Effects of Concurrent Dosing on the Efficacy of Tissue Plasminogen Activator and Deoxyribonuclease in the Treatment of Pleural Infection

Abstract

Background: The goal of this study was to evaluate how the administration of concurrent tissue plasminogen activator (tPA) and deoxyribonuclease (DNase) therapy with variable dosing for complicated parapneumonic effusions and empyema affects patient outcomes in an inner-city community hospital. Methods: This retrospective analysis was performed at an inner-city hospital located in Raleigh, North Carolina. A list of all patients treated with tPA and DNase between July 1, 2015, and December 31, 2017, was generated and screened. Data were collected through a review of past medical records, including demographics, past medical history, and details about their hospital course. Results: A total of 38 patients were found to have been treated with concurrent tPA and DNase for complicated parapneumonic effusion or empyema. Twenty (52.6%) patients received the full six doses of combined concurrent tPA/DNase. Of the 18 (47.4%) patients who did not receive the full six doses, 11 did not require the full six doses for effusion resolution, and seven had to discontinue therapy due to tube blockage or pain. Only seven (18.4%) patients had complications related to tPA/DNase administration, most commonly pain. Nineteen (50%) patients had complete radiological clearance of effusion, with 13 (34.2%) having partial clearance, and six (15.8%) having no change or worsening of their effusion. Eight (21.1%) patients needed further surgical management of their effusion. Conclusions: The current most common dosing pattern for combined tPA and DNase therapy of twice daily for three days may not be optimal for all patients. The dosing regimen should be individualized depending on clinical response. Concurrent dosing is safe.

Infective Pleural Effusions—A Comprehensive Narrative Review Article

“…Optimal dosing has not been established yet; however, the currently used regimen is derived from the original MIST 2 trial in which patients received a total of 10 mg of tPA and 5 mg of DNase intrapleurally twice a day in six doses [ 50 ]. However, such dosing might not be optimal in all patients [ 54 ]. An international survey of 49 practicing physicians involved in the management of pleural infections and who were either actively involved in pleural research and publications or were members of relevant pleural disease guideline panels observed a large variation in treatments offered [ 55 ].…”