Protamine sulfate

Protamine sulfate is a medication that is used to reverse the effects of heparin.[2] It is specifically used in heparin overdose, in low molecular weight heparin overdose, and to reverse the effects of heparin during delivery and heart surgery.[2][3] It is given by injection into a vein.[2] The onset of effects is typically within five minutes.[1]

Protamine sulfate
Clinical data
Trade namesProsulf, others
AHFS/Drugs.comMonograph
Routes of
administration		IV
Pharmacokinetic data
Onset of action5 minutes[1]
Identifiers
CAS Number
DrugBank
UNII
CompTox Dashboard (EPA)
ECHA InfoCard100.113.361

Common side effects include low blood pressure, slow heart rate, allergic reactions, and vomiting.[2] Allergic reactions may be severe and include anaphylaxis.[2] The risk is greater in males who have had a vasectomy.[4] While there is no evidence of harm from using during pregnancy it has not been well studied in this group.[5] Protamine works by binding with heparin.[2]

Protamine sulfate was approved for medical use in the United States in 1969.[2] It is on the World Health Organization's List of Essential Medicines.[6] It was originally made from the sperm of salmon (salmine, salmon protamine).[2] It is now mainly made using recombinant biotechnology.[7]

Medical uses

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

It is also used in gene transfer, protein purification and in tissue cultures as a crosslinker for viral transduction. In gene therapy, protamine sulfate has been studied as a means to increase transduction rates by both viral and nonviral-mediated delivery mechanisms (e.g. utilizing cationic liposomes).[8][9]

Protamine is used in insulin aspart protamine and NPH insulin.

Dosage

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

Adverse effects

Protamine has been reported to cause allergic reactions in patients who are allergic to fish, diabetics using insulin preparations containing protamine, and vasectomized or infertile men.[10][11] These occur at rates ranging from 0.28% to 6%.[11][12][13]

Avoiding rapid infusion of protamine sulfate and pre-treating at-risk patients with histamine receptor antagonists (H1 and H2) and steroids may minimize these reactions. A 5 to 10 mg test dose is recommended following pretreatment before administering the full dose.[11]

Mechanism

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

History

Protamine sulfate replaced hexadimethrine bromide (Polybrene), another cationic agent that was the original heparin reversal agent in the early days of heart surgery, until studies in the 1960s suggested that hexadimethrine bromide might cause kidney failure when used in doses in excess of its therapeutic range.[14]

References
  1. "Prosulf 10mg/ml Solution for Injection - Summary of Product Characteristics (SPC) - (eMC)". www.medicines.org.uk. Archived from the original on 20 December 2016. Retrieved 14 December 2016.
  2. "Protamine Sulfate". The American Society of Health-System Pharmacists. Archived from the original on 6 November 2016. Retrieved 8 December 2016.
  3. "Protamine sulfate". www.drugbank.ca. Retrieved 14 February 2019.
  4. World Health Organization (2009). Stuart MC, Kouimtzi M, Hill SR (eds.). WHO Model Formulary 2008. World Health Organization. p. 255. hdl:10665/44053. ISBN 9789241547659.
  5. "Protamine Use During Pregnancy | Drugs.com". www.drugs.com. Archived from the original on 21 December 2016. Retrieved 14 December 2016.
  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. Kern, Morton J. (2012). The Interventional Cardiac Catheterization Handbook E-Book. Elsevier Health Sciences. p. 131. ISBN 9781455740420.
  8. Sorgi, FL; Bhattacharya, S; Huang, L (Sep 1997). "Protamine sulfate enhances lipid-mediated gene transfer". Gene Therapy. 4 (9): 961–8. doi:10.1038/sj.gt.3300484. PMID 9349433. S2CID 22101764.
  9. Kenneth Cornetta; W.French Anderson (1989). "Protamine sulfate as an effective alternative to polybrene in retroviral-mediated gene-transfer: implications for human gene therapy". Journal of Virological Methods. 23 (2): 187–194. doi:10.1016/0166-0934(89)90132-8. PMID 2786000.
  10. Walker, WS; Reid, KG; Hider, CF; Davidson, IA; Boulton, FE. (1984). "Successful cardiopulmonary bypass in diabetics with anaphylactoid reactions to protamine". Br Heart J. 52 (1): 112–114. doi:10.1136/hrt.52.1.112. PMC 481594. PMID 6743419.
  11. Campbell, FW; Goldstein, MF; Atkins, PC. (1984). "Management of the patient with protamine hypersensitivity for cardiac surgery". Anesthesiology. 61 (6): 761–764. doi:10.1097/00000542-198412000-00021. PMID 6334459.
  12. Welsby, IJ; Newman, MF; Phillips-Bute, B; Messier, RH; Kakkis, ED. (2005). "Hemodynamic changes after protamine administration: association with mortality after coronary artery bypass surgery". Anesthesiology. 102 (2): 308–314. doi:10.1097/00000542-200502000-00011. PMID 15681944. S2CID 42687628.
  13. Sokolowska, E; Kalaska, B; Miklosz, J; Mogielnicki, A. (2016). "The toxicology of heparin reversal with protamine: past, present and future". Expert Opinion on Drug Metabolism & Toxicology. 6 (8): 897–909. doi:10.1080/17425255.2016.1194395. PMID 27223896. S2CID 22038832.
  14. Randsell, HT; Haller, JA; Stowens, DD; Barton, PB (1965). "Renal toxicity of polybrene (hexadimethrine bromide)". J Surg Res. 5 (5): 195–199. doi:10.1016/S0022-4804(65)80086-5. PMID 14281435.
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