A safety evaluation of drotrecogin alfa (activated) in hematopoietic stem cell transplant patients with severe sepsis: lessons in clinical research

Economic evaluation in critical care: a focus on severe sepsis in oncology

Hospital care, physician and clinical services, and prescription drugs continue to drive healthcare expenditures across healthcare systems and nations. The critical-care setting, owing to the complexity and intensity of care, is a high user of the resources that drive healthcare spending. Information regarding the cost and effectiveness of critical-care therapies is necessary to properly guide care and policies for this unique population. Many challenges exist for conducting and comparing economic evaluation in critical care. Recently, recommendations on cost and cost-effectiveness analysis in critical care have been developed that will guide future research. A focus area, severe sepsis in oncology, is reviewed to highlight the challenges and opportunities of economic evaluation in this setting.

Critical care of the hematopoietic stem cell transplant recipient

An estimated 50,000 to 60,000 patients undergo hematopoietic stem cell transplantation (HSCT) worldwide annually, of which 15.7% are admitted to the intensive care unit (ICU). The most common reason for ICU admission is respiratory failure and almost all develop single or multiorgan failure. Most HSCT recipients admitted to ICU receive invasive mechanical ventilation (MV). The overall short-term mortality rate of HSCT recipients admitted to ICU is 65%, and 86.4% for those receiving MV. Patient outcome has improved over time. Poor prognostic indicators include advanced age, poor functional status, active disease at transplant, allogeneic transplant, the severity of acute illness, and the development of multiorgan failure. ICU resource limitations often lead to triage decisions for admission. For HSCT recipients, the authors recommend (1) ICU admission for full support during their pre-engraftment period and when there is no evidence of disease recurrence; (2) no ICU admission for patients who refuse it and those who are bedridden with disease recurrence and without treatment options except palliation; (3) a trial ICU admission for patients with unknown status of disease recurrence with available treatment options.

Diagnosis and management of infectious complications in critically ill patients with cancer

Cancer and its treatments lead to profound suppression of innate and acquired immune function. In this population, bacterial infections are common and may rapidly lead to overwhelming sepsis and death. Furthermore, infections caused by viral and fungal pathogens should be considered in patients who have specific immune defects. As cancer therapies have become more aggressive the risk for infection has increased and many patients require intensive care support. Despite improvements in long-term survival, infections remain a common complication of cancer therapy and accounts for the majority of chemotherapy-associated deaths. By understanding the host defense impairments and likely pathogens clinicians will be better able to guide diagnosis and management of this unique population.

Pasteurella multocida septic shock following liver transplantation treated with drotrecogin alfa (activated)

Severe sepsis and progression to septic shock in solid organ transplant recipients is associated with a high mortality. We describe a fulminant case of septic shock in a liver transplant recipient caused by Pasteurella multocida, a gram-negative coccobacillus most commonly associated with domestic cats and dogs. P. multocida is a rare cause of bacteremia and has not been reported as a cause of septic shock following liver transplantation. In addition to standard therapy, the patient was managed with drotrecogin alpha (activated) recombinant activated protein C (APC), an evidence-based agent that has been shown to significantly improve outcome in severe sepsis in the non-transplant population. The known risk factors, clinical course, and outcomes of severe infection associated with P. multocida are also briefly reviewed. This case illustrates the need for transplant recipients and their healthcare providers to carefully consider the risk of severe infection associated with domestic animal exposure.

From bench to bedside: a review of the clinical trial development plan of drotrecogin alfa (activated)

OBJECTIVE

To provide a comprehensive overview of the various clinical trials of drotrecogin alfa (activated) (DrotAA) completed by Eli Lilly and Company over the past 10 years.

METHODS

Eli Lilly and Company data from phase 1 through phase 4 trials, observational studies, and compassionate-use studies of DrotAA were reviewed. Safety, efficacy, and pharmacokinetic data were included. The review excluded pediatric studies and studies recently concluded where the manuscript was in press. All studies included in the review were approved by the ethical review boards at the participating institutions.

RESULTS

Over 9000 adults with severe sepsis have been enrolled in DrotAA clinical trials through December 2005 and the results of the clinical evaluation of DrotAA have been widely disseminated in publications. Analyses of the data indicate that the pharmacokinetics of DrotAA are both linear and dose-proportional. The phase 2 and phase 3 studies of administration of DrotAA to patients with severe sepsis demonstrated a significant reduction in mortality and were associated with a favorable benefit/risk profile. Three of these trials (a phase 2 and two phase 3, PROWESS and ENHANCE) evaluated the effect of DrotAA in adult patients with sepsis associated with acute organ dysfunction (severe sepsis) while another phase 3 trial (ADDRESS) was conducted in the non-indicated population of adult patients with severe sepsis associated with a lower risk of death. A phase 4 trial demonstrated no significant difference in steady-state plasma concentrations or elimination half-life of DrotAA between patients < or =135 kg and >135 kg, indicating that DrotAA should be dosed by actual body weight.

DISCUSSION

The challenges and limitations of the clinical development plan for DrotAA are discussed.

CONCLUSION

DrotAA is indicated for the reduction of mortality in adult patients with severe sepsis (sepsis associated with acute organ dysfunction) who have a high risk of death. DrotAA is not indicated in adult patients with severe sepsis and low risk of death. The clinical plan for DrotAA continues with a focus on tailored therapy and identifying the most appropriate patients for DrotAA treatment.