AU677659B2 - Method of enhancing thrombolysis - Google Patents

Description

WO 94/25582 PCT/US94/04418 METHOD OF ENHANCING THROMBOLYSIS BACKGROUND OF THE INVENTION The present application is directed towards the use of a fragment of von Willebrand Factor (vWF) comprising the platelet glycoprotein Ib (GPIb) binding domain in conjunction with known therapies to obtain enhanced protection against thrombosis, improved thrombolysis, and a decreased likelihood of reocclusion following thrombolytic treatment.

The references referred to by Arabic numerals in parentheses are found at the end of the specification immediately prior to the claims.

Von Willebrand Factor (vWF) is a large plasma protein which is synthesized in the endothelial cells which form the inner surface lining of the blood vessel wall, and by megakarocytes, the precursor of platelets.

Mature vWF is a multivalent molecule comprising domains which constitute binding sites for several proteins. One of the domains constitutes a binding site for the platelet glycoprotein Ib (GPIb). Using proteolytic digests this site has been localized to the region between amino acid residues 449 and 7?8 of mature vWF. In addition, vWF has at least two collagen binding sites, at least two heparin binding sites, a Factor VIII binding site, and a RGD site which binds to the platelet GP IIb/IIIa receptor.

Von Willebrand factor plays an important role in hemostasis and its absence results in von Willebrand disease (VWD), an inherited bleeding disorder. Recent studies have found that von Willebrand factor is essential for the WO 94/25582 PCT/US94/04418 -2formation of platelet thrombi, especially under flow conditions characterized by high shear stress, such as occur in stenosed coronary arteries Von Willebrand factor interacts with glycoprotein Ib receptors on the platelet membrane to initiate platelet adhesion (13-15) and to activate platelet release of ADP, thromboxane, and serotonin, which cause platelet aggregation and thrombus formation (16-20). Therefore, efforts have been made to prevent platelet adhesion and thrombus formation by blocking the platelet glycoprotein Ib receptors. For example, aurin tricarboxylic acid blocks the platelet glycoprotein Ib recognition site on von Willebrand factor and may be useful in antithrombotic therapy Evidence that vWF, and specifically the binding of vWF to the platelet GPIb receptor, is essential for normal platelet adhesion, is based on both clinical observations and in vitro studies. Patients with the bleeding disorder von Willebrand Disease (vWD) have reduced levels of vWF or Lre completely lacking in vWF. Alternatively, they may have defective vWF. Another disorder, Bernard-Soulier Syndrome (BSS), is characterized by platelets lacking GPIb receptors.

Iemostasis is a dynamic and ongoing process. It includes on one hand formation of clots to prevent bleeding and on the other hand dissolution and lysis of unwanted fibrin deposits and platelet aggregates in order to maintain blood flow throughout the body.

Studies have revealed that most acute transmural myocardial infarctions are caused by throrbus formation in atherosclerotic coronary arteries An interruption of the protective endothelium covering the vessel wall results in platelet adhesion and aggregation and thrombosis, which blocks the blood supply to the myocardium Thrombolytic agents such as tissue plasminogen activator

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WO 94/25582 PCT/US94/04418 -3- (t-PA) and streptokinase have been effective in the treatment of thrombosis in patients with acute transmural myocardial infarction ("Q-wave infarcts") and are often administered with adjuncts such as anticoagulants, e.g. heparin and aspirin. However, 15-20% of patients do not achieve reperfusion. In addition, reocclusion of coronary arteries has limited the efficacy of thrombolytic therapy in some patients (11-12).

Therefore, enhancing thrombolytic treatment by shortening the time to thrombolysis and reducing the incidence of reocclusion following thrombolysis would be a significant advance in the field of thrombolytic therapy.

In both thrombosis and reocclusion of coronary artery, platelet adhesion is the initiating event. In platelet adhesion, von Willebrand factor (rWF), a multivalent protein, forms a bridge between the subendothelial extracellular matrix and glycoprotein Ib on the surface of circulating platelets (13-15). The adhesion of platelets to the subendothelium results in the activation of platelets and the release of adenosine diphosphate (ADP), thromboxane, and serotonin. These in turn activate additional platelets.

Ultimately, a platelet plug forms (16-20). Therefore, preventing platelet adhesion may be useful in preventing thrombosis and reocclusion in coronary arteries (21).

Several peptides isolated from von Willebrand factor have been shown to bind to the platelet membrane glycoprotein Ib receptor and inhibit the interaction of von Willebrand factor with glycoprotein Ib receptors. This inhibition has led to the inhibition of platelet adhesion and aggregation (22,23).

One such peptide, designated VCL, is a recombinant fragment of von Willebrand factor, Leu 5m Lys 7

Z

B

with a single WO 94/25582 PCT/US94/04418 -4intrachain disulfide bond linking residues Cys 5 0 and Cys 69 (23) VCL is disclosed in coassigned International Patent Application Publication No. W091/13903 which also discloses a method of inhibiting platelet aggregation in a subject prior to or after the subject has undergone angioplasty, thrombolytic treatment or coronary bypass surgery by use of the vWF fragment alone to achieve the desired effect.

It has now been surprisingly and unexpectedly discovered that administration of a vWF polypeptide fragment comprising the GPIb binding domain in conjunction with thrombolytic therapy provides greatly improved therapeutic results. In one aspect, the time required for thrombolysis is considerably lessened as evidenced by the shortened time to reperfusion. In another aspect there is a much lower incidence of reocclusion following the thrombolytic therapy.

If occurrence of thrombosis is foreseen, such as may occur during surgery e.g. cardiovascular surgery, pretreatment with the vWF polypeptide fragment may reduce occurrence of thrombosis.

Additionally, it has been discovered that the vWF GPIb binding domain polypeptide and aspirin synergistically prevent complications following traumatic vascular damage.

WO 94/25582 PCT/US94/04418 SUMMARY OF THE INVENTION The present invention provides a method of enhancing thrombolysis comprising administering a vWF GPIb binding domain polypeptide in conjunction with a thrombolytic agent and an anticoagulant which results in the shortening of the time to thrombolysis and reducing the incidence of reocclusion following thrombolysis.

In an additional embodiment, the invention provides a method for preventing complications following traumatic vascular damage in a subject comprising administering to the subject an amount of a vWF GPIb binding domain polypeptide in conjunction with an amount of aspirin, which together are effective to prevent the complications.

I- L I II~ L WO 94/25582 PCT/US94/04418 BRIEF DESCRIPTION OF THE FIGURES Figure 1: Plasmid pvWF-VC3 This figure shows plasmid pvWF-VC3 which expresses a vWF GPIb binding domain polypeptide under the control of the deo

PIP

2 promoter. This plasmid has been deposited in E. coli S0930 under ATCC Accession No. 68241.

Figure 2: Plasmid pvWF-VCL This figure shows plasmid pvWF-VCL which is under control of the XPL promoter and the deo ribosomal binding site and expresses the same vWF GPIb binding domain polypeptide as pvWF-VC3. This plasmid has been deposited in E.coli 4300(F') under ATCC Accession No. 68242.

Figures 3A-3C: Translated Sequence of the vWF GPIb Binding Domain Polypeptide Expressed by Plasmids pvWF-VC3 and pvWF-VCL This figure shows the translated sequence of the von Willebrand Factor GPIb binding domain polypeptide expressed by plasmids pvWF-VC3 (ATCC Accession No. 68241) and pvWF-VCL (ATCC Accession No. 68242). The sequence consists of 226 amino acids including an N-terminal methionine.

The nucleotide and amino acid numbering starting from 1 are shown in the margins. Met' is the initiator methionine. The sequence Leu 2 Lys 2 is identical to the sequence Leu 54 Lys 728 of von Willebrand factor as shown in Figure 12 of International Application Publication No. W091/13093.

Ficure 4: Occlusion Time in Pretreated Dogs Elapsed times from electrical injury to the formation of -e WO 94/25582 PCT/US94/04418 -7occlusive thrombi in coronary arteries of animals pretreated with saline, VCL,and aspirin (ASA) intravenously (protocol Compared to saline, *p 0.05; <0.001.

Figure 5: Thrombolysis Time in Pretreated Dogs Elapsed times from t-PA administration to thrombolysis in coronary arteries of animals pretreated with saline, VCL, and aspirin'(ASA) intravenously (protocol Compared to saline, *p 0.05.

Fiure 6. Thrombolysis Time in Non-pretreated Dogs Elapsed times from intravenous administration of thrombolytic agents to thrombolysis in coronary arteries of animals that were not pretreated (protocol 2).

Figure 7: Reocclusion Time in Pretreated Dogs Elapsed times from thrombolysis to reocclusion of coronary arteries in animals pretreated with saline, VCL, and aspirin (protocol Compared to saline plus t-PA and aspirin plus t-PA, *p 0.05.

Figure 8: Reocclusion Time in Non-pretreated Dogs Elapsed times from thrombolysis to reocclusion of coronary arteries of animals treated with t-PA, heparin, VCL, and aspirin (protocol Compared to t-PA plus heparin and t-PA plus heparin plus aspirin, *p 0.05; p 0.001.

Figure 9: Hematocrit Following Thrombolytic Treatment Changes in hematocrit before and after treatments with t-PA, heparin, VCL, and aspirin (protocol 2).

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WO 94/25582 PCT/US94/04418 -8- Figure 10: Clotting Time Following Thrombolytic Treatment Activated clotting times (ACT) before (time 0) and 5, 120, and 180 min after treatments with t-PA, heparin, VCL, and aspirin (ASA) (protocol Compared to control levels before each treatment, *p 0.05; 0.01; 0.001.

Figure 11: Platelet Aqqrecation Following VCL Treatment Changes in ex vivo ADP induced platelet aggregation (panel A) and botrocetin induced platelet aggregation (panel B) before (control) and after the treatment with intravenous VCL. Compared to control, *p 0.001.

Figure 12: Platelet Aggregation Following Aspirin Treatment Changes in ex vivo ADP induced platelet aggregation (panel A) and arachidonic acid induced platelet aggregation (panel B) before (control) and after treatment with intravenous aspirin. Compared to control, *p 0.001 Figure 13 Synervy of GPIb Binding Domain Polypeptide With Aspirin This figure shows the results of the experiments described in Example 3 as the amount of platelet deposition over time.

M aspirin VCL Img/kg 2mg/kg/hr; VCL alone 4mg/kg 8mg/kg/hr; A control; y VCL alone Img/kg 2mg/kg/hr; aspirin alone.

I Is WO 94/25582 PCT/US94/04418 -9- DETAILED DESCRIPTION OF THE INVENTION The present invention is directed to a method of enhancing a thrombolytic treatment in a subject comprising administering to the subject, in conjunction with a thrombolytic agent and an anticoagulant, an amount of a von Willebrand factor glycoprotein Ib binding domain polypeptide effective to enhance the thrombolytic treatment.

Enhancing a thrombolytic treatment is hereby defined as shortening the time to thrombolysis and reperfusion, and reducing the incidence of reocclusion following thrombolysis.

The term "in conjunction" is defined as meaning before, during or after.

The thrombolytic agent may be any thrombolytic agent known to those skilled in the art. Examples of thrombolytic agents include tissue plasminogen activator (tPA) and streptokinase. It is also envisaged that the combination treatments of the invention may also be used in conjunction with other known methods angioplasty) of obtaining revascularization of blocked blood vessels and of maintaining blood vessel patency.

The thrombolytic treatment includes, in addition to the thrombolytic agent, other pharmaceutical substances e.g.

anticoagulants such as heparin and aspirin separately or in conjunction. Other anticoagulants known to the skilled artisan administering the thrombolytic treatment may also be used.

In a particular embodiment of the invention, the polypeptide is administered intravenously.

WO 94/25582 PCT/US94/04418 In preferred embodiments of the invention, the intravenous administration is a bolus, continuous infusion, or bolus followed by continuous infusion.

In a particular embodiment of the invention, the polypeptide is administered intravenously as a bolus of 0.4-40 mg/kg body weight.

In a more preferred embodiment of the invention, the polypeptide is administered intravenously as a bolus of 1-20 mg/kg body weight.

In an especially preferred embodiment of the invention, the polypeptide is administered intravenously as a bolus of 2-10 mg/kg body weight.

In a particular embodiment of the invention, the polypeptide is administered intravenously by continuous infusion at a rate of 0.2-20 mg/kg body weight per hour.

In an especially preferred embodiment of the invention, the polypeptide is administered intravenously by continuous infusion at a rate of 1-10 mg/kg body weight per hour.

In the most preferred embodiment of the invention, the polypeptide is administered intravenously as a bolus of 0.4- 4 mg/kg body weight followed by continuous infusion of 0.2mg/kg body weight per hour.

In yet another aspect, the invention relates to situations in which occurrence of thrombosis may be foreseen, such as during surgery, for example cardiovascular surgery. In such situations, pretreatment with the vWF GPIb binding domain polypeptide may reduce the occurrence of thrombosis.

In another aspect, the invention provides a method for I WO 94/25582 PCT/US94/04418 -11preventing complications following traumatic vascular damage in a subject comprising administering to the subject an amount of a vWF GPIb binding domain polypeptide in conjunction with an amount of aspirin, which together are effective to prevent the complications.

The cause of the traumatic vascular damage is exemplified by but iot limited to coronary artery bypass surgery, angioplasty, thrombolysis, or unstable angina. Traumatic vascular damage caused by other therapeutic or clinical occurrences is also encompassed. The complications resulting from the traumatic vascular damage are exemplified by but not limited to myocardial infarction, ischemia, coronary bypass surgery, repeat angioplasty, or death.

Other complications resulting from traumatic vascular damage are also encompassed.

The effective amount of the vWF GPIb binding domain polypeptide is in the range of about 0.1-20 mg/kg bolus and 0.1-20 mg/kg/hr continuous 'nfusion of and the effective amount of aspirin i£ in the.range of about 0.1-50 mg/kg.

The precise dosages will be readily determined by one skilled in the art based on the details of the case in treatment.

The vWF GPIb binding domain polypeptide may be administered by any clinically appropriate means known to one skilled in the art; intravenous administration is a presently preferred embodiment.

The spirin may be administered by any clinically acceptable means such as orally or parenterally and may be administered in a single dose, in multiple doses or by continuous administration. Parenteral adminisration refers to intravenous, intraperitoneal, subcutaneous or intramuscular administration.

WO 94/25582 PCT/US94/04418 -12- The glycoprotein Ib (GPIb) binding domain of von Willebrand factor may be obtained from a variety of sources such as from naturally occurring von Willebrand factor or by recombinant protein production, e.g. in bacteria, fungi, plant, insect or mammalian cells.

The term "von Willebrand factor glycoprotein Ib binding domain polypeptide" also encompasses a homolog of the GPIb binding domain which may be used in the methods of the invention with the proviso that the homolog has GPIb binding activity.

As used herein, a homolog of the polypeptide is a polypeptide which has substantially the same amino acid sequence and substantially the same'biological activity as such polypeptide. Thus, a homolog may differ from the -polypeptide of the invention by the addition, deletion, or substitution of one or more non-essential amino acid residues, provided that the resulting polypeptide retains the biological activity of the polypeptide. Persons skilled in the art can readily determine which amino acids residues may be added, deleted, or substituted (including with which amino acids such substitutions may be made) using established and well known procedures, including, for example, conventional methods for the design and manufacture of DNA sequences coding for bacterial expression of polypeptide homologs of the subject polypeptide, the modification of cDNA and genomic sequences by site-directed mutagenesis techniques, the construction of recombinant proteins and expression vectors, the bacterial expression of the polypeptides, and the measurement of the biochemical activity of the polypeptides using conventional biochemical assays.

Examples of homologs of the polypeptide of the subject invention are deletion homologs containing less than all the

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WO 94/25582 PCT/US94/04418 -13residues specified in the subject polypeptide, substitution homologs wherein one or more residues specified are replaced by other residues, and addition homologs wherein one or more amino acids residues is added to a terminal or medial portion of the polypeptide, all of which homologs share the biological activity of the polypeptide of the subject invention.

Substantially the same amino acid sequence is herein defined as encompassing the addition or deletion of fewer than four amino acids at the N-terminus of the amino acid sequence of the polypeptide. Furthermore, there may be substitutions and/or deletions in the sequence which do not eliminate the biological activity of the protein. Examples of substitutions are ser for cys and ala for gly. Other substitutions are known to those skilled in the art.

Substitutions may encompass up to 10 residues in accordance with the homologous or equivalence groups described by e.g.

Lehninger, Biochemistry, 2nd ed. Worth Pub., N.Y. (1975); Creighton, Protein Structure, a Practical Approach, IRL Press at Oxford Univ. Press, Oxford, England (1989); and Dayhoff, Atlas of Protein Sequence and Structure 1972, National Biomedical Research Foundation, Maryland (1972).

Substantially the same biological activity refers to biological activity the same as that of the polypeptide possibly differing slightly in degree or level which would still be known by the skilled artisan to be the same biological activity.

The term "von Willebrand factor glycoprotein Ib binding domain polypeptide" also encompasses various mutants and variants of the vWF GPIb binding domain having different amino acid sequences, but having substantially the same biological activity.

Ir c. II WO 94/25582 PCT/US94/04418 -14- The biological activity of the polypeptides encompassed by the invention is the ability to bind to glycoprotein Ib of platelets or to prevent platelet adhesion to subendothelial matrix.

Examples of plasmids and hosts for production of recombinant polypeptides comprising the vWF GPIb binding domain are plasmids pvWF-VC3 in Escherichia coli S)930 and pvWF-VCL in Escherichia coli 4300(F') which were deposited on February 26, 1990, pursuant to, and in satisfaction of, the requirements of the Budapest Treaty on the Inzernational Recognition of the Deposit of Microorganisms for the Purposes of Patent Procedure with the American Type Culture Collection (ATCC), 12301 Parklawn Drive, Rockville, Maryland 20852 under ATCC Accession Nos. 68241 and 68242 respectively.

13 1 WO 94/25582 PCT/US94/04418

EXAMPLES

The Examples which follow are set forth to aid in understanding the invention but are not intended to, and should not be so construed as to, limit its scope in any way. The Examples do not include detailed descriptions for conventional methods employed in the construction of vectors, the insertion of genes encoding polypeptides of interest into such vectors or the introduction of the resulting plasmids into bacterial hosts. Such methods are well-known to those skilled in the art and are described in numerous publications including Sambrook, Fritsch and Maniatis, Molecular Cloning: A Laboratory Manual, 2nd Edition, Cold Spring Harbor Laboratory Press, USA, (1989).

Various methods and other aspects relating to vWF in general and to the GPIb binding domain polypeptide in particular have been disclosed in coassigned, copending application U.S.S.N. 753,815, filed September 3, 1991, and coassigned PCT Publication No. W091/13093, both of which are hereby incorporated by reference.

Methods involving expression of recombinant proteins by E.

coli transformed with plasmids controlled by the X PL promoter are disclosed inter alia in coassigned U.S. Patent No. 5,126,252, granted June 30, 1992 which is hereby incorporated by reference.

WO 94/25582 PCT/US94/04418 -16- Example 1: Production and Purification of Oxidized, Folded and Biologically Active vWF GPIb Binding Domain Polypeptide Plasmid pvWF-VCL (Figure 2) was constructed as described in coassigned, copending patent application U.S.S.N. 753,815, filed September 3, 1991 and is maintained in E.coli strain A4300(F') under ATCC Accession No. 68242. This host/plasmid system was fermented essentially as known in the art for vectors harboring a gene expressed under control of the XPL promoter, i.e. growth at 30°C until mid-log stage followed by induction at 42 0 C for about two hours, essentially as described in U.S. Patent No. 5,126,252. Following fermentation and induction, the growth medium was centrifuged and a cell cake obtained which was stored frozen until further processing.

The general scheme of the downstream process consists of steps A through H as follows: A. Isolation of Inclusion Bodies Following fermentation as described above, the cell cake is resuspended in 50mMa Tris-HCl pH=8, 50mM NaC1, ImM EDTA, ImM DTT, 1mM PMSF, and 10% glycerol. The suspension is then sonicated to disrupt the cells and centrifuged to obtain a pellet containing the insoluble inclusion bodies.

The resulting pellet containing the inclusion .bodies is dissolved at about 10% w/v in a solution such that the final concentrations are 8M urea, 20mM DTT, 20mM HEPES pH 8, and 100mM NaC1. The solution may be further purified by ion exchange chromatography as described below. Alternatively, the inclusion bodies may be solubilized in a buffer containing 6M guanidine hydrochloride followed by buffer exchange to urea. The inclusion bodies may also be -~sLI II WO 94/25582 PCT/US94/04418 -17dissolved at different concentrations of urea, guanidine hydrochloride or any other denaturant or in the absence of denaturants, for example, at extremes of pH.

B. Cation exchange chromatography This step eliminates most of the contaminants and produces the vWF GPIb binding domain polypeptide at greater than purity. Any cation exchange method carboxymethyl) may be used in this step such as CM-Sepharose fast flow (Pharmacia) chromatography. The functional group may be carboxymethyl, phospho group or sulphonic groups such as sulphopropyl. The matrix may be based on inorganic compounds, synthetic resins, polysaccharides, or organic polymers; possible matrices are agarose, cellulose, trisacryl, dextran, glass beads, oxirane acrylic beads, acrylamide, agarose/polyacrylamide copolymer (Ultrogel) or hydrophilic vinyl polymer (Fractogel). In a specific embodiment, the polypeptide is loaded onto a CM-Sepharose FF column equilibrated with 8M urea, ImM DTT, 20mM HEPES pH 8, 100mM NaCl. Pure polypeptide elutes in 8M urea, 1mM DTT, HEPES pH 8 and 200mM NaCl. Up to about 30 ODo 8 units of solubilized inclusion bodies may be loaded per ml CM-Sepharose FF. At this ratio the eluted polypeptide typically has a concentration of 4-5 OD 280 /ml.

C. Oxidation/Refolding The polypeptide solution eluted from the cation exchange step above is treated with 6M guanidine hydrochloride (GuCl) to disrupt any aggregates. The polypeptide is then diluted to 0.05 ODo 2 8 /ml in 2M GuCl, pH 5-11, preferably 20mM HEPES pH 8, 0.1mM GSSG (glutathione, oxidized form). This mixture is allowed to stand overnight at room temperature. The phproducts are analyzed by gel filtration on fast protein liquid chromatography (FPLC) such as Superose 12 before 9 WO 94/25582 PCT/US94/04418 -18proceeding. Analysis shows that this protein concentration reproducibly yields about 30% correctly oxidized monomers, and 70% S-linked dimers and multimers, as well as reduced and incorrectly oxidized monomers. A higher protein concentration gives a higher absolute yield of correctly oxidized monomers but a lower percentage yield due to increased formation of S-linked dimers and multimers. For example, a protein concentration of 0.1 OD 280 /ml yields only correctly oxidized monomers. Reducing the concentration to 0.025 OD 2 8 0 /ml yields 35-40% correctly oxidized monomers but a lower absolute yield per liter oxidation. Oxidations may also be performed in urea instead of in GuCl, or in any other denaturant or in the absence of denaturants under appropriate buffer conditions in which, for example, pH, ionic strength, and hydrophobicity are varied. The preferred concentration of urea is in the range 0.5M to preferably 4M, and the preferred oxidant is GSSG in the range 0.01mM to 5mM preferably 0.1mM. Other oxidants such as CuC1, may be used or alternatively no oxidant may be added, thereby utilizing air oxidation only. For scale-up, 4M urea is the presently preferred solution for the oxidation step.

D. Concentration The oxidation products are concentrated, preferably to about

OD

280 =l by a tangential flow ultrafiltration system with a cutoff membrane, such as a "MINITAN" or "PELLICON" system of Millipore. The filtrate is quite clear as the material is relatively clean and most of the contaminants are large enough not to pass through the 30K membrane. It is thus possible to reuse the filtrate for performing oxidations. No difference in the oxidation products of oxidations performed in reused versus freshly prepared 2M GuCl was detectable by FPLC analysis.

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WO 94/25582 PCT/US94/04418 -19- E. Dialysis To reduce the GuCl or urea concentration to less than dialysis against 20mM HEPES pH8, 100mM NaCl is performed in dialysis tubing with 2-3 changes of buffer, or alternatively by diafiltration against the same buffer in a tangential flow ultrafiltration system with a 10K MW cutoff membrane.

During dialysis, as the concentration of GuCl (or urea or other denaturant) decreases, a white precipitate forms.

This precipitate contains disulfide linked dimers, reduced and incorrectly oxidized monomer and some contaminants which coeluted from the cation exchange step. The supernatant is nearly 100% correctly oxidized and refolded monomer at a concentration of 0.2 OD 2 o/ml, which is about 20% of the protein yield of step D.

F. Recovery from pellet The yield of correctly oxidized monomer can be greatly increased by further recovery of correctly oxidized monomer from the precipitate. The solution containing the correctly oxidized monomer is clarified by centrifugation. The supernatant containing the correctly oxidized monomer is saved. The pellet containing disulfide linked dimers and reduced and incorrectly oxidized monomer is treated with DTT to reduce disulfide bonds. Accordingly, the pellet is dissolved in a minimal volume of 6M GuCl, 20ml HEPES pH 8, 150mM NaC1, 20mM DTT. The solution is passed through Sephadex G25 in a buffer similar to the dissolution buffer but containing only 1mM DTT (instead of 20mM). The eluate is then diluted to OD2o 0 =0.05 and treated as in steps C, D and E. This procedure may be repeated more than once as long as additional purified monomer is obtained. All of the supernatants may then be combined.

-I II WO 94125582 PCT/US94/04418 G. Cation exchange The combined supernatant of the dialysate of steps E and F is concentrated by binding to CM Sepharose in 20mM HEPES pH8, 100mM NaCl. Elution is with 20mM HEPES pH8, 400mM NaC1. The eluate is exclusively monomeric despite the high salt concentration. Concentrations of up to 3 mg/ml have been achieved by this method and that is not the upper limit. This step can alternatively be performed with Heparin-Sepharose which also binds the purified monomer in Tris pH 7.4, 150mM NaCl. Elution from Heparin- Sepharose is performed using 10mM Tris-HCl pH 7.4, 500mM NaCl.

H. Dialysis The product of the previous step is dialyzed against HEPES pH8, 150mM NaC1.

I. Storage At this stage the purified vWF GPIb binding domain polypeptide may be lyophilized. Upon reconstitution in a volume of water equal to the volume before lyophilization, the resultant solution contains exclusively monomeric protein showing no traces of dimers or other multimers on

FPLC.

In a specific embodiment of the above method, the following procedure was performed: a) 10 gm inclusion bodies (comprising 0.43 g net dry weight) were dissolved in a final volume of 100ml 8M urea, DTT, 20mM HEPES pH 8, 100 ,MI NaC1.

b) The protein was loaded onto a CM Sepharose column I WO 94/25582 PCT/US94/04418 -21equilibrated with 8M urea, 1mM DTT, 20mM HEPES pH 8, 100mM NaCl. The protein eluted at 200mM NaCL in 8M urea, HEPES pH 8, ImM DTT, and was saved.

c) The saved eluate of the previous step was treated with 6M GuCl to eliminate any aggregates, and was then diluted to 0.05 OD 280 /ml in 2M GuCl, 20mM HEPES pH 8, 0.1mM GSSG.

Oxidation was performed overnight at room temperature.

(Note that the oxidation step can be performed in the presence of urea instead of GuCl.) d) The oxidation products were concentrated to OD 2 o 0 =l by ultrafiltration on a "MINITAN" unit containing a membrane.

e) The concentrate of the previous step was dialyzed with three buffer changes against 20mM HEPES pH 8, 100mM NaCl.

During dialysis, as the GuCl concentration decreased, a white precipitate formed which was removed by centrifugation and reprocessed once as described above. The supernatants were combined.

f) The combined supernatants were concentrated by binding to CM Sepharose in 20mM HEPES pH 8, 100mM NaCl. The polypeptide was eluted in 20mM HEPES, pH 8, 400mM NaCl and stored at 4 0

C.

g) The saved eluate from the previous step was dialyzed against 20mM HEPES pH 8, 150mM NaCl at 4 0

C.

h) After dialysis, the purified vWF GPIb binding domain polypeptide, designated VCL, was lyophilized.

Analysis of VCL 1. Amino acid sequence analysis of VCL purified as I IP~ I I WO 94/25582 ICT/US94/04418 -22described above revealed that the N-terminal sequence is Met-Leu-His-Asp-Phe which is the expected sequence according to Figures 3A-3C.

2. Examination of VCL on polyacrylamide gels revealed that the VCL migrated under non-reducing conditions at a lower apparent molecular weight than under reducing conditions mercaptoethanol). This si.lft from compact to less compact configuration is consistent with the reduction of a disulfide bond. Such an intramolecular bond is formed between the cysteines at positions 509 and 695. (The shift in molecular weight is not large enough to be consistent with the reduction of an intermolecular bond.) eP WO 94/25582 PCT/US94/04418 -23- Example 2: Use of the vWF GPIb Binding Domain in Conjunction with Thrombolytic Treatment to Prevent Reocclusion

SUMMARY

The ability of a GPIb binding domain polypeptide fragment of vWF to enhance thrombolysis by shortening the time to reperfusion and to prevent reocclusion following thrombolysis was studied. The GPIb binding domain fragment tested was the VCL polypeptide described in Example 1. A canine model was evaluated for the effect of VCL on the formation of intracoronary thrombosis, the duration of thrombolysis, and the incidence of reocclusion of coronary arteries after thrombolysis with t-PA. The results suggest that VCL delays thrombus formation, shortens the duration of thrombolysis, and reduces the incidence reocculsion of coronary arteries following thrombolysis.

In this canine model, thrombus formation is induced in a coronary artery by electrical stimulation. Following thrombus formation, thrombolysis is induced by infusion of tissue plasminogen activator (tPA). The effect of the GPIb binding domain polypeptide in preventing thrombus formation and in reducing the incidence of reocclusion following thrombolysis was tested. The GPIb binding domain polypeptide proved effectiv in delaying onset of electrically stimulated thromw.s formation. In addition, the GPIb binding domain polypeptide shortened the time to reperfusion during thrombolysis and reduced the incidence of reocclusion when used in the thrombolytic therapy in conjunction with heparin and aspirin.

METHODS

All procedures used in this study were conducted according I I-e 'sll WO 94/25582 PCT/US94/04418 -24to the principles of the American Physiological Society and were approved by the Institutional Animal Care and Use Committee at the Texas Heart Institute, Houston, Texas.

Surgical Preparation Mongrel dogs (n=57 weighing 25 to 35 kg were anesthetized with sodium pentobarbital (30 mg/kg intravenously), intubated, and connected to mechanical respirators (Harvard Model 60, Natick, MA). Plastic catheters were placed in a carotid artery for monitoring aortic pressure and in a jugular and a peripheral vein for drug and fluid administration. A left fifth intercostal space thoracotomy was performed, and the heart suspended in a pericardial cradle. A 1- to 2-cm segment of left anterior descending coronary artery was carefully exposed and nearby branches .ligated. An ultrasonic Doppler flow probe (Hartley Instruments, Houston, TX) was placed around the proximal portion of the exposed left anterior descending coronary artery to measure the velocity of blood flow. Baseline hemodynamics, including heart rate, systolic nd diastolic aortic pressures and phasic and mean coronary blood flow velocities were recorded on an eight-channel recorder (Gould, Model 3000, Cleveland, OH).

A needle electrode (the 8-mm tip of a 25-gauge needle crimped on the end of a 10-cm length of 30-gauge Tefloninsv Pd silver wire) was inserted obliquely approximately 4 mm the lumen of the exposed left anterior descending coronary artery at a site distal to the Doppler flow probe.

The needle was stabilized on the vessel with 6-0 silk suture. To prevent the electric current from injuring the surrounding tissue, heat-shrink tubing was applied to the needle/wire and soldered connection. A ground wire was connected to the subcutaneous tissue to complete the electrical circuit. To induce thrombosis, a current of i WO 94/25582 PCT/US94/04418 150A was applied through the electrode, which was connected in series with the positive terminal of a 9-V battery, a potentiometer, a multimeter, and the ground wire.

Thrombus formation was determined by the reduction of coronary blood flow velocity, which was monitored by the externally positioned Doppler flow probe. The electric current was maintained until 30 min after persistent thrombotic occlusion had occurred.

Experimental Procedures Two separate protocols were employed in this study of VCL; one examined its effect on coronary arterial thrombus formation, the other its eect on thrombolysis and reocclusion.

Protocol 1. To evaluate the effect of VCL on intracoronary thrombus formation, treatment began on the dogs 30 min before electrical stimulation of their coronary arteries.

Three different groups of animals were studied. In the control group (n 12), saline was given intravenously at 1 ml/min. In one experimental group (n VCL was given intravenously at 4 mg/kg body weight as a bolus dose and at 2 mg/(kg-h) as a continuous infusion until the end of study.

In the other experimental group (n aspirin was given intravenously at 5 mg/kg body weight as a bolus dose. The change in coronary blood flow before and after electrical stimulation was carefully monitored. The amount of time elapsed from the beginning of electrical stimulation to the total occlusion of the coronary arteries was recorded.

Three hours after the total occlusion of coronary arteries, all animals were given t-PA (Genentech, Inc., San Francisco, CA) intravenously at 80/g/kg body weight as a bolus dose and at 8Ag/(kg-min) as a continuous infusion for 90 min. This treatment was intended to induce lysis of the thrombi formed in the coronary arteries.

wn WO 94/25582 PCT/US94/04418 -26- A thrombus was considered to be lysed (and the artery reperfused) when the flow velocity of the coronary artery returned to at least 70% of the value that existed before thrombus formation. The amount of time elapsed from t-PA administration to reperfusion was recorded as thrombolysis or reperfusion time. Dogs in whom reperfusion had not occurred after 90 min of t-PA infusion were excluded from further study. Dogs in whom reperfusion did occur were further monitored until the coronary arteries reoccluded or until 180 min had elapsed without reocclusion. The time from reperfusion to reocclusion was recorded as reocclusion time. Dogs in whom coronary arteries had not reoccluded after 180 min of reperfusion were considered not to have reoccluded. Dogs in whom reocclusion did occur were monitored for 30 min to verify persistent reocclusion.

Protocol 2. To further explore the effect of VCL on thrombolysis and reocclusion, additional animals were studied and treated three hours after the occlusion of coronary arteries. These animals were assigned to one of four additional groups: t-PA and heparin t-PA, heparin, and VCL t-PA, heparin, and aspirin and t-PA, heparin, VCL, and aspirin Heparin was given at 200 U/kg as an intravenous bolus. t-PA, VCL and aspirin were given at the same dose as in protocol 1. The follow-up for thrombolysis and reocclusion was also the same as in protocol 1.

Hematocrit, Coagulation, and Platelet Aqqregation Studies Hematocrit was checked before and at the end of t-PA administration in all dogs in protocol 2. Activated whole blood clotting time was measured in these dogs before and 120, and 180 min after the administration of t-PA on an automated blood coagulation timing device (HemoTec 2001370, Englewood, CO).

I--

WO 94/25582 PCT/US94/04418 -27- Ex vivo platelet aggregation was analyzed before and 10 min after the administration of VCL and aspirin in dogs in protocol 1. Blood samples were collected in plastic tubes containing a 3.8% solution of sodium citrate (9 volumes blood:l volume sodium citrate). Platelet-rich plasma was obtained by centrifuging blood samples at 200 x g for 20 min and platelet-poor plasma was obtained by centrifuging the residual blood at 3000 x g for 10 min. The platelet count in platelet-rich plasma was adjusted to 300,000/mm 3

A

four-channel platelet aggregometer (Bio-Data, Model PAP-4, Horsham, PA) was used for the assay. Agonists and their final concentrations were ADP (Sigma, St. Louis, MO) at and 20pM; botrocetin (produced as described by Fujimura et al., Biochemistry 1_Q:1957-1964 (1991)) at 1.1, 2.2, and 4.4 ig/ml; and arachidonic acid (Sigma, St. Louis, MO) at 12.5, 25, and 50 ig/ml. Because canine platelets do not aggregate in response to arachidonic acid, epinephrine was added to the platelet suspension at 10 pmol/l before arachidonic acid. The degree of platelet aggregation was reported as the maximal percentage that light transmission increased in platelet-rich plasma over light transmission in platelet-poor plasma.

Statistical Analyses All values are expressed as a mean standard error of mean (SEM). Fisher's exact test was used to compare the frequency of reperfusion and reocclusion in different groups of animals. A one-way analysis of variance (ANOVA) with repeated measurements was used to compare the hemodynamic values and activated clo-ting times obtained at different time periods and the duration of time to reperfusion and reocclusion in different groups of animals. Student's t test was used to compare the percentage of platelet aggregation and hematocrit values before and after treatment in each group of animals. A p value less than 0.05 was s WO 94/25582 PCT/US94/04418 -28considered significant.

RESULTS

Intracoronary Thrombus Formation Insertion of the electrode needle into the coronary artery caused some stenosis in the arteries of all animals, as determined by a reduction of blood flow velocity to approximately 65% of the baseline level (Tables 1 and 2 After electrical stimulation, all animals developed total occlusion of the affected coronary arteries. In protocol 1, the elapsed time from electrical stimulation to total occlusion of the coronary arteries was significantly longer in dogs treated with VCL (p 0.001) and aspirin (p 0.05) than in dogs treated with saline (Figure In all animals, aortic blood pressure and heart rate changed slightly after the occlusion of coronary arteries. In aspirin-treated animals, however, heart rate and mean aortic pressure increased at each time-point (Table 1).

L WO 94/25582 PCT/US94/04418 -29- Table 1. Hemodynamics Before and After Intercoronary Thrombosis and Thrombolysis in Animals in the 3 Pretreatment Groups (Protocol 1).

HR AOM (beats/min) (mmHg)

PHFLO

of baseline)

MNFLO

of baseline) Saline and t-rA (n 12) Baseline Needle-in 3-h occlusion Reperfusion (n 4) 1-h reperfusion Baseline Needle-in 149 7 149 6 135 10 133 9 138 7 78 5 77 5 96 4* 89 5 86 6 100 65 7 100 73 11 68 7 86 9 Pre-VCL and t-PA (n 7) 3-h occlusion 139 8 146 10 128 11 120 11 130 19 81 3 82 4 100 67 7 100 68 8 115 116 Reperfusion 95 15 79 18 117 22 88 22 l-h reperfusion (n 4) 96 6 Pre-aspirin and t-PA (n 8) Baseline Needle-in 3-h occlusion Reperfusion (n 4) 1-h reperfusion 144 8 159 7 172 5** 174 87 3 93 3 94 2 98 7 99 6 100 63 6 0 76 8 96 26 100 68 8 0 87 11 131 41 178 8 Values are mean SEM. Compared to baseline level, *p 0.05; 0.01; 0.001. AOM, mean aortic pressure; HR,, heart rate; MNFLO, mean flow velocity in the coronary artery; PHFLO, phasic flow velocity in the coronary artery; t-PA, tissue-type plasminogen activator.

L II WO 94/25582 WO 9425582PCT(US94/04418 Table 2. Hemodynaniics Before and After Ii;.;racoronary Thrombosis and Thrombolysis in Animals in the 4 Treatment Groups (Protocol 2).

Baseline Needle- in 3-h occlusion Reperfusion (n 1-h reperfusion (n=4) Baseline Needle -in 3-h occlusion Reperfusion (n=6)

HR

(beats/ min) t-PA 138 5 136 ±6 125 ±9 .132 ±14 114 ±6* a~nd Beparin 83 ±1 81 ±2 91 ±4 92 ±3

AOM

(mmHg)

PHFLO

(t of baseline) (n 7) 100 61 8 0 100 76 t 7 0

MNFLO

M~ of baseline) 57±9 72±15 60±16 60±19 88 4 t-PA, Heparin, and VCL 135 t6 89±3 132±60 88±4 112±7** 95±6 (N =7) 10 69 ±8 0 100 74 6 0 1-h reperfusion 3-h reperfusion (n=4) Baseline Needle- in 107 133 ±4 128 ±12 98 ±5 81 ±8 133 34 169 59 83 ±12 100 17 t PA, 140 140 137 Heparin, ±8 69 ±10 40±13 53±24 and Aspirin (n =8) 79 ±3 100 100 83±5 65±8 73±9 95 ±4 0 0 3-h occlusion Reperfusion 157 6 (n=7) 98 ±2 77 ±4 95±9 107±9 59±12 60±13 1-h reperfusion (n=4) 159 12 WO 94125582 WO 94/5582PUS94/0441 8 Table 2. cont'd.

HR AOM PHFLO MNFLO (beats! (mm-g) of (t of min) baseline) baseline) t-PA, Heparin, VCL, and Aspirin (n 8) Baseline 144 t 3 89 ±5 100 100 Needle-in 143 ±2 88 ±5 67 6 81 6 3-h 170 105 ±4 0 0 occlusion Reperfusion 175 109 ±5 88 10 108 12 (n=8) 1-h 178 78 ±5 82 32 102 42 reperfusion (n=7) 3-h 174 ±12* 65 5* 41 26 49 28 reperfusir~n Values are mean ±SEM. Compared to baseline level, p 0.05; 0.01; 4 0.001. ACM, mean aortizc pressure; HIR, heart rate; rMJFLO, mean flow velocity in the coronary artery; PHFLO, phasic flow velocity in the coronary artery; t-PA, tissue-type plasminogen activator.

WO 94/25582 PCTIUS94/04413 -32- Thrombolysis In protocol 1, 3 h after the occlusion of coronary arteries, only t-PA was given to the animals. The administration of t-PA resulted in thrombolysis in 4 of 12 saline-treated dogs 5 of 7 VCL-treated dogs and 4 of 8 aspirintreated dogs The average elapsed time from t-PA treatment to thrombolysis (thrombolysis time) was significantly shorter in VCL-treated than in saline-treated dogs (p 0.05, Figure In protocol 2, dogs were not pretreated before their coronary arteries were occluded, and 3 h after the occlusion of coronary arteries, they received thrombolytic treatments: t-PA and heparin induced thrombolysis in 5 of 7 dogs t-PA, heparin, and VCL induced thrombolysis in 6 of 7 dogs t-PA, heparin, and aspirin induced thrombolysis in 7 of 8 dogs and t-PA, heparin,VCL, and aspirin induced thrombolysis in 8 of 8 dogs The average thrombolysis time in dogs treated with t-PA, heparin, VCL, and aspirin was slightly more than half that in dogs treated only with t-PA and heparin (23.5 4 min vs 45 12 min).

The difference, however, was not statistically significant (Figure 6).

Reocclusion After thrombolysis, many animals developed reocclusion of the coronary arteries during the 3-h monitoring period. In protocol 1, the frequency of reocclusion was not significantly different among dogs pretreated with saline (4 of aspirin (4 of or VCL (4 of However, the average time from thrombolysis to reocclus on (reocclusion time) was significantly longer in dogs pretreated with VCL than in dogs pretreated with saline and aspirin (Figure 7).

In protocol 2, coronary artery reocclusion developed in 5 of ia WO 94/25582 PCT/US94/04418 -33dogs treated with t-PA and heparin, and the addition of aspirin did not change the frequency of reocclusion (7 of The addition of VCL to t-PA and heparin significantly reduced the frequency of reocclusion in the reperfused coronary arteries of dogs (2 of 6; p 0.05 compared to the t-PA and heparin group). The addition of VCL and aspirin also significantly reduced the frequency of reocclusion (1 of 8; -p 0.01 compared to the t-PA, heparin, VCL group).

The average reocclusion time was also significantly longer in VCL-treated dogs than in dogs who did not receive VCL (Figure 8).

Hematocrit. Coagulation, and Platelet Aggregation Studies In dogs treated with t-PA alone, bleeding around the surgical area was not significant. The addition of VCL or aspirin caused mild bleeding along the incisions. The combination of t-PA, heparin, VCL, and aspirin resulted in moderate to severe bleeding around the surgical areas.

However, hematocrit did not change significantly in any group after treatment with tPA, heparin, VCL and aspirin (Figure 9).

Activated clotting time was significantly prolonged immediately after t-PA and heparin administration (Figure It returned to 1.5 times the baseline value 1 h after treatment and to just above the baseline value 3 h after treatment. The addition of aspirin or VCL, or a combination of aspirin and VCL did not affect activated clotting time.

Ex vivo platelet aggregation induced by ADP was not affected by VCL infusion (Figure 11A) but was slightly reduced by aspirin injection (Figure 12A). Botrocetin-induced platelet aggregation was completely inhibited by VCL treatment (Figure 11B), and arachidonic acid-induced platelet aggregation was completely inhibited by aspirin injection (Figure 12B).

s _r I WO 94/25582 PCT/US94/04418 -34- Conclusion The data from the present study demonstrate that VCL prolongs the time of intracoronary thrombus formation, enhances t-PA-induced thrombolysis, and delays coronary artery reocclusion.

Intravenous administration of VCL before electrical injury to the coronary artery significantly increased the time required for formation of an occlusive thrombus in vivo.

The ex vivo platelet aggregation induced by botrocetin was completely inhibited by the treatment. These data suggest that blocking the interaction between von Willebrand factor and platelet glycoprotein Ib diminishes both platelet aggregation in the stenosed and endothelium-injured area of coronary arteries and also the formation of occlusive thrombi.

After occlusive thrombi had formed in the coronary arteries, the infusion of t-PA caused thrombolysis. The thrombolysis time was significantly shorter in VCL-pretreated animals than in control animals, which suggests that VCL pretreatment may enhance t-PA-induced thrombolysis in coronary arteries. VCL given after the formation of thrombi, however, did not enhance thrombolysis by t-PA as significantly.

Coronary artery reocclusion has limited the efficacy of thrombolytic therapy in patients with acute myocardial infarction (11, 12, 29-31). Most clinical trials have used adjunct treatment with antiplatelet agents aspirin) to prevent reocclusion (32-33). In the present study, upon administration of VCL with t-PA or t-PA and heparin, the time from thrombolysis to coronary artery reocclusion was significantly prolonged, and in some cases reocclusion was prevented. VCL was more effective than aspirin in the same conditions. These data suggest that VCL may be useful as an WO 94/25582 PCT/US94/04418 adjunct to t-PA in future thrombolytic therapy for coronary artery reocclusion.

Bleeding is a common complication of thrombolytic therapy.

In the present study, treatment with VCL, plus t-PA and heparin caused mild to moderate bleeding around the surgical incisions, and the combination of VCL, aspirin, t-PA, and heparin resulted in severe bleeding in some cases.

Thus, blocking platelet glycoprotein Ib receptors with VCL may be effective in diminishing the formation of thrombi in injured coronary arteries. In delaying the reocclusion of the coronary arteries after thrombolysis, VCL is comparable or superior to aspirin as an adjunctive treatment with t-PA and heparin. Treatment with VCL and aspirin, in addition to t-PA and heparin, may completely prevent reocclusion.

I -L WO 94/25582 PCT/US94/04418 -36- Example 3: Synergy of GPIb Binding Domain Polypeptide With AsDirin The effect of GPIb binding domain polypeptide was investigated using a model of traumatic vascular damage.

This model is essentially that described by Kelly et al.

In this model, segments of 2 mm collagen coated polytetrafluoroethylene (e-PFTE) tubes are inserted as extension pieces into chronic arteriovenous access shunts in baboons. The baboons are injected with autologous "'Inlabeled platelets and then administered one of the treatments being studied. At specified times, the amount of deposited platelets was determined with a scintillation camera.

A series of studies on three animals was conducted to investigate the activity of the GPIb binding domain polypeptide (VCL) alone and in the presence of aspirin. The GPIb binding domain polypeptide was produced as described in Example 1.

The first set of studies was directed to the effect of the GPIb binding domain polypeptide alone in the model. The reference for this study was the lowest dose from a dose response study previously performed, i.e. 1 mg/kg bolus and 2 mg/kg/hr continuous infusion for one hour. As seen in Figure 13, this.dose delayed the occlusion of the tubes to about 60 minutes compared to about 20 minutes in controls.

The second set of studies was directed to determining the effect of aspirin alone-in the model. Three animals were examined. 35 mg/kg aspirin were given orally two hours before the study. All specimens occluded less than minutes into the study. Qualitatively and quantitively, the aspirin curves were found to be similar to the control curves obtained using pure non-anticoagulated blood.

Platelet counts were similar in both groups.

I WO 94/25582 PCT/US94/04418 -37- The final set of experiments included study of the activity of the GPIb binding domain polypeptide in the presence of aspirin. Three animals were studied. Animals were given mg/kg aspirin orally two hours before the study. The GPIb binding domain polypeptide dose used was 1 mg/kg bolus and 2 mg/kg/hr continuous infusion for one hour.

All devices remained patent during the continuous infusion period of the GPIb binding domain polypeptide. After that period they began to occlude. Two devices occluded minutes into the study, while 4 stayed patent.

An increase in platelet deposition rate was observed when the continuous infusion stopped. Thus, unexpectedly, the GPIb binding domain polypeptide and aspirin exhibit synergistic activity regarding the retardation and/or prevention of platelet deposition.

The synergistic effect of the GPIb binding domain polypeptide and aspirin on platelet deposition was found to be equivalent to a four-fold higher dose of 4 mg/kg bolus plus 8 mg/kg/hr continuous infusion of the GPIb binding domain polypeptide when administered alone.

As an additional parameter, bleeding times were measured in the experiments described above. They are presented in Table 3. Bleeding times increased in a dose jependent manner, from 6 minutes at the lowest dose of the GPIb binding domain polypeptide to 22.5 minutes at the highest dose of the GPIb binding domain polypeptide. Aspirin alone resulted in a bleeding time of 6 minutes. The combination of aspirin plus the low dose of the GPIb binding domain polypeptide resulted in a slight increase to 7 minutes.

However, this combination had the anti-platelet deposition effect of'a dose of the GPIb binding domain polypeptide four times higher (4 mg/kg bolus and 8 mg/kg/hr infusion) with a bleeding time of 16.5 minutes. Thus, combination of the ~b I WO 94/25582 PCTIUS94/04 18 -38- GPIb binding domain polypeptide with aspirin resulted in a dramatic increase in efficacy without a concomitant increase in bleeding time.

I WO 94/25582 PCT/US94/04418 -39- Bleeding Times Table 3.

Study Bleeding Time (min) Controls 4 Aspirin 6 1 mg/kg bolus 2 mg/kg-hr 6 infusion 2 mg/kg bolus 4 mg/kg-hr 7 infusion 4 mg/kg bolus 8 mg/kg-hr 16.5 infusion 8 mg/kg bolus 16 mg/kg-hr 22.5 infusion Aspirin 1 mg/kg bolus 7 2 mg/kg-hr infusion WO 94/25582 WO 94/25582 'TUS94/044 18

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Claims (19)

1. A method for preventing complications following traumatic vascular damage in a subject comprising administering to the subject an amount of a von Willebrand factor glycoprotein Ib binding domain polypeptide in conjunction with an amount of aspirin, which together are effective to prevent the complications.

2. A method according to claim 1 wherein the traumatic vascular damage is caused by coronary artery bypass surgery, angioplasty, thrombolysis, or unstable angina.

3. A method according to claim 1 wherein the complications following the traumatic vascular damage are myocardial infarction, ischemia, coronary bypass surgery, repeat angioplasty, or death.

4. A method according to claim 1 wherein the effective ?-o\\owed amounts are 0.1-20 mg/kg bolus a4d. .1-20 mg/kg/hr continuous infusion of the vWF GPIb binding domain polypeptide and 0.1-50 mg/kg aspirin. A method according to claim 4 wherein the vWF GPIb binding domain polypeptide is administered intravenously.

6. A method according to claim 5 wherein the aspirin is administered orally or parenterally.

7. A method according to claim 6 wherein the aspirin is administered in a single dose, in multiple doses or by continuous administration. L-~-I WO 94/25582 PCT/US94/04418

8.

9.

11.

12. A method according to claim 7 wherein the parenteral adminisration is intravenous, intraperitoneal, subcutaneous or intramuscular. A method of enhancing a thrombolytic treatment in a subject comprising administering to the subject in conjunction with a thrombolytic agent and an anticoagulant, an amount of a von Willebrand factor glycoprotein Ib binding domain polypeptide effective to enhance the thrombolytic treatment. A method of claim 9 wherein the thrombolytic agent is tPA A method of claim 10 wherein the anticoagulant is heparin. A method of claim 11 .wherein .the thrombolytic treatment additionally comprises aspirin. A method of claim 9 wherein the von Willebrand factor glycoprotein Ib binding domain polypeptide is administered intravenously. A method of claim 13 wherein the intravenous administration is a bolus. A method of claim 13 wherein the intravenous administration is by continuous infusion. A method of claim 13 wherein the intravenous administration is a bolus followed by continuous infusion. A method of claim 14 wherein the bolus is an amount between 0.4-40 mg/kg body weight.

13.

14.

17. WO 94/25582 PCT/US94/04418 -46-

18.

19.

21.

22.

23.

24. A method of claim 17 wherein the bolus is 1-20 mg/kg body weight. A method of claim 18 wherein the bolus is 2-10 mg/kg body weight. A method of claim 15 wherein the infusion is at the rate of 0.2-20 mg/kg body weight per hour. A method of claim 20 wherein the infusion is at the rate of 1-10 mg/kg body weight per hour. A method of claim 16 wherein the bolus is 0.4-40 mg/kg body weight and the continuous infusion is 0.2-20 mg/kg body weight per hour. A method of claim 13 wherein the\polypeptide is administered prior to surgery. A method of claim 23 wherein the surgery is cardiovascular surgery. c