Intrapleural alteplase therapy: what are the knowns and unknowns?

Czech version

Authors: Judita Staša ¹; Jana Gregorová ^1,2; Norbert Pauk ³
Authors‘ workplace: Oddělení klinické farmacie, Nemocnice Na Bulovce, Praha ¹; Ústav aplikované farmacie, Farmaceutická fakulta VFU Brno ²; Klinika pneumologie 3. LF UK a Nemocnice Na Bulovce, Praha ³
Published in: Čas. Lék. čes. 2019; 158: 295-299
Category: Review Article

Overview

In pneumology, enzymatic properties of plasmin are used to disrupt fibrin adhesions and septations formed during pathological conditions of the pleural cavity. In that case, fibrinolytics are administrated locally via a chest tube in the pleural cavity to evacuate pathological effusion. Although the first intrapleural administration of fibrinolytic occurred seventy years ago, there has been no consensus on dosing or a uniform procedure of their application. The aim of the article is to summarize current knowledge of alteplase usage in pneumology and discuss practical aspects of its intrapleural application regarding specific possibilities in the Czech Republic.

Keywords:

intrapleural fibrinolytics – alteplase – pleural infection – fibrinolytic therapy

Sources

Žáčková P, Vašáková M. Diagnostika a léčba hrudního empyému. Česká pneumologická a ftizeologická společnost ČLS JEP, 2016. Dostupné na: www.pneumologie.cz/guidelines
Colice GL, Curtis A, Deslauriers J et al. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest 2000; 118: 1158–1171.
Davies HE, Davies RJ, Davies CW et al. Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax 2010; 65: ii41–ii53.
Tillett W, Sherry S. The effect in patients with streptococcal fibrinolysis (streptokinase) and streptococcal desoxyribonuclease on fibrinous, purulent, and sanguinous pleural exudations. J Clin Invest 1949; 28: 173–190.
Státní ústav pro kontrolu léčiv. Databáze léků. Dostupné na: www.sukl.cz/modules/medication/search.php
SPC Actilyse. Dostupné na: www.sukl.cz/modules/medication/detail.php?code=0093650&tab=texts
Thommi G, Nair CK, Aronow WS et al. Efficacy and safety of intrapleural instillation of alteplase in the management of complicated pleural effusion or empyema. Am J Ther 2007; 14: 341–345.
Froudarakis ME, Kouliatsis G, Steiropoulos P et al. Recombinant tissue plasminogen activator in the treatment of pleural infections in adults. Respir Med 2008; 102: 1694–1700.
Skeete DA, Rutherford EJ, Schlidt SA et al. Intrapleural tissue plasminogen activator for complicated pleural effusions. J Trauma 2004; 5: 1178–1183.
Rahman NM, Maskell NA, West A et al. Intrapleural use of tissue plasminogen activator and DNase in pleural infection. N Engl J Med 2011; 365: 518–526.
Piccolo F, Pitman N, Bhatnagar R et al. Intrapleural tissue plasminogen activator and deoxyribonuclease for pleural infection. An effective and safe alternative to surgery. Ann Am Thorac Soc 2014; 11: 1419–1425.
Majid A, Kheir F, Folch A et al. Concurrent intrapleural instillation of tissue plasminogen activator and DNase for pleural infection. A single-center experience. Ann Am Thorac Soc 2016; 13: 1512–1518.
Mehta HJ, Biswas A, Penley AM et al. Management of intrapleural sepsis with once daily use of tissue plasminogen activator and deoxyribonuclease. Respiration 2016; 91: 101–106.
Bishwakarma R, Shah S, Frank L et al. Mixing It Up: Coadministration of tPA/DNase in complicated parapneumonic pleural effusions and empyema. J Bronchology Interv Pulmonol 2017; 24: 40–47.
Popowicz N, Bintcliffe O, De Fonseka D et al. Dose de-escalation of intrapleural tissue plasminogen activator therapy for pleural infection. The alteplase dose assessment for pleural infection therapy project. Ann Am Thorac Soc 2017; 14: 929–936.
Lan NSH, Vekaria S, Sidhu C et al. Very low-dose intrapleural tPA for indwelling pleural catheter-associated symptomatic fluid loculation. Respirol Case Rep 2019; 7(7): e00457.
Hart JA, Badiei A, Lee YCG. Successful management of pleural infection with very low dose intrapleural tissue plasminogen activator/deoxyribonuclease regime. Respirol Case Rep 2019; 7(3): e00408.
Abu-Daff S, Maziak DE, Alshehab D et al. Intrapleural fibrinolytic therapy (IPFT) in loculated pleural effusions-analysis of predictors for failure of therapy and bleeding: a cohort study. BMJ Open 2013; 3: 2–7.
Kheir F, Cheng G, Rivera E et al. Concurrent Versus Sequential Intrapleural Instillation of Tissue Plasminogen Activator and Deoxyribonuclease for Pleural Infection. J Bronchology Interv Pulmonol 2018; 25: 125–131.
Alemán C, Porcel JM, Alegre J et al. Intrapleural fibrinolysis with urokinase versus alteplase in complicated parapneumonic pleural effusions and empyemas: a prospective randomized study. Lung 2015; 193: 993–1000.
Thommi G, Shehan JC, Robison KL et al. A double blind randomized cross over trial comparing rate of decortication and efficacy of intrapleural instillation of alteplase vs placebo in patients with empyemas and complicated parapneumonic effusions. Respir Med 2012; 106: 716–723.
McClune JR, Wilshire CL,Gorden JA et al. Safety and efficacy of intrapleural tissue plasminogen activator and DNase during extended use in complicated pleural space infections. Can Respir J 2016; 2016: 9796768.
Thomas R, Piccolo F, Miller D et al. Intrapleural fibrinolysis for the treatment of indwelling pleural catheter-related symptomatic loculations: a multicenter observational study. Chest 2015; 148: 746–751.
Komissarov AA, Florova G, Azghani AO. Dose dependency of outcomes of intrapleural fibrinolytic therapy in new rabbit empyema models. Am J Physiol Lung Cell Mol Physiol 2016; 311: L389–L399.

Labels

Addictology Allergology and clinical immunology Angiology Audiology Clinical biochemistry Dermatology & STDs Paediatric gastroenterology Paediatric surgery Paediatric cardiology Paediatric neurology Paediatric ENT Paediatric psychiatry Paediatric rheumatology Diabetology Pharmacy Vascular surgery Pain management Dental Hygienist

Clinical pharmacy in the Czech Republic

Is safe pharmacotherapy worthwhile?

Specialization in clinical pharmacy

Paediatric clinical pharmacist: a potential benefit?

Drug administration via feeding tubes: examples, working group

Proton pump inhibitors from clinical pharmacist’s point of view

Clinically significant drug interactions of antiretrovirals

Management of metabolic adverse effects of everolimus in patients with renal carcinoma

Medication treatment of singultus in palliative care

Combination of mirtazapine and paroxetine: possible clinically demonstrated interaction?

Complication during hospitalization of geronto-psychiatric patient for fatal Stevens-Johnson syndrome – a multidisciplinary approach

Sleep and its disturbances in neurology