Risks versus benefits: the alteplase experience.
The characteristics and efficacy of alteplase in treating acute myocardial infarction (AMI) are described, and the role of the pharmacist with respect to thrombolytic therapy is discussed. Most patients with AMI have an acute thrombotic occlusion in the coronary artery supplying the infarcted tissue. Subsequent mortality from AMI can be reduced if patients receive thrombolytic therapy within 4 to 24 hours after the onset of symptoms. Tissue-type plasminogen activator produced by recombinant DNA techniques (alteplase) is purported to be indistinguishable from the endogenous protein. When given intravenously, alteplase has a rapid onset of action and a half-life of three to nine minutes, producing plasma concentrations of plasminogen activator 1000 times greater than those seen under normal physiologic conditions. Because alteplase has an affinity for fibrin and is, therefore, clot specific, its use does not induce the systemic plasminogen activation seen with streptokinase or urokinase therapy. The major adverse effect of alteplase therapy is bleeding. Comparative studies have shown reperfusion rates of 66% to 75% with alteplase and of 36% to 76% with streptokinase. Alteplase has generally been more effective than streptokinase in initiating reperfusion. Alteplase may be used for treatment of reocclusion after initial treatment with either alteplase or streptokinase. Because alteplase costs approximately 30 times more than streptokinase, informed medical decision making is imperative. It is suggested that pharmacists develop protocols, monitor thrombolytic therapy in their institutions, stay informed about current research, regularly report their findings to medical colleagues, and provide information and education to physicians, nurses, and patients. The rational use of thrombolytic agents requires consideration of the attendant clinical and economic consequences.(ABSTRACT TRUNCATED AT 250 WORDS)
Green
J A
JA
Cardiovascular Clinical Pharmacology Research Program, Case Western Reserve University, Cleveland, OH.
D003362:Cost-Benefit Analysis; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy; D011994:Recombinant Proteins / Q000009:adverse effects / Q000235:genetics / Q000627:therapeutic use; D012307:Risk Factors; D010959:Tissue Plasminogen Activator / Q000009:adverse effects / Q000235:genetics* / Q000627:therapeutic use
D011994:Recombinant Proteins; D010959:Tissue Plasminogen Activator