The von Willebrand factor A-1 domain binding aptamer BT200 elevates plasma levels of von Willebrand factor and factor VIII: a first-in-human trial

Katarina D Kovacevic, Jürgen Grafeneder, Christian Schörgenhofer, Georg Gelbenegger, Gloria Gager, Christa Firbas, Peter Quehenberger, Petra Jilma-Stohlawetz, Andrea Bileck, Shuhao Zhu, James C Gilbert, Martin Beliveau, Bernd Jilma, Ulla Derhaschnig, Katarina D Kovacevic, Jürgen Grafeneder, Christian Schörgenhofer, Georg Gelbenegger, Gloria Gager, Christa Firbas, Peter Quehenberger, Petra Jilma-Stohlawetz, Andrea Bileck, Shuhao Zhu, James C Gilbert, Martin Beliveau, Bernd Jilma, Ulla Derhaschnig

Abstract

Von Willebrand factor (VWF) and factor VIII (FVIII) circulate in a noncovalent complex in blood and promote primary hemostasis and clotting, respectively. A new VWF A1-domain binding aptamer, BT200, demonstrated good subcutaneous bioavailability and a long half-life in non-human primates. This first-in-human, randomized, placebo-controlled, doubleblind trial tested the hypothesis that BT200 is well tolerated and has favorable pharmacokinetic and pharmacodynamic effects in 112 volunteers. Participants received one of the following: a single ascending dose of BT200 (0.18-48 mg) subcutaneously, an intravenous dose, BT200 with concomitant desmopressin or multiple doses. Pharmacokinetics were characterized, and the pharmacodynamic effects were measured by VWF levels, FVIII clotting activity, ristocetin-induced aggregation, platelet function under high shear rates, and thrombin generation. The mean half-lives ranged from 7-12 days and subcutaneous bioavailability increased dose-dependently exceeding 55% for doses of 6-48 mg. By blocking free A1 domains, BT200 dose-dependently decreased ristocetin-induced aggregation, and prolonged collagen-adenosine diphosphate and shear-induced platelet plug formation times. However, BT200 also increased VWF antigen and FVIII levels 4-fold (P<0.001), without increasing VWF propeptide levels, indicating decreased VWF/FVIII clearance. This, in turn, increased thrombin generation and accelerated clotting. Desmopressin-induced VWF/FVIII release had additive effects on a background of BT200. Tolerability and safety were generally good, but exaggerated pharmacology was seen at saturating doses. This trial identified a novel mechanism of action for BT200: BT200 dose-dependently increases VWF/FVIII by prolonging half-life at doses well below those which inhibit VWF-mediated platelet function. This novel property can be exploited therapeutically to enhance hemostasis in congenital bleeding disorders.

Figures

Figure 1.
Figure 1.
Plasma concentration versus time profiles of the anti-von Willebrand factor aptamer, BT200, in healthy volunteers. Mean (with standard error) plasma levels of BT200 over time after: (A) single subcutaneous injections or infusions in healthy volunteers (n=6); (B) single subcutaneous injections or infusions in healthy volunteers (n=6); (C) the last of five subcutaneous doses in healthy volunteers (part B of the study) (n=6). SE: standard error; SC: subcutaneous; IV: intravenous; D28: day 28.
Figure 2.
Figure 2.
Free von Willebrand factor A1-domains (%) afer single doses of BT200, measured by enzyme-linked immunosorbent assay. Data are mean values without error bars for better visibility (n=6 for BT200 groups, n=20 for placebo). VWF: von Willebrand factor; sc: subcutaneous; inj: injection; inf: infusion.
Figure 3.
Figure 3.
Plasma levels of von Willebrand factor antigen (%) afer single doses of BT200. Data are mean values without error bars for better visibility (n=6 for BT200 groups, n=20 for placebo). VWF: von Willebrand factor; sc: subcutaneous; inj: injection; inf: infusion.
Figure 4.
Figure 4.
von Willebrand factor antigen levels, free A1-domains and factor VIII activity (%) afer multiple doses of BT200. Subjects received 12 mg BT200 intravenously plus 12 mg subcutaneously on the first day and 12 mg subcutaneously weekly or placebo. Data are presented as mean values with 95% confidence intervals (n=6 for BT200 groups, n=20 for placebo). VWF: von Willebrand factor; Ag: antigen; FVIIIc: factor VIII activity.
Figure 5.
Figure 5.
Factor VIII activity levels after single doses of BT200. Data are mean values without error bars for better visibility (n=6 for BT200 groups, n=20 for placebo). sc: subcutaneous; inj: injection; inf: infusion.
Figure 6.
Figure 6.
Factor VIII cloting activity (%) afer combined administration of BT200/placebo with desmopressin or BT200/placebo alone. Data are represented as mean values with 95% confidence interval (n=6 for BT200 groups, n=20 for placebo, n=2 for placebo+desmopressin).

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