mI inj.
 HEPARINOIDS
Heparan sulfate : It is a heparin-like natural
substance found on cell surface and intercellular
matrix in many tissues. It is a less potent
anticoagulant than heparin, but may have a more
favourable profile of action.
Danaparoid is a preparation containing mainly
heparan sulfate, obtained from pig gut mucosa,
which is used in cases with heparin induced
thrombocytopenia.
Lepirudin : This recombinant preparation of
hirudin (a polypeptide anticoagulant secreted by
salivary glands of leech) acts by inhibiting
thrombin directly. It is indicated in patients with
heparin induced thrombocytopenia.
 Ancrod : It is an enzyme obtained from Malayan
pit viper venom. It degrades fibrinogen into an
unstable form of fibrin which is taken up by RE
cells. Thus, fibrinogen gets depleted and an
apparent heparin like effect results. It is given
only by slow infusion: 2 U /kg over 6 hours for
deep vein thrombosis in patients who develop
thrombocytopenia or hypersensitivity reactions to
heparin and require immediate anticoagulation.
 HEPARIN ANTAGONIST
Protamine sulfate It is a strongly basic, low
molecular weight protein obtained from the sperm
of certain fish.
Given i.v. it neutralises heparin weight for weight,
i.e. 1 mg is needed for every 100 U of heparin.
For the treatment of heparin induced bleeding, due
consideration must be given to the amount of
heparin that may have been degraded by the
patient's body in the mean time.
However, it is needed infrequently because the
action of heparin disappears by itself in a few hours,
and whole blood transfusion is indicated to replenish
the loss when bleeding occurs.
 Protamine is more commonly used when heparin
action needs to be terminated rapidly, e.g. after
cardiac or vascular surgery.
In the absence of heparin, protamine itself acts as
a weak anticoagulant by interacting with platelets
and fibrinogen.
Being basic in nature it can release histamine in
the body. Hypersensitivity reactions have
occurred.
Rapid i.v. injection causes flushing and breathing
difficulty.
PROTA, PROTAMINE SULFATE 50 mg in 5 ml inj
 ORAL ANTICOAGULANTS
Warfarin and its congeners act as anticoagulants
only in vivo, not in vitro. This is so because they
act indirectly by interfering with the synthesis of
vit K dependent clotting factors in liver.
They apparently behave as competitive
antagonists of vit K and reduce the plasma levels
of functional clotting factors in a dose-dependent
manner.
In fact, they interfere with regeneration of the
active hydroquinone form of vit K which carries
out the final step of y carboxylating glutamate
residues of prothrombin and factors VII, IX and X.
This carboxylation is essential for the ability of
the clotting factors to bind Ca2+ and to get
 Factor VII has the shortest plasma t1/2 (6hr), its level
falls first when warfarin is given, followed by factor IX
(t1/2 24 hr), factor X (t1/2 40 hr) and prothrombin
(t1/2 60 hr).
Though the synthesis of clotting factors diminishes
within 2-4 hours of warfarin administration,
anticoagulant effect develops gradually over the next
1-3 days as the levels of the clotting factors already
present in plasma decline progressively. Thus, there
is always a delay between administration of the drug
and the anticoagulant effect. Larger initial doses
hasten the effect only slightly.
 Treatment of bleeding due to
oral anticoagulants consists of:
Withhold the anticoagulant.
Give fresh blood transfusion: supplies clotting
factors and replenishes lost blood. Alternatively
fresh frozen plasma may be used as a source of
clotting factors.
Give vit K1-specific antidote, but it takes 6-24
hours for the clotting factors to be resynthesized
and released in blood after vit K administration.
 Dose regulation
The dose of oral anticoagulant must be individualised
by repeated measurement of prothrombin time; the
aim is to achieve a therapeutic effect without unduly
increasing the chances of bleeding.
The optimum ratio of PT during treatment to the
normal value (of the testing laboratory) has been
defined for various indications. But this value differs
depending on whether rabbit brain or human brain
thromboplastin (Tp) has been used for the test.
A standardized system called the International
Normalized Ratio (INR) based on the use of human
brain Tp has been developed by WHO and adopted in
all countries.
 Recommended INR for various
indications of oral
anticoagulants Recommended INR for
various indications of oral
anticoagulants
1. Prophylaxis of deep vein thrombosis and similar
indications : 2-2.5
2.Treatment of deep vein thrombosis, pulmonary
embolism, TIAs, hip surgery : 2-3
3. Recurrent thromboembolism, arterial disease
(MI), prosthetic heart valves : 3-3.5
Factors enhancing effect of oral anticoagulants
are:

Debility, malnutrition, malabsorption and

prolonged antibiotic therapy: the supply of vit K to
liver is reduced in these conditions.
Liver disease, chronic alcoholism: synthesis of
clotting factors may be deficient.
Hyperthyroidism: the clotting factors are
degraded faster.
Newborns: have low levels of vit K and clotting
factors (there should be no need of these drugs in
neonates anyway).
Factors decreasing effect of oral anticoagulants are:

Pregnancy: plasma level of clotting factors is

higher.
Nephrotic syndrome: drug bound to plasma
protein is lost in urine.
Genetic warfarin resistance: the affinity of
warfarin (as well as of vitK epoxide) to bind to the
reductase enzyme, which generates the active vit
K hydroquinone, is low. Dose of oral anticoagulant
is 4-5 times higher.
 References
Robbins and Cotran pathologic basis of disease
8th edition
Guyton and Hall textbook of medical physiology
12th edition
Ganongs review of medical physiology 23rd
edition
Essentials of medical pharmacology 6th edition
Various net sources
THANK
YOU