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Popowicz N, Ip H, Lau EPM, Piccolo F, Dootson K, Yeoh C, Phu WY, Brown R, West A, Ahmed L, Lee YCG. Alteplase Dose Assessment for Pleural infection Therapy (ADAPT) Study-2: Use of 2.5 mg alteplase as a starting intrapleural dose. Respirology 2022; 27:510-516. [PMID: 35441458 DOI: 10.1111/resp.14261] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/09/2022] [Accepted: 03/28/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Intrapleural tissue plasminogen activator/deoxyribonuclease (tPA/DNase) therapy is increasingly used in pleural infection. Bleeding risks and costs associated with tPA remain the clinical concerns. Our dose de-escalation series aims to establish the lowest effective dosing regimen for tPA/DNase. This study assesses the intrapleural use of 2.5 mg tPA/5 mg DNase for pleural infection. METHODS Consecutive patients with pleural infection treated with a starting regime of 2.5 mg tPA/5 mg DNase were included from two centres in Australia and UK. Escalation of tPA dose was permitted if clinical response was inadequate. RESULTS Sixty-nine patients (mean age 61.0 years) received intrapleural 2.5 mg tPA/5 mg DNase. Most (88.4%) were treated successfully and discharged from hospital without surgery by 90 days. Patients received a median of 5 [interquartile range [IQR] = 3-6] doses of tPA/DNase. Total amount of tPA used per patient was 12.5 mg [median, IQR = 7.5-15.0]. Seventeen patients required dose escalation of tPA; most (n = 12) for attempted drainage of distant non-communicating locule(s). Treatment success was corroborated by clearance of pleural opacities on radiographs (from median 27.0% [IQR = 17.1-44.5] to 11.0% [IQR = 6.4-23.3] of hemithorax, p < 0.0001), increased pleural fluid drainage (1.98 L [median, IQR = 1.38-2.68] over 72 h following commencement of tPA/DNase) and reduction of serum C-reactive protein level (by 45.0% [IQR = 39.3-77.0] from baseline at day 5, p < 0.0001). Two patients required surgery. Six patients with significant comorbidities (e.g., advanced cancer) had ongoing infection when palliated and died. Two patients experienced self-limiting pleural bleeding and received blood transfusion. CONCLUSION A starting intrapleural regime of 2.5 mg tPA/5 mg DNase, with up-titration if needed, can be effective and deserves further exploration.
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Affiliation(s)
- Natalia Popowicz
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia.,Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Pharmacy Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Hugh Ip
- Respiratory Medicine, Royal Free Hospital, London, UK
| | - Estee P M Lau
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Francesco Piccolo
- Respiratory Medicine, St John of God Midland, Perth, Western Australia, Australia
| | - Kirstie Dootson
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Cindy Yeoh
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Wint Ywe Phu
- School of Allied Health, Division of Pharmacy, University of Western Australia, Perth, Western Australia, Australia
| | - Rebecca Brown
- Pharmacy Department, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Alex West
- Respiratory Medicine, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
| | - Liju Ahmed
- Respiratory Medicine, King Faisal Specialist Hospital and Research Centre Madinah, Riyadh, Saudi Arabia
| | - Y C Gary Lee
- Pleural Medicine Unit, Institute for Respiratory Health, Perth, Western Australia, Australia.,Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Centre for Respiratory Health, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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Lau EP, Eshraghi M, Dootson K, Yeoh C, Ywe Phu W, Lee YG, Popowicz ND. An international survey on the use of intrapleural tissue plasminogen activator/DNase therapy for pleural infection. ERJ Open Res 2021; 8:00590-2021. [PMID: 35141321 PMCID: PMC8819248 DOI: 10.1183/23120541.00590-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/16/2021] [Indexed: 01/20/2023] Open
Abstract
Introduction Intrapleural tissue plasminogen activator (tPA) combined with human recombinant DNase (DNase) could be an effective alternative to surgery in managing pleural infection, as demonstrated in the Multi-centre Intrapleural Sepsis Trial (MIST)-2. However, the optimal delivery regimen is still unknown. The aim of this survey was to identify the current practice of tPA/DNase use by physicians with published interests in pleural infection, and their opinions on dose de-escalation of tPA/DNase therapy. Methods Potential participants were identified using four search strategies. Only practising physicians who were managing patients with pleural infections and either actively involved in pleural research and publications, or were members of relevant pleural disease guideline panels at the time of survey were included. Results An invitation email with the questionnaire was sent to 102 participants, of whom 49 (48%) responded. Most respondents (90%, n=44) have used tPA/DNase to manage pleural infection, but the dosing and delivery regimens employed varied. Many (86%, 38 out of 44) respondents have used 10 mg tPA, while 73% (n=32), 16% (n=7) and 9% (n=4) have used 5 mg, 2.5 mg and 1 mg doses, respectively. Most respondents instilled tPA/DNase concurrently (61%, n=27) and routinely administered six doses of tPA/DNase (52%, n=23) twice daily (82%, n=36). Respondents would consider using a lower starting dose of tPA (with the possibility of escalation if clinically needed) if a median 80% (interquartile range 50–80%) of patients could be successfully treated at that dose. Conclusion This survey observed a large variation in the current treatment protocol of intrapleural tPA/DNase therapy worldwide and the need for more data on this subject. This international survey observed a large variation in the delivery of tPA/DNase therapy for pleural infection. Respondents were open to the concept of starting with a lower (<10 mg) dose of tPA (with the possibility of escalation) if evidence accumulates.https://bit.ly/2ZfPRrL
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