Objective-Serine protease inhibitors (serpin) play a central role in various pathological processes including coagulation, fibrinolysis, malignancy, and inflammation. Inhibition of serpins may prove therapeutic. As yet, however, only very few small molecule serpin inhibitors have been reported. For the first time, we apply a new approach of virtual screening to discover novel, orally active, small molecule serpin inhibitors and report their effectiveness. Methods and Results-We focused on a clinically important serpin, plasminogen activator inhibitor-1 (PAI-1), whose crystal structure has been described. We identify novel, orally active molecules able to enter into the strand 4 position (s4A) of the A -sheet of PAI-I as a mock compound. In vitro they specifically inhibit the PAI-1 activity and enhance fibrinolysis activity. In vivo the most effective molecule (TM5007) inhibits coagulation in 2 models: a rat arteriovenous (AV) shunt model and a mouse model of ferric chloride-induced testicular artery thrombosis. It also prevents the fibrotic process initiated by bleomycin in mouse lung. Conclusions-The present study demonstrates beneficial in vitro and in vivo effects of novel PAI-1 inhibitors. Our methodology proves to be a useful tool to obtain effective inhibitors of serpin activity. Serpins consist of a -sheets-rich body. They contain an exposed mobile reactive center loop (RCL) 2 which, once cleaved by a target serine protease, inserts its N terminus part into the strand 4 position (s4A) of the A -sheet, triggering its antiprotease activity. Small molecule compounds able to enter into the s4A position of the A -sheet as a mock molecule may thus prevent the biological activity of the serpin.Up to now, however, only very few small molecule serpin inhibitors have been described, none of which are in clinical use. Most have been discovered by high-throughput random screening (HTS) of a large chemical library, 3-5 a rather inefficient strategy. In the present study, a new approach of virtual screening based on the 3-dimensional structure of a serpin, (PAI-1), was used to discover novel, orally active, small molecule compounds able to inhibit the target molecule.PAI-1 regulates the plasminogen activation system through inhibition of its target serine proteases, tissue-type and urokinase-type plasminogen activator (tPA and uPA). 1 Studies in humans and animals have demonstrated that PAI-1 expression is enhanced in various disorders such as thrombosis, fibrotic diseases, atherosclerosis, radiation damage, and cancer progression. 6 PAI-1 has been linked with fibrin deposition evolving into organ fibrosis and atherosclerosis, or with striking alterations of cell adhesion and migration mediating cancer progression. 7 The absence of PAI-1 in PAI-1 knockout mice markedly attenuates these pathological processes. 8 -12 Inhibition of PAI-1 by a neutralizing antibody 13 provides similar promising results in animal experiments. Small molecule PAI-1 inhibitors, active orally, should prove useful to treat not only thrombot...