Comparative In Vitro Study of Various α2-Adrenoreceptor Agonist Drugs for Ticagrelor Reversal

Abstract

Ticagrelor, an antiplatelet adenosine diphosphate (ADP)-P2Y 12 receptor antagonist, increases the risk of bleeding. Its management is challenging because platelet transfusion is ineffective and no specific antidote is currently available. Epinephrine, a vasopressor catecholamine prescribed during shock, restores platelet functions inhibited by ticagrelor through stimulation of α 2A -adrenoreceptors. It subsequently inhibits cyclic adenosine monophosphate (cAMP) pathway and PI3K signaling. However, since epinephrine may expose a patient to deleterious hemodynamic effects, we hypothesized that other α 2 -adrenoreceptor agonist drugs used in clinical practice with fewer side effects could reverse the antiplatelet effects of ticagrelor. We compared in vitro the efficacy of clonidine, dexmedetomidine, brimonidine, and norepinephrine with epinephrine to restore ADP-and PAR-1-AP-induced washed platelet aggregation inhibited by ticagrelor, as well as resulting platelet cAMP levels. In ticagrelor-free samples, none of the α 2 -adrenoreceptor agonists induced aggregation by itself but all of them potentiated ADP-induced aggregation. Compared with epinephrine, norepinephrine, and brimonidine partially restored ADP-and fully restored PAR-1-AP-induced aggregation inhibited by ticagrelor while clonidine and dexmedetomidine were ineffective. Indeed, this lack of effect resulted from a lower decrease in cAMP concentration elicited by these partial α 2 -adrenoreceptor agonists, clonidine, and dexmedetomidine, compared with full α 2 -agonists. Our results support the development of specific full and systemic α 2 -adrenoreceptor agonists for ticagrelor reversal.2 of 11 acid, and desmopressin are unlikely to reverse ticagrelor antiplatelet effects [2][3][4][5][6][7], and no specific antidote is currently available [8,9]. We recently showed that epinephrine, a vasopressor agent used to treat shock, is able in vitro to restore platelet functions inhibited by ticagrelor. Epinephrine acts through stimulation of α 2A -adrenoreceptors coupled with G z -protein on the platelet membrane surface. The α subunit of G z -protein binds to adenylate cyclase and inhibits the synthesis of the second messenger cyclic adenosine monophosphate (cAMP), which plays a central role in platelet inhibition, while the dissociated βγ subunit activates phosphoinositide 3-kinase (PI3K) pathway [10,11]. Therefore, α 2A -adrenoreceptor stimulation participates in platelet activation. In combination with ADP stimulating the P2Y 1 receptor signaling and subsequent Ca 2+ mobilization, epinephrine induces aggregation of ticagrelor-treated platelets through inhibition of the cAMP pathway and activation of the PI3K pathway. However, epinephrine is a catecholamine and cumulates α 1 -, α 2 -, β 1 -, and β 2adrenoreceptor agonist effects that induce hemodynamic changes including tachycardia, heart rhythm disorders, peripheral arterial vasoconstriction, and lactic acidosis, which are potentially deleterious in the context of acute bleeding. We therefore hypothesized that ot...

Adrenaline May Contribute to Prothrombotic Condition via Augmentation of Platelet Procoagulant Response, Enhancement of Fibrin Formation, and Attenuation of Fibrinolysis

“…This effect was associated with the restoration of P2Y 12 -like signaling by adrenaline since P2Y 12 and α 2 -AR receptors share similar effectors: Gα-mediated inhibition of AC and Gβγ-related activation of PI-3K ( Martin et al, 2020 ). Also other α 2 -AR agonists: noradrenaline and brimonidine have been recently found to restore aggregation in ticagrelor-treated platelets ( Bonete et al, 2020 ). However, above studies did not include evaluation of platelet procoagulant response and fibrinolysis after adrenaline (or other α 2 -AR agonists) infusion.…”