Etamsylate introduces platelets into priming state and enhances platelet procoagulant response – Functional and mechanistic update of a classical hemostatic agent

Etamsylate is a classical hemostatic agent, used to control bleeding in various clinical settings. Yet, the precise mechanism of its action is unknown. Hereby, we evaluated the complex effect of etamsylate on platelet-dependent hemostasis, with the aim of supplementing the model of its mechanism of action. Fluorescence microscopy was used to study thrombus formation under flow, exposure of phosphatidylserine (PS), P-selectin, and PECAM-1 in adhered platelets. Flow cytometry was utilized to assess activation markers in non-adhered platelets. Kinetics of clot formation was evaluated by thromboelastometry. Platelet aggregation and ATP secretion was measured by lumiaggregometry. Changes in cytosolic calcium level was measured fluorimetrically. We found that etamsylate (30–300 μM) dose-dependently enhanced platelet adhesion to collagen, as well as agonist-evoked platelet aggregation. Etamsylate per se induced platelet secretion and PS exposure and produced a rapid and sustained rise in cytosolic calcium level. These effects were substantially reduced by ADP receptors antagonists, or ADP/ATP scavenger - apyrase. Etamsylate enhanced platelet responses evoked by collagen and induced a loss of platelet PECAM-1 (negative regulator of collagen GPVI receptor), which was attenuated by calcium signaling blockers, and by calpain inhibitor. Etamsylate significantly augmented coagulation in whole blood, but not in plasma. Etamsylate amplifies a broad range of platelet responses, with particular ability to augment the action of collagen. This study provides insight into the mechanisms through which etamsylate exerts its hemostatic effect. This suggests new potential clinical perspectives for etamsylate usage in novel hemostatic therapies. Graphical abstract • Etamsylate is commonly used hemostatic drug with partially known mechanism of action. • There is no data describing effect of etamsylate on platelet procoagulant response. • As we show, etamsylate enhances a range of platelet responses inducing priming state. • Etamsylate raises platelet procoagulant response and platelet-fibrin clot formation. • This advocates for using of etamsylate in future single or dual hemostatic therapies.