Synergistic Platelet Inhibitory Effects of Riociguat and Nitric Oxide Are Decreased By Protein Binding
Authors: WU Yifeng , Michelson Alan D , Frelinger Andrew L 
Published: October 2019

Abstract
Introduction
Nitric oxide (NO) released by endothelial cells interacts with platelets in which it stimulates soluble guanylate cyclase (sGC), thereby increasing platelet cyclic guanosine monophosphate (cGMP) and inhibiting platelet activation. Stimulation of sGC in other cells has been suggested as an attractive target for intervention in a range of diseases including pulmonary arterial hypertension, heart failure, and diabetes mellitus. Riociguat, the first FDA-approved sGC stimulator, potently increases platelet cGMP and inhibits platelet aggregation in washed platelets. Because riociguat binds to plasma proteins, higher concentrations of riociguat are required to inhibit platelet function in whole blood. However the potential synergistic inhibition of platelet function by riociguat and NO has not been well studied.
Goal
To investigate the possible synergistic effects of riociguat and NO on platelet inhibition and to determine the effects of protein binding.
Methods
Platelet-rich plasma (PRP) was prepared from citrate (3.2%) anticoagulated whole blood collected from healthy donors following informed consent. Riociguat (10 mM) in DMSO and DETA-NONOate 10 mM (an NO donor) in 10 mM NaOH were stored at -80°C until use. PRP was diluted 10-fold in either HEPES-Tyrode's buffer or platelet poor plasma (PPP), then incubated with vehicle or riociguat 1, 10, or 100 µM, alone or in combination with DETA-NONOate 16, 31, or 250 µM for 30 minutes, then analyzed by flow cytometry. Platelet surface activated GPIIb-IIIa (detected by monoclonal antibody PAC1) and platelet surface P-selectin were measured with and without activation by ADP 5 µM or thrombin receptor activating peptide (TRAP) 5 µM. For light transmission platelet aggregation (LTA) and 96-well platelet aggregation, PRP was used without dilution.
Results
For PRP diluted in buffer, riociguat and DETA-NONOate each produced concentration-dependent inhibition of ADP- and TRAP-stimulated platelet activation, as reported by platelet surface activated GPIIb-IIIa (Figure A) and P-selectin, and a synergistic inhibitory effect was observed when riociguat and DETA-NONOate were combined (for platelet surface activated GPIIb-IIIa, 40% inhibition with 1 µM riociguat alone; 30% inhibition with 31 µM DETA-NONOate alone; 90% inhibition with 1 µM riociguat and 31 µM DETA-NONOate combined). In contrast, when PRP was diluted in PPP, the concentrations of riociguat alone and DETA-NONOate alone needed to inhibit activation were dramatically increased and the combination of 1 µM riociguat and 31 µM DETA-NONOate produced less than 10% inhibition of platelet surface activated GPIIb-IIIa (Figure B). Synergistic inhibition in plasma was observed when DETA-NONOate was increased to 250 µM. Based on these results, a sub-threshold concentration of DETA-NONOate was chosen for investigation of the effects of riociguat on platelet aggregation. Using ADP 5 µM, TRAP, 2 µM, or collagen 2 µg/mL, riociguat alone at 10 µM (Figure C) and DETA-NONOate alone at 31 µM showed no inhibition of platelet aggregation. However, in the presence of 31 µM DETA-NONOate, riociguat showed a concentration-dependent inhibition of aggregation by each agonist (Figure C).
Conclusions
Platelets exposed to riociguat in combination with sub-threshold concentrations of NO, such as may occur in microvessels adjacent to the endothelial layer, are inhibited from undergoing platelet activation and aggregation. The presence of plasma proteins blunts the effects of riociguat and has even larger effects on the NO donor, DETA-NONOate. Taken together, these data suggest that NO potently synergizes with riociguat to inhibit platelet activation and aggregation, but in vivo this effect likely only occurs immediately adjacent to endothelial cells where NO concentrations are highest.
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Disclosures
Michelson: Alnylam, Instrumentation Laboratory, Surface Oncology: Consultancy; AstraZeneca, Chiesi, Dova, Janssen, LightIntegra, Megakaryon, Remora: Other: Scientific Advisory Board; Baxalta, Cellular Preservation Technologies, Ionis, Ironwood, Medtronic, Megakaryon, Pfizer, Sysmex: Research Funding. Frelinger:Surface Oncology: Consultancy; Cellular Preservation Technologies, Ironwood, Ionis, Medtronic, Megakaryon, Pfizer and Sysmex: Research Funding.