Streptokinase

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Streptokinase
Sk surface 3.png
Complex of catalytic domain of human plasmin and streptokinase
Clinical data
Other namesSK
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Routes of
administration 		Intravenous
ATC code
Identifiers
CAS Number
DrugBank
ChemSpider
  • none
UNII
ECHA InfoCard 100.029.667 OOjs UI icon edit-ltr-progressive.svg
Chemical and physical data
Formula C2100H3278N566O669S4
Molar mass 47286.86 g·mol−1

Streptokinase is a thrombolytic medication activating plasminogen by nonenzymatic mechanism. [1] As a medication it is used to break down clots in some cases of myocardial infarction (heart attack), pulmonary embolism, and arterial thromboembolism. [2] The type of heart attack it is used in is an ST elevation myocardial infarction (STEMI). [3] It is given by injection into a vein. [2]

Contents

Side effects include nausea, bleeding, low blood pressure, and allergic reactions. [2] A second use in a person's lifetime is not recommended. [2] While no harm has been found with use in pregnancy, it has not been well studied in this group. [4] Streptokinase is in the antithrombotic family of medications and works by turning on the fibrinolytic system. [3]

Streptokinase was discovered in 1933 from beta-hemolytic streptococci. [5] It is on the World Health Organization's List of Essential Medicines. [6] It is no longer commercially available in the United States. [7]

Medical uses

If percutaneous coronary intervention (PCI) is not available within 90–120 minutes of first contact, streptokinase is recommended intravenously as soon as possible after the onset of a ST elevation myocardial infarction (STEMI). As streptokinase is a bacterial product, the body has the ability to build up an immunity to it. Therefore, it is recommended that this medication should not be used again after four days from the first administration, as it may not be as effective and can also cause an allergic reaction. For this reason, it is usually given only for a person's first heart attack. Further thrombotic events could be treated with tissue plasminogen activator (tPA). Overdose of streptokinase or tPA can be treated with aminocaproic acid.

Contraindications

Absolute

Relative

[8]

Mechanism of action

Streptokinase C
Identifiers
Organism Streptococcus dysgalactiae subsp. equisimilis
Symbolskc
Entrez 8110746
PDB 1BML
UniProt P00779
Search for
Structures Swiss-model
Domains InterPro
Staphylokinase/Streptokinase family
PDB 2sak EBI.jpg
Structure of staphylokinase, a plasminogen activator. [9]
Identifiers
SymbolStaphylokinase
Pfam PF02821
InterPro IPR004093
SCOP2 2sak / SCOPe / SUPFAM
Available protein structures:
Pfam   structures / ECOD  
PDB RCSB PDB; PDBe; PDBj
PDBsum structure summary
PDB 1bml ​, 1bui ​, 1c4p ​, 1c76 ​, 1c77 ​, 1c78 ​, 1c79 ​, 1l4d ​, 1l4z ​, 1qqr ​, 1ssn ​, 2sak ​
Proposed counterion for Asp740 is Lys698 create salt-bridge Saltbridge 1.png
Proposed counterion for Asp740 is Lys698 create salt-bridge
Substrate Enzyme Mechanism Movie Sk-plgn 57.png
Substrate Enzyme Mechanism Movie

Streptokinase belongs to a group of medications known as fibrinolytics, and complexes of streptokinase with human plasminogen can hydrolytically activate other unbound plasminogen by activating through bond cleavage to produce plasmin. There are three domains to streptokinase, denoted α (residues 1–150), β (residues 151–287), and γ (residues 288–414). Each domain binds plasminogen, although none can activate plasminogen independently. [10]

Plasmin is produced in the blood to break down fibrin, the major constituent of blood thrombi, thereby dissolving clots once they have fulfilled their purpose of stopping bleeding. Extra production of plasmin caused by streptokinase breaks down unwanted blood clots, for example, in the lungs (pulmonary embolism). The usual activation of plasminogen is by proteolysis of the Arg561—Val562 bond. [11] The amino group of Val562 then forms a salt-bridge with Asp740, which triggers a conformational change producing the active protease plasmin. When streptokinase is present, it binds to plasminogen to form a complex (streptokinase·plasminogen) that converts substrate plasminogen to plasmin. Residues 1–59 of streptokinase regulate its capacity to induce an active site in bound plasminogen by a nonproteolytic mechanism and to activate substrate plasminogen in a fibrin-independent manner. This complex subsequently rearranges to an active complex although the Arg561–Val562 bond remains intact. Therefore, another residue must substitute for the free amino group of Val562 and provide a counterion for Asp740 in this active complex. [12] Two candidates for this counterion have been suggested: Ile1 of streptokinase and Lys698 of plasminogen. Deletion of Ile1 of streptokinase markedly inhibits its capacity to induce an active site in plasminogen, which supports the hypothesis that establishment of a salt bridge between Ile1 of streptokinase and Asp740 of plasminogen is necessary for streptokinase to induce an active site in plasminogen by a nonproteolytic mechanism. [13] In contrast with the Ile1 substitutions, the Lys698 mutations also decreased the dissociation constant of the streptokinase complex by 15 to 50 fold. These observations suggest that Lys698 is involved in formation of the initial streptokinase·plasminogen complex. [14]

Biology

Streptokinase is naturally produced by Streptococci spp. bacteria, which use this enzyme to break up blood clots so that they can spread from the initial site of infection. It can also activate fibrin. [15]

It is similar, both in function and in structure, to staphylokinase (Sak) found in Staphylococcus aureus. Staphylokinase is considered a virulence factor, [16] although its presence after the establishment of infection actually decreases disease severity. Both enzymes are carried by phages. [17]

History

After many years of work along with his student Sol Sherry, William S. Tillett discovered streptokinase in 1933. Initially used in treatment of fibrinous pleural exudates, hemothorax and tuberculous meningitis, its role in acute myocardial infarction was serendipitous. [5]

Research

Streptokinase may find a use in helping to prevent postoperative adhesions, a common complication of surgery, especially abdominal surgery (appendectomy, gall stones, hysterectomy, etc.) One study using animal models (rats) found that when used with a PHBV membrane drug-delivery system, it was 90 percent effective in preventing adhesions. [18] However, it has not been shown to be effective in humans in a clinical trial.

Marketing

It is marketed in Chile as Streptase by Alpes Selection, under license of CSL Behring Germany.

Available in Vietnam under the name Mutose. Available in Cuba, Venezuela, Ecuador and other Latin American countries under the trademark Heberkinasa, commercialized by Heber Biotech, Havana, Cuba. Available in India under the name STPase by Cadila Pharmaceuticals, and Myokinase by Biocon Limited.

Related Research Articles

<span class="mw-page-title-main">Thrombus</span> Blood clot

A thrombus, colloquially called a blood clot, is the final product of the blood coagulation step in hemostasis. There are two components to a thrombus: aggregated platelets and red blood cells that form a plug, and a mesh of cross-linked fibrin protein. The substance making up a thrombus is sometimes called cruor. A thrombus is a healthy response to injury intended to stop and prevent further bleeding, but can be harmful in thrombosis, when a clot obstructs blood flow through healthy blood vessels in the circulatory system.

<span class="mw-page-title-main">Coagulation</span> Process of formation of blood clots

Coagulation, also known as clotting, is the process by which blood changes from a liquid to a gel, forming a blood clot. It potentially results in hemostasis, the cessation of blood loss from a damaged vessel, followed by repair. The mechanism of coagulation involves activation, adhesion and aggregation of platelets, as well as deposition and maturation of fibrin.

<span class="mw-page-title-main">Disseminated intravascular coagulation</span> Medical condition

Disseminated intravascular coagulation (DIC) is a condition in which blood clots form throughout the body, blocking small blood vessels. Symptoms may include chest pain, shortness of breath, leg pain, problems speaking, or problems moving parts of the body. As clotting factors and platelets are used up, bleeding may occur. This may include blood in the urine, blood in the stool, or bleeding into the skin. Complications may include organ failure.

<span class="mw-page-title-main">Fibrinogen</span> Soluble protein complex in blood plasma and involved in clot formation

Fibrinogen is a glycoprotein complex, produced in the liver, that circulates in the blood of all vertebrates. During tissue and vascular injury, it is converted enzymatically by thrombin to fibrin and then to a fibrin-based blood clot. Fibrin clots function primarily to occlude blood vessels to stop bleeding. Fibrin also binds and reduces the activity of thrombin. This activity, sometimes referred to as antithrombin I, limits clotting. Fibrin also mediates blood platelet and endothelial cell spreading, tissue fibroblast proliferation, capillary tube formation, and angiogenesis and thereby promotes revascularization and wound healing.

<span class="mw-page-title-main">Thrombin</span> Enzyme involved in blood coagulation in humans

Thrombin is a serine protease, an enzyme that, in humans, is encoded by the F2 gene. Prothrombin is proteolytically cleaved to form thrombin in the clotting process. Thrombin in turn acts as a serine protease that converts soluble fibrinogen into insoluble strands of fibrin, as well as catalyzing many other coagulation-related reactions.

Fibrinolysis is a process that prevents blood clots from growing and becoming problematic. Primary fibrinolysis is a normal body process, while secondary fibrinolysis is the breakdown of clots due to a medicine, a medical disorder, or some other cause.

<span class="mw-page-title-main">Thrombolysis</span> Breakdown (lysis) of blood clots formed in blood vessels, using medication

Thrombolysis, also called fibrinolytic therapy, is the breakdown (lysis) of blood clots formed in blood vessels, using medication. It is used in ST elevation myocardial infarction, stroke, and in cases of severe venous thromboembolism.

<span class="mw-page-title-main">Tissue-type plasminogen activator</span> Protein involved in the breakdown of blood clots

Tissue-type plasminogen activator, short name tPA, is a protein involved in the breakdown of blood clots. It is encoded in the human by the PLAT gene. It is a serine protease found on endothelial cells, the cells that line the blood vessels. As an enzyme, it catalyzes the conversion of plasminogen to plasmin, the major enzyme responsible for clot breakdown. Human tPA has a molecular weight of ~70 kDa in the single-chain form.

<span class="mw-page-title-main">Plasmin</span> Enzyme in human blood that degrades clots and other proteins

Plasmin is an important enzyme present in blood that degrades many blood plasma proteins, including fibrin clots. The degradation of fibrin is termed fibrinolysis. In humans, the plasmin protein is encoded by the PLG gene.

<span class="mw-page-title-main">Urokinase</span> Human protein

Urokinase, also known as urokinase-type plasminogen activator (uPA), is a serine protease present in humans and other animals. The human urokinase protein was discovered, but not named, by McFarlane and Pilling in 1947. Urokinase was originally isolated from human urine, and it is also present in the blood and in the extracellular matrix of many tissues. The primary physiological substrate of this enzyme is plasminogen, which is an inactive form (zymogen) of the serine protease plasmin. Activation of plasmin triggers a proteolytic cascade that, depending on the physiological environment, participates in thrombolysis or extracellular matrix degradation. This cascade had been involved in vascular diseases and cancer progression.

<span class="mw-page-title-main">Alteplase</span> Thrombolytic medication

Alteplase, sold under the brand name Activase among others, is a biosynthetic form of human tissue-type plasminogen activator (t-PA). It is a thrombolytic medication used to treat acute ischemic stroke, acute ST-elevation myocardial infarction, pulmonary embolism associated with low blood pressure, and blocked central venous catheter. It is given by injection into a vein or artery. Alteplase is the same as the normal human plasminogen activator produced in vascular endothelial cells and is synthesized via recombinant DNA technology in Chinese hamster ovary cells (CHO). Alteplase causes the breakdown of a clot by inducing fibrinolysis.

<span class="mw-page-title-main">Factor XIII</span>

Factor XIII or fibrin stabilizing factor is a zymogen found in blood of humans and some other animals. It is activated by thrombin to factor XIIIa. Factor XIIIa is an enzyme of the blood coagulation system that crosslinks fibrin. Deficiency of XIII worsens clot stability and increases bleeding tendency.

<span class="mw-page-title-main">Plasminogen activator</span> Type of protein

Plasminogen activators are serine proteases that catalyze the activation of plasmin via proteolytic cleavage of its zymogen form plasminogen. Plasmin is an important factor in fibrinolysis, the breakdown of fibrin polymers formed during blood clotting. There are two main plasminogen activators: urokinase (uPA) and tissue plasminogen activator (tPA). Tissue plasminogen activators are used to treat medical conditions related to blood clotting including embolic or thrombotic stroke, myocardial infarction, and pulmonary embolism.

Anistreplase is a thrombolytic drug. It is also known as anisoylated plasminogen streptokinase activator complex (APSAC). As a thrombolytic drug, it is used to treat blood clots in emergency situations.

Tenecteplase, sold under the trade names TNKase, Metalyse and Elaxim, is an enzyme used as a thrombolytic drug.

<span class="mw-page-title-main">Désiré Collen</span> Belgian chemist, physician

Désiré, Baron Collen is a Belgian physician, chemist, biotechnology entrepreneur and life science investor. He made several discoveries in thrombosis, haemostasis and vascular biology in many of which serendipity played a significant role. His main achievement has been his role in the development of tissue-type plasminogen activator (t-PA) from a laboratory concept to a life-saving drug for dissolving blood clots causing acute myocardial infarction or acute ischemic stroke. Recombinant t-PA was produced and marketed by Genentech Inc as Activase and by Boehringer Ingelheim GmbH as Actilyse, and is considered biotechnology's first life saving drug.

Staphylokinase is a protein produced by Staphylococcus aureus. It contains 136 amino acid residues and has a molecular mass of 15kDa. Synthesis of staphylokinase occurs in late exponential phase. It is similar to streptokinase.

The fibrinolysis system is responsible for removing blood clots. Hyperfibrinolysis describes a situation with markedly enhanced fibrinolytic activity, resulting in increased, sometimes catastrophic bleeding. Hyperfibrinolysis can be caused by acquired or congenital reasons. Among the congenital conditions for hyperfibrinolysis, deficiency of alpha-2-antiplasmin or plasminogen activator inhibitor type 1 (PAI-1) are very rare. The affected individuals show a hemophilia-like bleeding phenotype. Acquired hyperfibrinolysis is found in liver disease, in patients with severe trauma, during major surgical procedures, and other conditions. A special situation with temporarily enhanced fibrinolysis is thrombolytic therapy with drugs which activate plasminogen, e.g. for use in acute ischemic events or in patients with stroke. In patients with severe trauma, hyperfibrinolysis is associated with poor outcome. Moreover, hyperfibrinolysis may be associated with blood brain barrier impairment, a plasmin-dependent effect due to an increased generation of bradykinin.

<span class="mw-page-title-main">Reperfusion therapy</span>

Reperfusion therapy is a medical treatment to restore blood flow, either through or around, blocked arteries, typically after a heart attack. Reperfusion therapy includes drugs and surgery. The drugs are thrombolytics and fibrinolytics used in a process called thrombolysis. Surgeries performed may be minimally-invasive endovascular procedures such as a percutaneous coronary intervention (PCI), which involves coronary angioplasty. The angioplasty uses the insertion of a balloon and/or stents to open up the artery. Other surgeries performed are the more invasive bypass surgeries that graft arteries around blockages.

<span class="mw-page-title-main">Darexaban</span> Chemical compound

Darexaban (YM150) is a direct inhibitor of factor Xa created by Astellas Pharma. It is an experimental drug that acts as an anticoagulant and antithrombotic to prevent venous thromboembolism after a major orthopaedic surgery, stroke in patients with atrial fibrillation and possibly ischemic events in acute coronary syndrome. It is used in form of the maleate. The development of darexaban was discontinued in September 2011.

References

  1. ↑ Mican J, Toul M, Bednar D, Damborsky J (2019). "Structural Biology and Protein Engineering of Thrombolytics". Computational and Structural Biotechnology Journal. 17: 917–938. doi: 10.1016/j.csbj.2019.06.023 . PMC   6637190 . PMID   31360331.
  2. 1 2 3 4 World Health Organization (2009). Stuart MC, Kouimtzi M, Hill SR (eds.). WHO Model Formulary 2008. World Health Organization. pp. 291–2. hdl: 10665/44053 . ISBN   9789241547659.
  3. 1 2 "Streptokinase 1,500,000 iu - Summary of Product Characteristics (SPC) - (eMC)". www.medicines.org.uk. 1 July 2015. Archived from the original on 20 December 2016. Retrieved 14 December 2016.
  4. ↑ "Streptokinase Use During Pregnancy | Drugs.com". www.drugs.com. Archived from the original on 21 December 2016. Retrieved 14 December 2016.
  5. 1 2 Sikri N, Bardia A (2007). "A history of streptokinase use in acute myocardial infarction". Texas Heart Institute Journal. 34 (3): 318–327. PMC   1995058 . PMID   17948083.
  6. ↑ 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.
  7. ↑ "streptokinase (Intravenous route, Intracoronary route)". Truven Health Analytics. Archived from the original on 8 December 2015. Retrieved 28 November 2015.
  8. ↑ O'Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, et al. (January 2013). "2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines". Circulation. 127 (4): e362–e425. doi: 10.1161/CIR.0b013e3182742cf6 . PMID   23247304.
  9. ↑ Rabijns A, De Bondt HL, De Ranter C (May 1997). "Three-dimensional structure of staphylokinase, a plasminogen activator with therapeutic potential". Nature Structural Biology. 4 (5): 357–360. doi:10.1038/nsb0597-357. PMID   9145104. S2CID   32914387.
  10. ↑ Mundada LV, Prorok M, DeFord ME, Figuera M, Castellino FJ, Fay WP (July 2003). "Structure-function analysis of the streptokinase amino terminus (residues 1-59)". The Journal of Biological Chemistry. 278 (27): 24421–24427. doi: 10.1074/jbc.M301825200 . PMID   12704199.
  11. ↑ Young KC, Shi GY, Wu DH, Chang LC, Chang BI, Ou CP, Wu HL (January 1998). "Plasminogen activation by streptokinase via a unique mechanism". The Journal of Biological Chemistry. 273 (5): 3110–3116. doi: 10.1074/jbc.273.5.3110 . PMID   9446629.
  12. ↑ Loy JA, Lin X, Schenone M, Castellino FJ, Zhang XC, Tang J (December 2001). "Domain interactions between streptokinase and human plasminogen". Biochemistry. 40 (48): 14686–14695. doi:10.1021/bi011309d. PMID   11724583.
  13. ↑ Wang S, Reed GL, Hedstrom L (April 1999). "Deletion of Ile1 changes the mechanism of streptokinase: evidence for the molecular sexuality hypothesis". Biochemistry. 38 (16): 5232–5240. doi:10.1021/bi981915h. PMID   10213631.
  14. ↑ Wang X, Lin X, Loy JA, Tang J, Zhang XC (September 1998). "Crystal structure of the catalytic domain of human plasmin complexed with streptokinase". Science. 281 (5383): 1662–1665. doi:10.1126/science.281.5383.1662. PMID   9733510.
  15. ↑ Wang H, Lottenberg R, Boyle MD (March 1995). "Analysis of the interaction of group A streptococci with fibrinogen, streptokinase and plasminogen". Microbial Pathogenesis. 18 (3): 153–166. doi:10.1016/S0882-4010(95)90013-6. PMID   7565010.
  16. ↑ Bokarewa MI, Jin T, Tarkowski A (2006). "Staphylococcus aureus: Staphylokinase". The International Journal of Biochemistry & Cell Biology. 38 (4): 504–509. doi:10.1016/j.biocel.2005.07.005. PMID   16111912.
  17. ↑ Kwiecinski J, Jacobsson G, Karlsson M, Zhu X, Wang W, Bremell T, et al. (September 2013). "Staphylokinase promotes the establishment of Staphylococcus aureus skin infections while decreasing disease severity". The Journal of Infectious Diseases. 208 (6): 990–999. doi: 10.1093/infdis/jit288 . PMID   23801604.
  18. ↑ Yagmurlu A, Barlas M, Gursel I, Gokcora IH (2003). "Reduction of surgery-induced peritoneal adhesions by continuous release of streptokinase from a drug delivery system". European Surgical Research. 35 (1): 46–49. doi:10.1159/000067035. PMID   12566787. S2CID   37453555.
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