Protamine sulfate is a medication that is used to reverse the effects of

heparin Heparin, also known as unfractionated heparin (UFH), is a medication and naturally occurring glycosaminoglycan. Since heparins depend on the activity of antithrombin, they are considered anticoagulants. Specifically it is also used in the treat ...

. 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. It is given by

injection into a vein Intravenous therapy (abbreviated as IV therapy) is a medical technique that administers fluids, medications and nutrients directly into a person's vein. The intravenous route of administration is commonly used for rehydration or to provide nutrie ...

. The onset of effects is typically within five minutes. Common side effects include

low blood pressure Hypotension is low blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. Blood pressure is indicated by two numbers, the systolic blood pressure (the top number) and the di ...

slow heart rate Bradycardia (also sinus bradycardia) is a slow resting heart rate, commonly under 60 beats per minute (BPM) as determined by an electrocardiogram. It is considered to be a normal heart rate during sleep, in young and healthy or elderly adults, a ...

allergic reactions Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic derm ...

, and vomiting. Allergic reactions may be severe and include

anaphylaxis Anaphylaxis is a serious, potentially fatal allergic reaction and medical emergency that is rapid in onset and requires immediate medical attention regardless of use of emergency medication on site. It typically causes more than one of the follo ...

. The risk is greater in males who have had a

vasectomy Vasectomy, or vasoligation, is an elective surgical procedure for male sterilization or permanent contraception. During the procedure, the male vasa deferentia are cut and tied or sealed so as to prevent sperm from entering into the urethra and ...

. While there is no evidence of harm from using during pregnancy it has not been well studied in this group. Protamine works by binding with

. Protamine sulfate was approved for medical use in the United States in 1969. It is on the

World Health Organization's List of Essential Medicines The WHO Model List of Essential Medicines (aka Essential Medicines List or EML), published by the World Health Organization (WHO), contains the medications considered to be most effective and safe to meet the most important needs in a health s ...

. It was originally made from the sperm of

salmon Salmon () is the common name for several commercially important species of euryhaline ray-finned fish from the family Salmonidae, which are native to tributaries of the North Atlantic (genus '' Salmo'') and North Pacific (genus '' Onco ...

(salmine, salmon

protamine Protamines are small, arginine-rich, nuclear proteins that replace histones late in the haploid phase of spermatogenesis and are believed essential for sperm head condensation and DNA stabilization. They may allow for denser packaging of DNA in t ...

). It is now mainly made using recombinant biotechnology.

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 In chemistry and biology a cross-link is a bond or a short sequence of bonds that links one polymer chain to another. These links may take the form of covalent bonds or ionic bonds and the polymers can be either synthetic polymers or natural ...

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). Protamine is used in insulin aspart protamine and

NPH insulin Neutral Protamine Hagedorn (NPH) insulin, also known as isophane insulin, is an intermediate-acting insulin given to help control blood sugar levels in people with diabetes. It is used by injection under the skin once to twice a day. Onset of ...

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 Protamines are small, arginine-rich, nuclear proteins that replace histones late in the haploid phase of spermatogenesis and are believed essential for sperm head condensation and DNA stabilization. They may allow for denser packaging of DNA in t ...

has been reported to cause

in patients who are allergic to fish, diabetics using

insulin Insulin (, from Latin ''insula'', 'island') is a peptide hormone produced by beta cells of the pancreatic islets encoded in humans by the ''INS'' gene. It is considered to be the main anabolic hormone of the body. It regulates the metabolism ...

preparations containing protamine, and vasectomized or infertile men. These occur at rates ranging from 0.28% to 6%. Avoiding rapid

infusion Infusion is the process of extracting chemical compounds or flavors from plant material in a solvent such as water, oil or alcohol, by allowing the material to remain suspended in the solvent over time (a process often called steeping). An in ...

of protamine sulfate and pre-treating at-risk patients with

histamine receptor antagonist Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provides re ...

s (H1 and H2) and

steroids A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and ...

may minimize these reactions. A 5 to 10 mg test dose is recommended following pretreatment before administering the full dose.

Mechanism

It is a highly

cationic An ion () is an atom or molecule with a net electrical charge. The charge of an electron is considered to be negative by convention and this charge is equal and opposite to the charge of a proton, which is considered to be positive by convent ...

peptide that binds to either heparin or

low molecular weight heparin Low-molecular-weight heparin (LMWH) is a class of anticoagulant medications. They are used in the prevention of blood clots and treatment of venous thromboembolism (deep vein thrombosis and pulmonary embolism) and in the treatment of myocardial in ...

(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 anatomy the term "reticuloendothelial system" (abbreviated RES), often associated nowadays with the mononuclear phagocyte system (MPS), was originally launched by the beginning of the 20th century to denote a system of specialised cells that eff ...

. In large doses, protamine sulfate may also have an independent — however weak — anticoagulant effect.

History

Protamine sulfate replaced

hexadimethrine bromide Hexadimethrine bromide (commercial brand name Polybrene) is a cationic polymer with several uses. Currently, it is primarily used to increase the efficiency of transduction of certain cells with retrovirus in cell culture. Hexadimethrine bromi ...

(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.

References

External links

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