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Learning From Discontinued Toxin-Based Drugs
Most cases of drugs withdrawn from the market (voluntarily or prohibited by regulatory agencies) are related to different events, ranging from safety issues, like serious side effects, to several non-safety issues, encompassing those related to the manufacturing process, regulatory or business issues, or lack of efficacy.The foreseen toxicity of some toxin-based drugs may not be completely avoided, impairing the process at different stages of drug development.Therefore, understanding the mechanisms of toxicity is of utmost importance as an attempt to prevent post-marketing withdrawals (Siramshetty et al., 2016).
A mimetic peptide isolated from Naja spp.cobra venom, ximelagatran (Exanta®, AstraZeneca), was discontinued in 2006, due tohepatotoxic potential(King, 2011). This prodrug anticoagulant agent, orally administered,had been approvedin Europe and South America for thrombin inhibition (Eriksson et al., 2003; Koh et al., 2006; Fox and Serrano, 2007; King, 2011). While Ximelagatran was mostly well tolerated in specific trial populations, a small proportion of the treated patients developed elevated liver enzyme levels, during phase II of clinical trials, which caused the FDA to reject its approval.
A phase III study of agkisacutacin (also known as hemocoagulase) in perioperative bleeding (Wei et al., 2010) was ceased due toanaphylactic reactions(Xu et al., 2016). The enzyme, which acts on fibrinogen and fibrin, is a heterodimeric serine protease from Deinagkistrodon acutus venom whose monomers A and B are comprised of 123 and 129 amino acid residues, respectively, linked by a disulfide bond (Wei et al., 2010). On the other hand, a phase IV randomized study (NCT03270735) to evaluate the efficacy and safety of hemocoagulase injection in the treatment of moderate to severe hemoptysis is recruiting patients since 2017. However, updated information regarding the evolution of this study could not be retrieved.
https://www.frontiersin.org/articles/10.3389/fphar.2020.01132/full#B107