Activity and dosage of alteplase dilution for clearing occlusions of venous-access devices

Abstract

The activity and sterility of reconstituted alteplase solution and the effectiveness of an alteplase dose-escalation protocol for the clearance of midline-catheter and central-venous-access device occlusions were studied. Reconstituted alteplase solution was stored at -70, -25, or 2 degrees C at concentrations of 0.5, 1, or 2 mg/mL. Durations of storage in the freezer were 0, 7, and 14 days, and durations of storage in the refrigerator were 0, 48, and 72 hours and 7 and 14 days. Samples were also assayed and cultured without prior freezing after refrigeration at 2 degrees C for 0, 48, and 72 hours and 7, 14, and 28 days. Fifty-eight pediatric and adult patients were enrolled in a separate study in which catheter clearance was initiated with alteplase 0.5 mg, and the dose was escalated to 1 and 2 mg sequentially until the catheter was cleared. The primary endpoint was restoration of catheter patency, and the secondary endpoint was the occurrence of bleeding episodes within 24 hours of alteplase administration. Catheter removal due to failure to restore patency was also documented. The activity and sterility of alteplase were maintained under all conditions studied. Fifty catheters (86.2%) were cleared with alteplase 0.5 mg, 5 (8.6%) after dose escalation to 1 mg, and 1 (1.7%) after escalation to 2 mg. The alteplase solution did not clear the occlusion in 2 catheters (3.4%): 1 had a mechanical obstruction and 1 cleared two hours after the 1-mg dose was deemed a failure. None of the six catheter removals was due to recalcitrant clots. Bleeding observed was not considered to be the result of alteplase administration. For use in clearing occlusions of venous-access devices, alteplase 0.5, 1, and 2 mg/mL retained sufficient fibrinolytic activity when stored for up to 14 days at 2 degrees C (28 days for the 0.5-mg/mL dilution) and when stored for 14 days at -70 or -25 degrees C followed by up to 14 days at 2 degrees C. The dose-escalation protocol was effective.