Objective-Ibrutinib is an irreversible Bruton tyrosine kinase inhibitor approved for treatment of Waldenstrom macroglobulinemia, chronic lymphocytic leukemia, and mantle cell lymphoma that increases the risk of bleeding among patients. Platelets from ibrutinib-treated patients exhibit deficiencies in collagen-evoked signaling in suspension; however, the significance of this observation and how it relates to bleeding risk is unclear, as platelets encounter immobile collagen in vivo. We sought to clarify the effects of ibrutinib on platelet function to better understand the mechanism underlying bleeding risk. Approach and Results-By comparing signaling in suspension and during adhesion to immobilized ligands, we found that the collagen signaling deficiency caused by ibrutinib is milder during adhesion to immobilized collagen. We also found that platelets in whole blood treated with ibrutinib adhered to collagen under arterial shear but formed unstable thrombi, suggesting that the collagen signaling deficiency caused by ibrutinib may not be the predominant cause of bleeding in vivo. However, clot retraction and signaling evoked by platelet adhesion to immobilized fibrinogen were also inhibited by ibrutinib, indicating that integrin α IIb β 3 outside-in signaling is also effected in addition to GPVI signaling. When ibrutinib was combined with the P2Y 12 inhibitor, cangrelor, thrombus formation under arterial shear was inhibited additively. Conclusions-These findings suggest that (1) ibrutinib causes GPVI and integrin α IIb β 3 platelet signaling deficiencies that result in formation of unstable thrombi and may contribute toward bleeding observed in vivo and (2) combining ibrutinib with P2Y 12 antagonists, which also inhibit thrombus stability, may have a detrimental effect on hemostasis.
Bye et al Ibrutinib Causes Unstable Thrombus Formation 2327regulate phospholipase Cγ2 (PLCγ2) activation, and thereby Ca 2+ release and protein kinase C (PKC) activation, which are critical events in platelet activation. 6,7 In addition to GPVI, platelets also express α 2 β 1 and the glycoprotein Ib (GPIb) receptor complex that can mediate adhesion to collagen and generate intracellular signaling that supports hemostatic platelet function. 8 Btk has an established role in the signaling pathway evoked by GPIb 9 and consequent inhibition of adhesion to Von Willebrand factor (vWF) in the presence of ibrutinib has been reported. 4 The role of Btk in α 2 β 1 -mediated signaling is less clear, as is the ability for α 2 β 1 to function in the absence of signaling evoked by GPVI, 8 making the effects of ibrutinib on collagen-evoked adhesion and signaling under shear difficult to predict.The role of Btk may not be limited to collagen and vWFevoked pathways, as integrin α IIb β 3 -evoked outside-in signaling is thought to share many features of the GPVI signaling pathway, although conflicting reports about the involvement of Btk in outside-in signaling have been published. A study reporting that phosphorylation of Btk occurs after direct ac...