DDAVP and factor VIII: a tale from Edinburgh
2003; Elsevier BV; Volume: 1; Issue: 4 Linguagem: Inglês
10.1046/j.1538-7836.2003.00191.x
ISSN1538-7933
Autores Tópico(s)Enzyme Production and Characterization
ResumoJournal of Thrombosis and HaemostasisVolume 1, Issue 4 p. 619-621 Free Access DDAVP and factor VIII: a tale from Edinburgh J. D. Cash, J. D. Cash Former Director of the Scottish National Blood Transfusion Service, Edinburgh, UKSearch for more papers by this author J. D. Cash, J. D. Cash Former Director of the Scottish National Blood Transfusion Service, Edinburgh, UKSearch for more papers by this author First published: 21 March 2003 https://doi.org/10.1046/j.1538-7836.2003.00191.xCitations: 4 Professor John Cash, 1 Otterburn Park, Craiglockhart Drive South, Edinburgh, UK. E-mail: cash_rcpe@ednet.co.uk AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat The DDAVP/factor (F)VIII story, as viewed from Edinburgh, is a tale of serendipity. The truth is we were searching for a better understanding of the physiological control mechanisms for the release plasminogen activator (PA) in man, and perhaps thereby contribute to the development of a therapeutic agent that would assist the dissolution of clots. In the event we found an agent that promoted clot formation! In 1958 I was persuaded by the late Mary Pickford FRS to take temporary leave from my undergraduate studies in the Edinburgh Medical School and spend 12 months reading human physiology in the Department of Physiology. At that time Pickford was Reader in this Department and its head was David Whitteridge FRS. During this memorable year, I had an opportunity to spend several weeks working in Pickford's laboratory and became fascinated with her interest in and expertise and international reputation on the interactions between the endocrine/humoral systems and blood vessel wall function. I was also influenced by Reg Passmore (another Reader in the Department) who taught me much about the physiology of exercise. This year spent reading physiology proved to be one of the most influential in my life. I became enthused with the interface between the endocrine system and the blood vessel and learnt some of the basics of scientific investigative methodology. I also learnt to survive the wrath of a distinguished and authoritative Head of Department who tried, but without success, to persuade me to give up playing rugby football for the 1958 season and concentrate on the study of physiology. Some 30 years later I was to renew my acquaintance with Mary Pickford, Reg Passmore and David Whitteridge; they were memorable occasions. In 1956 I joined the Royal Medical Society in Edinburgh − a unique and ancient undergraduate Society founded in 1737. This learned Society facilitated discussion and debate among its members on all things medical. On joining, members were expected to accept, if invited, an invitation to lead an evening's discussion and in doing so select the topic for the event and introduce it with a dissertation of not more than 30 min. In the Spring of 1960 I received my invitation to lead the Society meeting on 20 January 1961. In the months before the event I spent much time trying to find a topic that would be both novel and retain interest. The Lancet came to my rescue when I read an article entitled, 'The effect of beer on blood fibrinolytic activity'[1]. At the time I (and my fellow students) knew much about beer, but nothing about the fibrinolysis. Fibrinolysis was to be the topic for my dissertation and I entered a new world of an enzyme system in man, which appeared to act as a defense against thrombosis and whose prime trigger (PA) was synthesized in endothelial cells [2]. I spent some time discussing this with Pickford and not surprisingly she pointed out that there was little data to explain the control mechanisms for the release of PA in man. As a consequence, I determined that if in the future I could somehow generate an opportunity to contribute to this field then I would take it – beginning with exercise and thereafter explore the possible role of adrenergic mechanisms in controlling the release of plasminogen activator (PA). This dream had been developing since the summer of 1960 when I spent 6 weeks in the laboratory of George Fearnley in Gloucester and visited Alister Todd in Dundee. The opportunity to begin these studies came in 1964 when, during my postgraduate internal medicine training, I was advised by Ken Donald (Regis Professor of Medicine) to take time off and undertake some research, which could be submitted for a PhD thesis. I readily accepted this proposal but to his dismay insisted I wished to work in the area of fibrinolysis rather than in his area of expertise − cardio-pulmonary physiology. To his great credit, and my good fortune, he arranged for me to be seconded to the South-east Scotland Regional Blood Transfusion Centre (headed by Robert Cumming) where biochemical work on fibrinolysis was already underway. I rapidly settled into this new environment. Within 6 months, through the good offices of Cumming, I had a well-equipped laboratory of my own and the beginnings of a research team when Gordon Allan (an outstanding technician) was seconded to the laboratory. I was also given free access to the exercise laboratory in Donald's department and Howard Davies (Senior Haematologist at the Royal Infirmary Edinburgh) agreed to act as supervisor for my PhD. As in most research ventures first efforts were directed towards methodology [3]. Thereafter, we began a series of experiments using exercise as the physiological stimulus of PA release in man. These studies suggested that there was a small subpopulation of healthy volunteers who seemed to be consistently 'poor releasers' of PA following exercise [4]. Prolonged mental stress was the only factor we found which changed (diminished) this PA response to exercise [5]. This latter observation was the subject of many discussions with and later played a significant contribution to directing our attention to the effects of vasopressin. The publication of these early findings had two important effects. Our team enlarged with the arrival of Graeme Woodfield (from New Zealand) in 1967 and Abdul Gader (from the Sudan) in 1970. Graeme directed most of his attention to the fibrinolytic enzyme system in pregnancy and Abdul joined the team, which had already started to explore the PA responses to adrenergic agonists and antagonists in healthy volunteers. Quite by chance I had the remarkable good fortune to discuss the early results on our PA/adrenergic receptor studies with Ilsley Ingram. He was characteristically generous in his comments but gently admonished me for not giving any attention to FVIII. Ilsley Ingram had performed some of the first key studies on the effects of adrenergic agonists on the FVIII release in man [6] and it was he who persuaded us to go back and do some further work, but this time incorporate FVIII responses. I recall Graeme Woodfield voiced his strong support of Ingram's suggestions. The outcome of this programme of experiments revealed that the PA response in man to intravenous adrenergic agonist was exclusively beta-2 receptor in origin but that it could only be partially blocked with the beta blockers available at that time [7, 8]. We were unable to explain these PA observations. On the other hand the FVIII responses seemed also to be beta-2 type but behaved in the way first reported by Ingram's group [9] − they were completely blocked by the beta blockers. Further studies suggested the FVIII and PA adrenergic endothelial receptors might be physically close or perhaps overlap in some way [10]. The anomalous results in the PA/adrenergic receptor studies, combined with those earlier studies on mental stress, led us to explore the effects of posterior pituitary hormones. The first experiments in 1972 were frustrating. Infusions of Pitressin into healthy volunteers produced so many severe gastrointestinal side-effects (well known to hepatologists) that we felt able to explain the marked associated PA and FVIII responses to a secondary release of endogenous catecholamines. As a consequence the posterior pituitary programme ground to a halt. In the early summer of 1972 I attended the annual scientific meeting of the European Society for Clinical Investigation in Scheveningen, the Netherlands. A Joe Cort from Prague presented a paper on the antidiuretic effects of a peptide (DDAVP) in healthy volunteers. I listened to this presentation with mounting excitement. This man had synthesized a peptide with powerful ADH properties but was devoid of the unpleasant side-effects of Pitressin. The question was, would it release PA and FVIII? The other question was, what was an American scientist doing synthesizing peptides in Prague during the Cold War? I waylaid Joe as he left the rostrum and soon learnt that he was probably the only US citizen who had defected to the Eastern Block. We were later joined by Jan Mulder (CEO of a small Swedish pharmaceutical company (Ferring) which was manufacturing the peptides developed by Cort's group in Prague). Joe and Jan knew nothing about the fields of hemostasis and fibrinolysis and I suggested they came to Edinburgh, met the team and hear about our work. This they did 10 days later and, at the end of an exciting day over dinner in the Caledonian Hotel, Jan Mulder handed me 5 vials of DDAVP, along with suggestions about intravenous dosages. One week later we had demonstrated (I was the volunteer) that DDAVP produced a dose-related PA response and seemed without side-effects. These results were immediately transmitted to Mulder and Cort. More DDAVP was dispatched allowing us to confirm the original observations on several other healthy volunteers [11]. It must be confessed that our primary interest had always been PA and in the excitement of this first DDAVP chase the FVIII assays, we had promised Ilsley Ingram to incorporate, were not done until a week or so later (and on frozen/thawed samples). When available, the results amazed us and were deemed to be of such potential clinical importance that we undertook further infusions of DDAVP and made sure the FVIII assays were done on non-frozen/thawed samples. The original observations were confirmed and, using the FVIII assays available at the time, we conclude that DDAVP stimulated a release of FVIII in healthy volunteers. The team spent much of the evening when these FVIII results were finally confirmed discussing what to do next. It seemed possible that these findings might be of potential clinical importance in the management of mild and moderate hemophiliacs. Accordingly, we agreed I would speak to the Director of the Haemophilia Center in Edinburgh and seek his permission to undertake DDAVP infusions into one or two mild and moderate hemophilia A patients. Looking back, although mortified at the time, I have some sympathy with the Edinburgh Haemophilia Centre Director's position. In short, he took the view that he could not, on the information available, agree to the proposed experiments on his patients. That evening I returned to our group (Abdul Gader, Tony Clarkson, John da Costa and Gordon Allen) with the 'bad news'. We agreed that I should call Piero Mannucci and see if he would be interested and able to undertake the key patient experiments. (I believe the first time I met Piero Mannucci was in 1971, at the 2nd Congress of the International Society for Thrombosis and Haemostasis in Oslo. At this meeting we must have discussed our mutual interests in the neurohumoral control of coagulation and fibrinolysis. We particularly enjoyed the later visit of Zaverio Ruggeri (one of Piero Mannucci's research team) and introduced him to the arts of measuring FDPs, tickling brown trout and avoiding wild Scottish honey bees.) The following morning I contacted Piero and as expected he conveyed extreme interest, agreed to undertake the proposed experiments and requested that I contacted Jan Mulder to arrange that supplies of DDAVP be shipped to Milan. That morning saw the arrival of a group of other peptides from Jan Mulder which allowed us to quickly undertake preliminary structural receptor studies on the responses to DDAVP [12]. Jan Mulder was less than enthusiastic with our recommendation that the developing clinical DDAVP/FVIII work should move to Milan. He was conscious of the sensitivities of his company's Swedish roots and wished to see this part of the programme develop under the supervision of Inga Marie Nilsson in Malmö. He also believed that from a purely commercial/licensing point of view this novel clinical work would be better done in Sweden. Joe Cort proved decisive in persuading Jan Mulder to accept our recommendation, although Jan insisted that before a final decision was taken he would go to Milan and visit Mannucci's group. As expected Mulder was well pleased with what he found in Milan and as expected there was much subsequent collaboration between the Swedish and Italian groups in this area. Supplies of DDAVP were soon thereafter sent to Milan. In due course, Mannucci's group, in close collaboration with Inga Marie Nilsson's group in Malmö, confirmed that mild and moderate hemophila patients were able to release FVIII to this peptide. Fortuitously, these important clinical observations were to have a profound worldwide impact. At a critical time in the developing HIV tragedy, DDAVP limited the exposure of these patients to FVIII concentrates. Soon, thereafter, Jan Mulder died following a boat accident. We advised Joe Cort, who had acquired a Presidential pardon and was now returning to the USA, that further explorations of the FVIII/DDAVP saga should be led by the Milan group. The Edinburgh team would now direct its attention exclusively to elucidating the nature of the receptors controlling the release of PA from endothelial cells, with a view to developing a drug, which might contribute to the emerging field of thrombolytic therapy. After an initial disappointing sortie [13] our work in this area suddenly lost impetus, primarily as a consequence of the shocking and tragic news that Joe Cort had been sacked from his university following allegations of scientific fraud. Of no less relevance was my own career change, which saw me turning away from 'hands on' research management to corporate (health service) management. It has been said that an attractive definition of serendipity is the one, which describes the man who searched for a needle in the haystack and found the farmer's daughter. There is much resonance to this agricultural story in regard to Edinburgh's contribution to the DDAVP/FVIII connection. But for the man in the haystack and us − the search was fun! References 1 Fearnley GR, Ferguson J, Chakrabati R, Vincent CT. Effect of beer on blood fibrinolytic activity. Lancet 1960; i: 184– 6. CrossrefGoogle Scholar 2 Todd AS. The histological localisation of fibrinolysin activator. J Path Bact 1959; 78: 281– 3. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 3 Cash JD. Leask Multichannel system for the automatic recording of clot lysis J Clin Path 1967; 20: 209– 10.CrossrefCASPubMedWeb of Science®Google Scholar 4 Cash JD. Effect of moderate exercise on the fibrinolytic enzyme system in young men and women. Br Med J 1966; 2: 502– 6. CrossrefCASPubMedWeb of Science®Google Scholar 5 Cash JD, Allan AGE. The effect of mental stress on the fibrinolytic reactivity to exercise. Br Med J 1967; 1: 545– 8.CrossrefPubMedWeb of Science®Google Scholar 6 Forwell GD, Ingram GIC. The effect of adrenaline infusions on human blood coagulation. J Physiol 1957; 135: 371– 3. Wiley Online LibraryPubMedWeb of Science®Google Scholar 7 Cash JD, Woodfield DG, Allen AGE. Adrenergic mechanism in the systemic plasminogen activator response to adrenaline in man. Br J Haematol 1970; 18: 487– 93.Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 8 Gader AMA, Clarkson AR, Cash JD. The plasminogen activator and coagulation factor VIII responses to adrenaline, noradrenaline, isoprenaline and salbutamol in man. Thromb Res 1973; 2: 9– 16. CrossrefCASGoogle Scholar 9 Ingram GIC, Vaughan Jones R. The rise in clotting factor VIII induced in man by adrenaline; effect of alpha and beta blockers. J Physiol 1966; 187: 447– 9.Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 10 Gader AMA, Da Costa J, Cash JD. The effect of propranolol, alprenolol, and practolol on the firbrinolytic and factor VIII responses to adrenaline and salbutamol in man. Thromb Res 1974; 4: 25– 33. CrossrefCASPubMedWeb of Science®Google Scholar 11 Gader AMA, Da Costa J, Cash JD. A new vasopressin analogue and fibrinolysis. Lancet 1973; ii: 1417. CrossrefGoogle Scholar 12 Cash JD, Gader AMA, Da Costa J. The release of plasminogen activator and factor VIII to lysine vasopressin, arginine vasopressin, DDAVP and oxytocin in man. Br J Haematol 1974; 27: 363– 4.PubMedWeb of Science®Google Scholar 13 Cash JD, Gader AMA, Mulder JL, Cort JH. Structure-activity relations of the fibrinolytic response to vasopressins in man. Clin Sci Mol Med 1978; 54: 403– 9.CASPubMedWeb of Science®Google Scholar Citing Literature Volume1, Issue4April 2003Pages 619-621 ReferencesRelatedInformation
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