UMEM Educational Pearls

Title: should we do it half dose for patients with pulmonary embolism

Posted: 4/30/2024 by Quincy Tran, MD, PhD (Updated: 11/22/2024)
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Title: Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study

Settings: Retrospective observational study from a combination of Abbott Northwestern Hospital and 15 others as part of the Mayo Health system.

Participants: Patients between 2012 – 2020 who were treated for PE. Patients were propensity-matched according to the probability of a patient receiving a reduced- dose of alteplase.

Outcome measurement:

Primary outcome: all-cause and PE-related mortality or hemorrhage within 7 days of alteplase administration.
Secondary outcomes: shock index at 8 hours after alteplase administration, LOS.

Study Results:

A total of 284 patients were included in the retrospective analysis; 98 were treated with the full-dose and 186 with the reduced-dose alteplase regimen.
Primary outcome was similar in both groups:
- 7-day all-cause (5.6% in full- dose vs. 8% in reduced-dose, p = 0.45)
- PE-related (4% in full-dose vs. 4.2% in reduced-dose, p = 0.93)
All other secondary outcomes were similar between both groups
overall rates of hemorrhagic complications were significantly lower in the reduced-dose group than in the full-dose group (13% vs. 24.5%, respectively, p = 0.014).
Major intracranial hemorrhage was higher, but not statistically significant, for full-dose group: 1.3% in reduced-dose vs. 7.1% in full-dose for major, (p = 0.067)

Discussion:

Overall, there was more risk for full-dose. However, this is a retrospective study so whether it will be factored into clinical practice remains to be seen.
The PERT team at UMMC still recommends full dose for hemodynamic unstable patients. Perhaps for those with somewhat instability, a half dose should be considered?
There is still not enough data regarding the newer ones, as UMMS hospitals are starting to use TNK more frequently nowadays.

Conclusion:

In this retrospective, Propensity-score matching study, the full-dose regimen but is associated with a lower risk of bleeding.

References

Melamed R, Tierney DM, Xia R, Brown CS, Mara KC, Lillyblad M, Sidebottom A, Wiley BM, Khapov I, Gajic O. Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study. Crit Care Med. 2024 May 1;52(5):729-742. doi: 10.1097/CCM.0000000000006162. Epub 2024 Jan 3. PMID: 38165776.