suggested that a C-terminal extension into the FVIIa active site could yield a chimeric inhibitor that was not only potent and selective but complete as well. A novel two-step "protease switch" approach using substrate phage display was developed by first binding all phage containing A-183 and C-terminal extension libraries to immobilized and inactive FVIIa. Upon altering pH and adding TF to switch on FVIIa enzymatic activity, only those phage released by proteolytic cleavage within the extension were propagated. This process selected for both preferred sequence and length in the extension, leading to a 27-mer peptide A-183X (EEWEVLCWTWET-CERGEGVEEELWEWR) with a C-terminal 12-mer extension containing an Arg in the P 1 position. A-183X was a more potent and complete inhibitor of FX activation, having a maximal extent of inhibition of ϳ99% with an IC 50 of 230 pM versus A-183 which maximally inhibited to 74% with an IC 50 of 1.5 nM. A-183X also had a maximal prolongation of the prothrombin time of 7.6-versus 1.9-fold for A-183, making it a more effective anticoagulant.The limitations of current anticoagulant therapies have stimulated the search for new alternatives based on selective inhibition of serine proteases in the coagulation pathway (1-4). Commonly used anticoagulants, such as coumarin and heparin, lack specificity and have a narrow therapeutic window, leading to undesirable side effects such as bleeding. The tightly regulated coagulation cascade consists of several highly homologous serine proteases and their cofactors and inhibitors (5, 6). The development of a specific inhibitor for a single coagulation factor could reduce side effects and improve the therapeutic profile. The architecture of the active site in all these proteases is very similar, which makes the development of a specific small molecule active site inhibitor challenging. Although relatively nonselective with respect to small chromogenic substrates, these proteases are highly specific for their natural macromolecular substrates. In order to achieve this, exosites on these enzymes play an important role in substrate recognition and catalysis (7-12). Blocking such important interactions could result in the specific inhibition of a single protease in this pathway.Factor VIIa (FVIIa) 1 is the initiator of the extrinsic blood coagulation pathway. Upon vascular damage, zymogen FVII binds to tissue factor (TF), a membrane-bound protein cofactor that is expressed in the surrounding tissue (13). This results in the formation of the active complex TF⅐FVIIa, which activates FX to FXa, FIX to FIXa, and FVII to FVIIa through specific proteolytic cleavages. Ultimately, this cascade leads to the generation of thrombin, resulting in the formation of fibrin and eventually a blood clot. Because FVII/FVIIa is present only in relatively low concentrations in blood (10 nM) and it initiates the coagulation cascade (13), this enzyme is an attractive drug target for the development of anticoagulants.Recent focus on the search for specific inhibitors has lead to ...