History of Thrombolytics

Albert Dastre (1844 – 1917), a French physiologist, published the first observations of a possible “enzyme” that removes fibrin in blood clots in the Archives of Normal Pathology, introducing the term “fibrinolysis” for the first time. 

1. Dastre A. Arch Norm Pathol 1893;5:661–663.

2. MARDER VJ et al. J Thromb Hemost 2011;9: 364-373.

3. Medcalf RL & Keragala CB. Int J Mol Sci 2021; 22:3406.

Aoi describes the first fibrinolytic activity in isolates of Staphylococcus, now known as Staphylokinase.

1. Aoi F. Kitasato Arch Exptl Med 1932;9:171–201.

2. Neter E. J Bact 1937;34(8):243.

3. Medcalf RL & Keragala CB. Int J Mol Sci 2021; 22:3406. 

William Smith Tillet and R. L. Garner from the Biological Division of the Department of Medicine of The Johns Hopkins School of Medicine describe fibrinolytic activity found in culture broth of beta haemolytic Streptococcus. This would become known as Streptokinase.

1. Tillett WS & Garner RL. J Exp Med 1933;58:485-502.

2. Garner RL & Tillett WS. J Exp Med 1934;60:239-254.

3. Garner RL & Tillett WS. J Exp Med 1934;60:255-267.

4. Medcalf RL & Keragala CB. Int J Mol Sci 2021;22:3406.

Haskel Milstone discovers that a plasma precursor is necessary for the fibrinolytic action of Staphylo- and Strepto-kinase. This plasma precursor was originally referred to as “pro-fibrinolysin”, with “fibrinolysin” being the name for the active fibrinolytic form. Today, these are known as plasminogen and plasmin. 

1. Milstone HA. J Immunol 1941;42(2): 109-116. 

2. Macfarlane RG & Pilling J. Lancet 1946;2:562-565. 

3. Medcalf RL & Keragala CB. Int J Mol Sci 2021; 22:3406.

First description of human-derived plasminogen activators in human cells – tissue cytofibrinolysin/ fibrinokinase, which would later be known as tissue-type plasminogen activator, t-PA.

1. Astrup T & Permin PM. Nature 1947; 159: 681. 

2. Collen D & Lijnen HR. Arterioscl Thromb Vascul Biol 2009;29(8)1151-1155.

3. Medcalf RL & Keragala CB. Int J Mol Sci 2021; 22:3406.

Fibrinolytic activity in human urine was described in 1947 by R. G. McFarlane and J. Pilling from the Pathological Department of Radcliffe Infirmary in Oxford. Five years later, in 1952, human-derived plasminogen activator from urine is detected, urokinase-type plasminogen activator, u-PA. Findings are presented at the American Society of Physiology Fall Meeting in New Orleans.

Also in 1952, Tage Astrup and Agnete Stage from the Biological Institute of the Carlsberg Foundation in Copenhagen showed, for the first time, that a soluble fibrinolytic activator can be extracted from animal tissues by using strong chaotropic agents. 

1. Macfarlane RG & Pilling J. Nature 1947; 159:779.

2. Astrup T & Stage A. Nature 1952; 170: 929.

3. Collen D & Lijnen HR. Arterioscl Thromb Vascul Biol 2009;29(8):1151-1155.

4. Medcalf RL & Keragala CB. Int J Mol Sci 2021; 22:3406.

Neurosurgeons Sussman and Fitch report the use of a thrombolytic agent in the treatment of cerebral arterial occlusions. They treated 3 patients with intravenous plasmin (fibrinolysin) daily for 4–6 days, of which 1 patient showed clinical improvement.

Furthermore, Sussman and Fitch suggest that the success of stroke treatment depends on the amount of time that has passed since symptom onset. The concept that “time is brain” still dominates AIS treatment today.

1. Sussman BJ & Fitch TS. JAMA 1958;167(14):1705-1709. 

2. Röther J et al. Cerebrovasc Dis 2013;35:313-319. 

3. Dewar B & Shamy M. Neurohospitalist 2020;10(1):5-10.

The first human brain computed tomography image is produced offering better diagnoses and improving patient selection for fibrinolytic therapy.

Higgins ES. The Conversation. 50 years ago, the first CT scan let doctors see inside a living skull. 1 Oct 2021. 

D. C. Rijken et al. at the Gaubius Institute of the Health Research Organisation TNO in Leiden, Netherlands, developed a process for the purification and partial characterisation of plasminogen activator from human uterine tissue. Subsequently, while at the Centre for Thrombosis and Vascular Research, Department of Medical Research at the University of Leuven in Belgium, Rijken and team described the process for purification and partial characterisation of plasminogen activator from human melanoma cells in culture. The purification of human tissue-type plasminogen activator in centigram quantities paved the way for use in animal and human studies. 

1. Rijken DC et al. Biochim Biophys Acta 1979;580(1):140-153. 

2. Rijken DC & Collen D. J Biol Chem 1981;256(13):7035-7041. 

3. Collen D et al. Thromb Hemost 1982;48(3):294-296. 

4. Collen D & Lijnen HR. Arterioscl Thromb Vascul Biol 2009;29(8):1151-1155.

The first time cloning of t-PA derived from human melanoma cell mRNA. A plasmid containing the Escherichia coli trp promoter and the complementary DNA sequence coding for the t-PA protein was constructed for expression in E. coli.  

Pennica D et al. Nature 1983;301:214–221.   

Recombinant t-PA (alteplase) synthesised using Chinese Hamster Ovary cells is approved for the treatment of myocardial infarction. 

1. Jayapal KP et al. Chem Eng Prog 2007;103(7): 40–47.

2. https://www.ninds.nih.gov/sites/default/files/documents/tpa_design_508c.pdf

The National Institute of Neurological Disorders and Stroke (NINDS 1/2) trials begin, evaluating the therapeutic potential of rt-PA, showing, for the first time, the safety of rt-PA and better outcomes vs placebo when administered up to 3 hours after AIS onset. 

1. NINDS rt-PA Stroke Study Group. N Engl J Med 1995; 333:1581-1588. 

2. Campbell BCV et al. Stroke 2015;46(8):2341-2346. 

Based on the results of the Global Utilisation of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) trial, rt-PA becomes the reference thrombolytic therapy for the treatment of acute myocardial infarction. 

GUSTO Investigators. N Engl J Med 1993;329(10):673-682. 

Tenecteplase, a multiple-point mutation of t-PA, was specifically bioengineered to have an extended half-life, allowing convenient single-bolus dosing while maintaining a high level of fibrin specificity and potency.

Keyt BA et al. Proc Natl Acad Sci USA 1994;91(9):3670-4.

NINDS 1/2 shows rt-PA is an effective AIS therapy when administered within 3 hours of the onset of symptoms in select patients. 

NINDS rt-PA Stroke Study Group. N Engl J Med 1995; 333:1581-1588.

The US Food and Drug Administration approves rt-PA for the treatment of AIS in the first 3 hours after symptom onset

https://www.ninds.nih.gov/sites/default/files/documents/tpa_design_508c.pdf

The European Medicines Agency approves rt-PA for the treatment of AIS within 3 hours of symptom onset

https://www.ema.europa.eu/en/medicines/human/referrals/actilyse

The results of a pilot dose-escalation safety study of tenecteplase in acute ischemic stroke were published.

Haley EC et al. Stroke 2005;36:607–612.

The American Heart Association/American Stroke Association recommends rt-PA for the treatment of AIS:
Intravenous rt-PA (0.9 mg/kg, maximum dose 90 mg) is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke.

Adams HP et al. Stroke 2007;38(5):1655-1711.

The third European Cooperative Acute Stroke Study (ECASS 3) results show alteplase has an acceptable safety profile and is effective when administered between 3 and 4.5 hours after AIS symptom onset. 

Hacke W et al. N Engl J Med 2008;359:1317-1329. 

The American College of Chest Physicians recommend intravenous t‑PA for patients with acute ischaemic stroke < 3 hours from symptom onset 

Albers G et al. Chest 2008;133(6 Suppl): 630S-669S. 

In light of the ECASS 3 results, the American Heart Association/American Stroke Association puts out a Science Advisory stating: 
rt-PA should be administered to eligible patients who can be treated in the time period of 3 to 4.5 hours after stroke 

Del Zoppo GJ et al. Stroke 2009;40:2945-2948. 

Results of a prematurely terminated randomised phase IIB/III trial of tenecteplase in acute ischemic stroke published.

Haley EC et al. Stroke 2010;41:707–711.

Results from the first randomised trial of tenecteplase versus alteplase for acute ischemic stroke were published.

Parsons M et al. N Engl J Med 2012;366:10991107.

Based on the published data comparing IVT with tenecteplase and alteplase in AIS, tenecteplase 0.25 mg/kg was recommended as a safe and effective alternative to alteplase in patients with AIS of <4.5h duration who are eligible for IVT.

Alamowitch et al. European Stroke Journal 2023;8(1) 8–54

Tenecteplase (TNK-tPA, Metalyse^®) receives positive opinion from EMA for the change in marketing authorization to include the thrombolytic treatment of acute ischemic stroke (AIS) in adult patients, indicated within 4.5 hours from the last known well and after exclusion of intracranial haemorrhage.

https://www.ema.europa.eu/en/medicines/human/variation/metalyse

Thrombolytic treatment has transformed the treatment of vascular occlusions by allowing rapid reperfusion.Thrombolytics are an emergency treatment for myocardial infaction, stroke and pulmonary embolism. Tenecteplase 0.25 mg/kg and alteplase 0.9 mg/kg are both approved as thrombolytic treatments for acute ischaemic stroke (AIS) patients within 4.5 hours from onset of symptoms/last known well and after exclusion of intracranial haemorrhage.
 

Tsivgoulis G et al. Lancet Neurol 2023;22:418-429