Protamine sulfate

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Protamine sulfate
Clinical data
Trade names Prosulf, others
AHFS/Drugs.com Monograph
Routes of
administration
IV
Legal status
Legal status
Pharmacokinetic data
Onset of action 5 minutes [2]
Identifiers
CAS Number
DrugBank
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ECHA InfoCard 100.113.361 OOjs UI icon edit-ltr-progressive.svg

Protamine sulfate is a medication that is used to reverse the effects of heparin. [3] It is specifically used in heparin overdose, in low molecular weight heparin overdose, and to reverse the effects of heparin during delivery and heart surgery. [3] [4] It is given by injection into a vein. [3] The onset of effects is typically within five minutes. [2]

Contents

Common side effects include low blood pressure, slow heart rate, allergic reactions, and vomiting. [3] Allergic reactions may be severe and include anaphylaxis. [3] The risk is greater in males who have had a vasectomy. [5] While there is no evidence of harm from using during pregnancy it has not been well studied in this group. [6] Protamine works by binding with heparin. [3]

Protamine sulfate was approved for medical use in the United States in 1969. [3] It is on the World Health Organization's List of Essential Medicines. [7] It was originally made from the sperm of salmon (salmine, salmon protamine). [3] It is now mainly made using recombinant biotechnology. [8]

Medical uses

Protamine sulfate is usually administered to reverse the large dose of heparin administered during certain surgeries, especially heart surgery where anti-coagulation is necessary to prevent clot formation within the cardiopulmonary bypass pump apparatus. A dose of protamine is given, by drip administered over several minutes, once the patient is off-pump, when extracorporeal circulation and anticoagulation are no longer needed.

It is also used in gene transfer, protein purification and in tissue cultures as a crosslinker for viral transduction. In gene therapy, protamine sulfate has been studied as a means to increase transduction rates by both viral and nonviral-mediated delivery mechanisms (e.g. utilizing cationic liposomes). [9] [10]

Protamine is used in insulin aspart protamine and NPH insulin.

Dosage

Dosage for heparin reversal is 0.5mg to 1.0 mg  mg protamine sulfate IV for every 100 IU of active heparin. Partial thromboplastin time (PTT) should be monitored at 5 to 15 minutes after dose then in 2–8 hours afterward.

Adverse effects

Protamine has been reported to cause allergic reactions in patients who are allergic to fish, diabetics using insulin preparations containing protamine, and vasectomized or infertile men. [11] [12] These occur at rates ranging from 0.28% to 6%. [12] [13] [14]

Avoiding rapid infusion of protamine sulfate and pre-treating at-risk patients with histamine receptor antagonists (H1 and H2) and steroids may minimize these reactions. A 5 to 10 mg test dose is recommended following pretreatment before administering the full dose. [12]

Mechanism

It is a highly cationic peptide that binds to either heparin or low molecular weight heparin (LMWH) to form a stable ion pair, which does not have anticoagulant activity. The ionic complex is then removed and broken down by the reticuloendothelial system. In large doses, protamine sulfate may also have an independent — however weak — anticoagulant effect.

History

A Swiss medical student, Friedrich Miescher (1844-1895) became ill with typhoid fever complicated with partial deafness. Although he received his MD in 1868, Miescher left medicine and turned to physiological chemistry. While Friedrich analyzing the composition of salmon sperm, he isolated for the first time the alkaline substance of “protamine” nucleic acid in 1869 and he called it “nuclein” [15] [16] .

Albrecht Kossel (1853-1927) a German biochemist showed that the substance, called "nuclein", consisted of a protein component and a non-protein component. Kossel further isolated and described the non-protein component. This substance has become known as nucleic acid, which contains the genetic information found in all living cells. Although the first protamine was isolated by Friedrich Miescher in 1869 from salmon sperm, Protamine published article was in 1874. Later, Kossel was awarded the Nobel Prize in Physiology or Medicine in 1910 for his research in cell biology, the chemical composition of the cell nucleus, and for his work in isolating and describing nucleic acids [17] [18] .

All protamine precipitated as the double salt of platinum and was free of sulfur and phosphorus. Protamine sulfate was originally made from the sperm of salmon. The protamine of salmon, later named “salmine”, which can be extracted with hydrochloric acid and precipitated with platinum chloride, corresponds to about 26.8 % of the dried sperm. Protamine sulfate was approved for medical use in 1969 and now it is mainly made using recombinant biotechnology [19] [20] .

Protamine sulfate replaced hexadimethrine bromide (Polybrene), another cationic agent that was the original heparin reversal agent in the early days of heart surgery, until studies in the 1960s suggested that hexadimethrine bromide might cause kidney failure when used in doses in excess of its therapeutic range [21] .

Related Research Articles

<span class="mw-page-title-main">Nucleic acid</span> Class of large biomolecules essential to all known life

Nucleic acids are large biomolecules that are crucial in all cells and viruses. They are composed of nucleotides, which are the monomer components: a 5-carbon sugar, a phosphate group and a nitrogenous base. The two main classes of nucleic acids are deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). If the sugar is ribose, the polymer is RNA; if the sugar is deoxyribose, a variant of ribose, the polymer is DNA.

<span class="mw-page-title-main">Friedrich Miescher</span> Swiss biochemist (1843-1895)

Johannes Friedrich Miescher was a Swiss physician and biologist. He was the first scientist to isolate nucleic acid in 1869. He also identified protamine and made several other discoveries.

<span class="mw-page-title-main">Heparin</span> Anticoagulant

Heparin, also known as unfractionated heparin (UFH), is a medication and naturally occurring glycosaminoglycan. Heparin is a blood anticoagulant that increases the activity of antithrombin. It is used in the treatment of heart attacks and unstable angina. It can be given intravenously or by injection under the skin. Its anticoagulant properties make it useful to prevent blood clotting in blood specimen test tubes and kidney dialysis machines.

<span class="mw-page-title-main">Albrecht Kossel</span> German biochemist and pioneer in the study of genetics

Ludwig Karl Martin Leonhard Albrecht Kossel was a German biochemist and pioneer in the study of genetics. He was awarded the Nobel Prize for Physiology or Medicine in 1910 for his work in determining the chemical composition of nucleic acids, the genetic substance of biological cells.

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<span class="mw-page-title-main">Subcutaneous administration</span> Insertion of medication under the skin

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<span class="mw-page-title-main">Ribonucleotide</span> Nucleotide containing ribose as its pentose component

In biochemistry, a ribonucleotide is a nucleotide containing ribose as its pentose component. It is considered a molecular precursor of nucleic acids. Nucleotides are the basic building blocks of DNA and RNA. Ribonucleotides themselves are basic monomeric building blocks for RNA. Deoxyribonucleotides, formed by reducing ribonucleotides with the enzyme ribonucleotide reductase (RNR), are essential building blocks for DNA. There are several differences between DNA deoxyribonucleotides and RNA ribonucleotides. Successive nucleotides are linked together via phosphodiester bonds.

Low-molecular-weight heparin (LMWH) is a class of anticoagulant medications. They are used in the prevention of blood clots and treatment of venous thromboembolism and in the treatment of myocardial infarction.

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<span class="mw-page-title-main">Cationic liposome</span>

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References

  1. "FDA-sourced list of all drugs with black box warnings (Use Download Full Results and View Query links.)". nctr-crs.fda.gov. FDA . Retrieved 22 Oct 2023.
  2. 1 2 "Prosulf 10mg/ml Solution for Injection - Summary of Product Characteristics (SPC) - (eMC)". www.medicines.org.uk. Archived from the original on 20 December 2016. Retrieved 14 December 2016.
  3. 1 2 3 4 5 6 7 8 "Protamine Sulfate". The American Society of Health-System Pharmacists. Archived from the original on 6 November 2016. Retrieved 8 December 2016.
  4. "Protamine sulfate". www.drugbank.ca. Retrieved 14 February 2019.
  5. World Health Organization (2009). Stuart MC, Kouimtzi M, Hill SR (eds.). WHO Model Formulary 2008. World Health Organization. p. 255. hdl: 10665/44053 . ISBN   9789241547659.
  6. "Protamine Use During Pregnancy". Drugs.com. Archived from the original on 21 December 2016. Retrieved 14 December 2016.
  7. World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl: 10665/325771 . WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
  8. Kern MJ, Seto AR, Parise CM (2012). "Antithrombotic and Antiplatelet Therapy for Percutaneous Coronary Interventions". In Kern MJ (ed.). The Interventional Cardiac Catheterization Handbook E-Book. Elsevier Health Sciences. p. 131. ISBN   9781455740420.
  9. Sorgi FL, Bhattacharya S, Huang L (September 1997). "Protamine sulfate enhances lipid-mediated gene transfer". Gene Therapy. 4 (9): 961–968. doi: 10.1038/sj.gt.3300484 . PMID   9349433. S2CID   22101764.
  10. Cornetta K, Anderson WF (February 1989). "Protamine sulfate as an effective alternative to polybrene in retroviral-mediated gene-transfer: implications for human gene therapy". Journal of Virological Methods. 23 (2): 187–194. doi:10.1016/0166-0934(89)90132-8. PMID   2786000.
  11. Walker WS, Reid KG, Hider CF, Davidson IA, Boulton FE, Yap PL (July 1984). "Successful cardiopulmonary bypass in diabetics with anaphylactoid reactions to protamine". British Heart Journal. 52 (1): 112–114. doi:10.1136/hrt.52.1.112. PMC   481594 . PMID   6743419.
  12. 1 2 3 Campbell FW, Goldstein MF, Atkins PC (December 1984). "Management of the patient with protamine hypersensitivity for cardiac surgery". Anesthesiology. 61 (6): 761–764. doi: 10.1097/00000542-198412000-00021 . PMID   6334459.
  13. Welsby IJ, Newman MF, Phillips-Bute B, Messier RH, Kakkis ED, Stafford-Smith M (February 2005). "Hemodynamic changes after protamine administration: association with mortality after coronary artery bypass surgery". Anesthesiology. 102 (2): 308–314. doi: 10.1097/00000542-200502000-00011 . PMID   15681944. S2CID   42687628.
  14. Sokolowska E, Kalaska B, Miklosz J, Mogielnicki A (August 2016). "The toxicology of heparin reversal with protamine: past, present and future". Expert Opinion on Drug Metabolism & Toxicology. 12 (8): 897–909. doi:10.1080/17425255.2016.1194395. PMID   27223896. S2CID   22038832.
  15. Thess, Andreas; Hoerr, Ingmar; Panah, Benyamin Yazdan; Jung, Günther; Dahm, Ralf (2021-08-23). "Historic nucleic acids isolated by Friedrich Miescher contain RNA besides DNA". Biological Chemistry. 402 (10): 1179–1185. doi:10.1515/hsz-2021-0226. ISSN   1431-6730.
  16. Lamm, Ehud; Harman, Oren; Veigl, Sophie Juliane (2020-06-01). "Before Watson and Crick in 1953 Came Friedrich Miescher in 1869". Genetics. 215 (2): 291–296. doi:10.1534/genetics.120.303195. ISSN   1943-2631.
  17. Mathews, Albert P. (1927-09-30). "Professor Albrecht Kossel". Science. 66 (1709): 293–293. doi:10.1126/science.66.1709.293-a. ISSN   0036-8075.
  18. Thachil, Jecko (2021-11-02). "Protamine—The Journey from DNA to Heparin Neutralization to Gene therapy". Seminars in Thrombosis and Hemostasis. 48 (02): 240–243. doi:10.1055/s-0041-1736574. ISSN   0094-6176.
  19. Ando, Toshio; Yamasaki, Makoto; Suzuki, Koichi (1973), "Chemical Structure of Nucleoprotamines and Protamines", Protamines, Berlin, Heidelberg: Springer Berlin Heidelberg, pp. 30–40, ISBN   978-3-642-46296-2 , retrieved 2024-04-15
  20. Corfield, M. C.; Robson, A. (1953-10-01). "The amino acid composition of salmine". Biochemical Journal. 55 (3): 517–522. doi:10.1042/bj0550517. ISSN   0306-3283.
  21. Ransdell HT, Haller JA, Stowens D, Barton PB (May 1965). "Renal toxicity of polybrene (hexadimethrine bromide)". The Journal of Surgical Research. 5 (5): 195–199. doi:10.1016/S0022-4804(65)80086-5. PMID   14281435.