Charles University Faculty of Pharmacy in Hradec Králové Department of Pharmacology and Toxicology Student: Bc. Ladislava Cablíková Supervisors: Ass. Prof. Mojca Božič-Mijovski, Ph.D., prof. PharmDr. Petr Pávek, Ph.D., RNDr. Jana Nekvindová, Ph.D. Thesis title: The Impact of Apixaban on Overall Hemostatic Potential Disorders at certain levels of the complicated haemostatic system can lead to either bleeding or excessive blood coagulation. These pathological conditions are treated with anticoagulants, which aim to correct excessive coagulation. However, traditional anticoagulant therapy has many limitations, which initiated efforts to develop oral anticoagulants with a better profile. These new-generation anticoagulants are called DOAC - Direct Oral AntiCoagulans. Apixaban, as one of xabans, has predictable pharmacokinetics and pharmacodynamics and therefore does not require a routine laboratory monitoring of the treatment effect. Nevertheless, it still requires evaluation in urgent clinical situations. Standard coagulation screening assays, e.g., PT (prothrombin test) and APTT (activated partial thromboplastin test), do not fully reflect the actual status of the drug. Therefore, researchers aim is to find a relatively simple and fast hemostatic assay that would correlate with the actual condition...

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INTRODUCTION Apixaban has revolutionized anticoagulation in patients with atrial fibrillation in preventing strokes. Anticoagulant-induced nephropathy with warfarin is well known, but nephropathy with apixaban is a rare entity, and here we present a case of Apixaban-induced nephropathy. Case Description A 71-year-old patient with a medical history of persistent atrial fibrillation on apixaban, Ischemic cardiomyopathy, and chronic kidney disease stage (CKD) IIIa presented to the hospital with complaints of dyspnea and hemoptysis and tea-colored urine of three-day duration. On admission, the patient had acute kidney injury (AKI) on CKD, Methicillin sensitive Staphylococcus aureus (MSSA) bacteremia, and elevated international normalized ratio (INR) and apixaban were held. The hemoptysis worsened and prompted bronchoscopy revealing diffuse alveolar hemorrhage. The urinalysis showed gross hematuria with high red blood cell (RBC) count and 1+ proteinuria presumed secondary to MSSA associated glomerulonephritis. Evaluation for coagulopathy with serum mixing studies and autoimmune workup has been unremarkable. The patient's coagulopathy was considered secondary to decreased clearance of apixaban with AKI on CKD. However, the patient's kidney function continued to worsen, needing continuous renal replacement therapy and a kidney biopsy for a definitive diagnosis for his decline in kidney function. Kidney biopsy revealed IgA dominant infection associated glomerulitis with one out of hundred glomeruli with the crescent formation and signs of anticoagulant induced nephropathy with several intratubular RBC casts out of proportion to the degree of glomerular injury causing acute tubular damage. The patient's INR improved on dialysis. However, he continued to be oliguric before being terminally extubated. DISCUSSION With the increasing incidence of atrial fibrillation and the use of oral anticoagulants, it is vital to have anticoagulant induced as a differential in patients presenting with supra therapeutic INR and AKI. Apixaban-induced nephropathy is a subset of anticoagulant-induced nephropathy and an uncommon cause of the acute decline in kidney function needing dialysis. Prompt recognition and treatment will prevent further deterioration in kidney function and possible improvement.

Apixabana é um novo fármaco da classe dos anticoagulantes orais utilizado na prevenção e no tratamento de eventos de tromboembolismo venoso em pacientes submetidos à cirurgia de quadril e joelho, além de reduzir os riscos de acidente vascular cerebral e fibrilação arterial. Uma vez que impurezas e contaminantes podem estar presentes no produto farmacêutico final, as agências regulatórias preveem leis para monitorar essas substâncias. O conceito de Quality by Design (QbD), uma abordagem sistemática que inicia com objetivos pré-definidos e análise de risco, está sendo amplamente utilizado no âmbito farmacêutico para desenvolver formulações e metodologias analíticas. Sendo assim, este trabalho almejou desenvolver e validar um método indicativo de estabilidade simples, rápido e sensível utilizando cromatografia líquida de alta eficiência (CLAE) para determinação simultânea da apixabana e três impurezas sintéticas aplicando a abordagem QbD. O desenho experimental foi feito através do software MODDE® 11 (Umetrics, Suíça) e executado utilizando um cromatógrafo Shimadzu® LC-20A Prominence CLAE-DAD com detecção a 220 nm. O método cromatográfico foi estabelecido utilizando uma coluna Inertsil® CN-3 (150 × 4,6 mm, 5,0 μm) com temperatura do forno de 30°C e volume de injeção de 10 μL. A constituição da fase móvel foi metanol e água (50,2:49,8) com fluxo de 1,015 mL/min sem ajuste de pH. O método foi validado seguindo as guias do ICH e da ANVISA, sendo considerado específico, sensível, linear (r > 0,999), preciso (DPRs < 10% para as impurezas) e exato. Para especificidade, foi realizada busca de produtos de degradação submetendo os comprimidos de apixabana a condições de estresse (radiação UVC, temperatura, oxidação e hidrólise). As substâncias envolvidas no presente trabalho também foram caracterizadas quimicamente e avaliadas quanto ao seu perfil toxicológico in vitro através dos ensaios de MTT e vermelho neutro. A mistura da APX e suas impurezas demonstrou toxicidade aguda, porém este resultado não se manteve durante a exposição prolongada, sugerindo um mecanismo de compensação mitocondrial. Já a impureza 3 apresentou danos significativos em 96 horas de exposição, de modo que mais estudos devem efetuados para avaliar sua toxicidade. / Apixaban is a novel anticoagulant agent used to prevent and treat venous thromboembolic events in adults who have undergone total hip or knee replacement surgery and to lower the risk of stroke in patients with atrial fibrillation. As impurities and contaminants may be present in the pharmaceutical product, current regulatory guidelines recommend monitoring such substances. The concept of Quality by Design (QbD), a systematic approach that begins with predefined objectives and risk management, is being widely used in the pharmaceutical field to develop new formulations and analytical methods. Thus, the aim of this work was to develop and validate a simple, fast and sensitive stability indicating method by high-performance liquid chromatography (HPLC) for the simultaneous determination of apixaban and three synthesis impurities using QbD approach. Experiments were designed and assessed on MODDE® 11 (Umetrics, Sweden) software and carried out in a Shimadzu® LC-20A Prominence HPLC-DAD at 220 nm. The HPLC method was established using an Inertsil® CN-3column (150 × 4.6 mm, 5.0 μm) at the temperature of 30°C and injection volume of 10 μL. The mobile phase consisted of methanol and water (50.2:49.8) at a flow rate of 1.015 mL/min with no pH adjustment. Validation of the method was conducted according to ICH and ANVISA Guidelines, which was considered specific, sensitive, linear (r > 0,999), precise (RSD < 10% for impurities) and accurate. For specificity, a degradation study was performed by exposing apixaban tablets to stress conditions (UVC radiation, temperature, oxidation and hydrolysis). The related substances in the present study were also chemically characterized and toxicological profile was evaluated by in vitro tests MTT and neutral red. The mixture of APX and its impurities showed acute toxicity, but this result did not persist during prolonged exposure, suggesting a mitochondrial compensation mechanism. Yet, impurity 3 presented significant damages in 96 hours of exposure and further studies should be considered to evaluate its toxicity.

Apixabana é um novo fármaco da classe dos anticoagulantes orais utilizado na prevenção e no tratamento de eventos de tromboembolismo venoso em pacientes submetidos à cirurgia de quadril e joelho, além de reduzir os riscos de acidente vascular cerebral e fibrilação arterial. Uma vez que impurezas e contaminantes podem estar presentes no produto farmacêutico final, as agências regulatórias preveem leis para monitorar essas substâncias. O conceito de Quality by Design (QbD), uma abordagem sistemática que inicia com objetivos pré-definidos e análise de risco, está sendo amplamente utilizado no âmbito farmacêutico para desenvolver formulações e metodologias analíticas. Sendo assim, este trabalho almejou desenvolver e validar um método indicativo de estabilidade simples, rápido e sensível utilizando cromatografia líquida de alta eficiência (CLAE) para determinação simultânea da apixabana e três impurezas sintéticas aplicando a abordagem QbD. O desenho experimental foi feito através do software MODDE® 11 (Umetrics, Suíça) e executado utilizando um cromatógrafo Shimadzu® LC-20A Prominence CLAE-DAD com detecção a 220 nm. O método cromatográfico foi estabelecido utilizando uma coluna Inertsil® CN-3 (150 × 4,6 mm, 5,0 μm) com temperatura do forno de 30°C e volume de injeção de 10 μL. A constituição da fase móvel foi metanol e água (50,2:49,8) com fluxo de 1,015 mL/min sem ajuste de pH. O método foi validado seguindo as guias do ICH e da ANVISA, sendo considerado específico, sensível, linear (r > 0,999), preciso (DPRs < 10% para as impurezas) e exato. Para especificidade, foi realizada busca de produtos de degradação submetendo os comprimidos de apixabana a condições de estresse (radiação UVC, temperatura, oxidação e hidrólise). As substâncias envolvidas no presente trabalho também foram caracterizadas quimicamente e avaliadas quanto ao seu perfil toxicológico in vitro através dos ensaios de MTT e vermelho neutro. A mistura da APX e suas impurezas demonstrou toxicidade aguda, porém este resultado não se manteve durante a exposição prolongada, sugerindo um mecanismo de compensação mitocondrial. Já a impureza 3 apresentou danos significativos em 96 horas de exposição, de modo que mais estudos devem efetuados para avaliar sua toxicidade. / Apixaban is a novel anticoagulant agent used to prevent and treat venous thromboembolic events in adults who have undergone total hip or knee replacement surgery and to lower the risk of stroke in patients with atrial fibrillation. As impurities and contaminants may be present in the pharmaceutical product, current regulatory guidelines recommend monitoring such substances. The concept of Quality by Design (QbD), a systematic approach that begins with predefined objectives and risk management, is being widely used in the pharmaceutical field to develop new formulations and analytical methods. Thus, the aim of this work was to develop and validate a simple, fast and sensitive stability indicating method by high-performance liquid chromatography (HPLC) for the simultaneous determination of apixaban and three synthesis impurities using QbD approach. Experiments were designed and assessed on MODDE® 11 (Umetrics, Sweden) software and carried out in a Shimadzu® LC-20A Prominence HPLC-DAD at 220 nm. The HPLC method was established using an Inertsil® CN-3column (150 × 4.6 mm, 5.0 μm) at the temperature of 30°C and injection volume of 10 μL. The mobile phase consisted of methanol and water (50.2:49.8) at a flow rate of 1.015 mL/min with no pH adjustment. Validation of the method was conducted according to ICH and ANVISA Guidelines, which was considered specific, sensitive, linear (r > 0,999), precise (RSD < 10% for impurities) and accurate. For specificity, a degradation study was performed by exposing apixaban tablets to stress conditions (UVC radiation, temperature, oxidation and hydrolysis). The related substances in the present study were also chemically characterized and toxicological profile was evaluated by in vitro tests MTT and neutral red. The mixture of APX and its impurities showed acute toxicity, but this result did not persist during prolonged exposure, suggesting a mitochondrial compensation mechanism. Yet, impurity 3 presented significant damages in 96 hours of exposure and further studies should be considered to evaluate its toxicity.

Apixabana é um novo fármaco da classe dos anticoagulantes orais utilizado na prevenção e no tratamento de eventos de tromboembolismo venoso em pacientes submetidos à cirurgia de quadril e joelho, além de reduzir os riscos de acidente vascular cerebral e fibrilação arterial. Uma vez que impurezas e contaminantes podem estar presentes no produto farmacêutico final, as agências regulatórias preveem leis para monitorar essas substâncias. O conceito de Quality by Design (QbD), uma abordagem sistemática que inicia com objetivos pré-definidos e análise de risco, está sendo amplamente utilizado no âmbito farmacêutico para desenvolver formulações e metodologias analíticas. Sendo assim, este trabalho almejou desenvolver e validar um método indicativo de estabilidade simples, rápido e sensível utilizando cromatografia líquida de alta eficiência (CLAE) para determinação simultânea da apixabana e três impurezas sintéticas aplicando a abordagem QbD. O desenho experimental foi feito através do software MODDE® 11 (Umetrics, Suíça) e executado utilizando um cromatógrafo Shimadzu® LC-20A Prominence CLAE-DAD com detecção a 220 nm. O método cromatográfico foi estabelecido utilizando uma coluna Inertsil® CN-3 (150 × 4,6 mm, 5,0 μm) com temperatura do forno de 30°C e volume de injeção de 10 μL. A constituição da fase móvel foi metanol e água (50,2:49,8) com fluxo de 1,015 mL/min sem ajuste de pH. O método foi validado seguindo as guias do ICH e da ANVISA, sendo considerado específico, sensível, linear (r > 0,999), preciso (DPRs < 10% para as impurezas) e exato. Para especificidade, foi realizada busca de produtos de degradação submetendo os comprimidos de apixabana a condições de estresse (radiação UVC, temperatura, oxidação e hidrólise). As substâncias envolvidas no presente trabalho também foram caracterizadas quimicamente e avaliadas quanto ao seu perfil toxicológico in vitro através dos ensaios de MTT e vermelho neutro. A mistura da APX e suas impurezas demonstrou toxicidade aguda, porém este resultado não se manteve durante a exposição prolongada, sugerindo um mecanismo de compensação mitocondrial. Já a impureza 3 apresentou danos significativos em 96 horas de exposição, de modo que mais estudos devem efetuados para avaliar sua toxicidade. / Apixaban is a novel anticoagulant agent used to prevent and treat venous thromboembolic events in adults who have undergone total hip or knee replacement surgery and to lower the risk of stroke in patients with atrial fibrillation. As impurities and contaminants may be present in the pharmaceutical product, current regulatory guidelines recommend monitoring such substances. The concept of Quality by Design (QbD), a systematic approach that begins with predefined objectives and risk management, is being widely used in the pharmaceutical field to develop new formulations and analytical methods. Thus, the aim of this work was to develop and validate a simple, fast and sensitive stability indicating method by high-performance liquid chromatography (HPLC) for the simultaneous determination of apixaban and three synthesis impurities using QbD approach. Experiments were designed and assessed on MODDE® 11 (Umetrics, Sweden) software and carried out in a Shimadzu® LC-20A Prominence HPLC-DAD at 220 nm. The HPLC method was established using an Inertsil® CN-3column (150 × 4.6 mm, 5.0 μm) at the temperature of 30°C and injection volume of 10 μL. The mobile phase consisted of methanol and water (50.2:49.8) at a flow rate of 1.015 mL/min with no pH adjustment. Validation of the method was conducted according to ICH and ANVISA Guidelines, which was considered specific, sensitive, linear (r > 0,999), precise (RSD < 10% for impurities) and accurate. For specificity, a degradation study was performed by exposing apixaban tablets to stress conditions (UVC radiation, temperature, oxidation and hydrolysis). The related substances in the present study were also chemically characterized and toxicological profile was evaluated by in vitro tests MTT and neutral red. The mixture of APX and its impurities showed acute toxicity, but this result did not persist during prolonged exposure, suggesting a mitochondrial compensation mechanism. Yet, impurity 3 presented significant damages in 96 hours of exposure and further studies should be considered to evaluate its toxicity.

No description available.

Class of 2013 Abstract / Specific Aims:  To determine the efficacy of apixaban when compared to LMWH (enoxaparin) when used as thromboprophylaxis for patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and medically ill patients  To determine the safety of apixaban when compared to LMWH (enoxaparin) when used as thromboprophylaxis for patients undergoing total hip arthroplasty (THA), total knee arthroplasty (TKA), and medically ill patients Methods: A systematic search of the literature for randomized controlled trials of apixaban thromboprophylaxis therapy versus enoxaparin was conducted using three databases: PubMed, EMBASE, and the Cochrane library. Data from five studies with 12,938 total patients were analyzed using Bayesian random effects meta-analysis. To evaluate efficacy, a composite of venous thromboembolism and death during follow-up was measured. To evaluate safety, major and total bleeding events were considered. Main Results: The odds ratio (OR) for the composite outcome of thromboembolism/death was 0.66 (95% CI: 0.33 to 1.29) for apixaban compared to enoxaparin, while there was a similar risk of major bleeding (OR=1.03, 95%CI: 0.36 to 3.73) and total bleeding (OR=0.92, 95%CI: 0.64 to 1.20). Conclusion: These results suggest a lack of clear superiority of apixaban relative to enoxaparin. Apixaban is an oral alternative with similar efficacy and safety to existing anticoagulant therapies.

Trois essais cliniques ARISTOTLE, RE-LY et ROCKET-AF, sont réalisés sur les quatre nouveaux anticoagulants oraux qui sont l’Apixaban, le Dabigatran 110mg, Dabigatran 150mg et le Rivaroxaban, afin d’améliorer la prise en charge de la fibrillation auriculaire (FA). Ils ne permettent pas de déterminer la meilleure option thérapeutique. L’objectif de cette thèse est de développer une approche d’aide multicritère à la décision pour la problématique du choix thérapeutique appliquée au cas de la FA afin d’évaluer ces quatre options thérapeutiques médicamenteuses. La méthodologie d’aide multicritère développée, PROMETHEE-GAIA appliquée à la FA permet de comparer ces quatre nouveaux anticoagulants (l’Apixaban, le Dabigatran 110mg, Dabigatran 150mg et le Rivaroxaban) en se basant sur les cinq critères essentiels élaborés selon un processus de concertation cadrée, qui sont l’efficacité, la sécurité, la fonction rénale, l’observance et le prix. Les résultats de l’évaluation de ces quatre nouveaux anticoagulants est un classement de ces options thérapeutiques par leur ordre de performance dans la prise en charge des patients de la FA selon ces cinq critères en considération.

Trois essais cliniques ARISTOTLE, RE-LY et ROCKET-AF, sont réalisés sur les quatre nouveaux anticoagulants oraux qui sont l’Apixaban, le Dabigatran 110mg, Dabigatran 150mg et le Rivaroxaban, afin d’améliorer la prise en charge de la fibrillation auriculaire (FA). Ils ne permettent pas de déterminer la meilleure option thérapeutique. L’objectif de cette thèse est de développer une approche d’aide multicritère à la décision pour la problématique du choix thérapeutique appliquée au cas de la FA afin d’évaluer ces quatre options thérapeutiques médicamenteuses. La méthodologie d’aide multicritère développée, PROMETHEE-GAIA appliquée à la FA permet de comparer ces quatre nouveaux anticoagulants (l’Apixaban, le Dabigatran 110mg, Dabigatran 150mg et le Rivaroxaban) en se basant sur les cinq critères essentiels élaborés selon un processus de concertation cadrée, qui sont l’efficacité, la sécurité, la fonction rénale, l’observance et le prix. Les résultats de l’évaluation de ces quatre nouveaux anticoagulants est un classement de ces options thérapeutiques par leur ordre de performance dans la prise en charge des patients de la FA selon ces cinq critères en considération.