Streptokinase

About streptokinase: action, indications, contraindications, dosage and administration and adverse effects.

1. STREPTOKINASE NEELU ARYAL Msc NURSING 2 nd YEAR

2. ACTION Recombinent streptokinase and plasminogen together form a stochiometric 1:1 activator complex. Activator complex converts remaining plasminogen , present either in the blood or in a thrombus to plasmin . Plasmin lyses thrombi by converting insoluble fibrin into soluble fibrin degradation products.

3. The plasma half-life of the activator complex is around 20 minutes. Following IV administration, the effect on coagulation may persist for up to 12 hours. Recombinent streptokinase is weakly antigenic and may be neutralized by anti-streptokinase antibodies, normally present in the blood as a result of previous streptococcal infections.

4. A fibrinolytic state is initiated when the amount of recombinant streptokinase administered exceeds the anti-streptokinase antibody titre . Thrombolysis commences when the streptokinase activator complex diffuses into the thrombus.

5. INDICATIONS Acute myocardial infarction: less than 12 hours Deep venous thrombosis: less than 14 days Acute massive pulmonary embolism Acute arterial thrombosis and embolism. Clotting in haemodialysis shunts.

6. CONTRAINDICATIONS Since thrombolytic therapy increase the risk of bleeding, it is contraindicated in the following situations:- Recent (<10 days) trauma ( eg facial or head trauma) or traumatic procedures ( eg surgery, biopsy or invasive diagnostic procedure). Several uncontrolled hypertension.

7. Recent cerebrovascular events ( eg stroke) within the last 2 months or intracranial malignancy. Potential for internal bleeding ( eg peptic ulcer, ulcerative colitis, diverticulitis or visceral tumors) including thrombocytopenia.

8. All forms of reduced blood coagulability , in particular spontaneous fibrinolysis and extensive clotting disorders. Pronounced hepatic and renal dysfunction. Recombinant streptokinase is also contraindicated in patients with potential for cardiac embolism ( eg bacterial endocarditis )

9. DOSAGE AND ADMINISTRATION 1 . Acute myocardial infarction 15,00,000 IU of streptokinase in 50 ml of physiological saline or dextrose 5% is administered as an intravenous infusion at a constant rate cover over 30-60 minutes. To ensure that the contents of the vial are rapidly and completely reconstituted, 5 ml of physiological saline should be first injected into vacuum vial and the residual vacuum abolished by briefly loosening the needle from the syringe.

10. For dissolution, the vial needs to be swirled gently and shaking avoided to prevent foaming. This reconstituted solution should then be diluted further in an infusion bottle with physiological saline or dextrose 5% in preparation for infusion.

11. Streptokinase should be administered as soon as possible after onset of symptoms of myocardial infarction. The greatest benefit in mortality reduction is achieved when recombinant streptokinase is administered within the first 6 hours but substantial benefit has been demonstrated at up to 12 hours.

12. 2. Deep venous thrombosis, pulmonary embolism and arterial occlusions: The standard dosage comprises an initial loading dose sufficient to overcome the circulating anti-streptokinase antibodies, followed by a maintenance infusion to sustain a continuous systemic lytic state.

13. The loading dose of 2,50,000 IU dissolved in 100-300ml of physiological saline or dextrose 5% should be administered intravenously over 30 minutes. This is followed by a maintenance infusion of 1,00,000 IU per hour (dissolved in physiological saline or dextrose 5%) administered for up to 3 days. If possible, an angiographic assessment should then be performed. If no clinical effect is noted after 3 days, treatment should be discontinued. Streptokinase therapy may otherwise be continued for an additional 1-3 days if considered necessary.

14. 3. Clotting in haemodialysis shunts It is dissolved in physiological saline. 10,000-25,000 IU are deposited in the clotted part of the shunt and it is sealed on the venous side by forceps. A sterile single dose syringe is attached on the arterial side to form an air cushion against which the artery can pulsate. If necessary, this treatment may be repeated after 30-45 minutes.

15. FOLLOW-UP TREATMENT After every course of recombinant streptokinase therapy, a follow-up treatment with anticoagulants or platelet aggregation inhibitors can be instituted as a prevention of rethrombosis . With heparin therapy, in particular, an increased risk of haemorrhage must be considered.

16. ADVERSE EFFECTS COMMON Hypotension/ bradycardia in about 10% of the cases. Allergic reactions such as fever, chills, gastrointestinal symptoms, generalized exanthema and muscoskeletal pain may occur, but usually respond well to symptomatic therapy. Minor bleedings from punctures and surgical sites.

17. LESS COMMON Tachycardia Major haemorrhagic episodes requiring transfusion and entailing termination of streptokinase administration. Menstrual bleeding may be aggravated. Mild allergic effects such as headache, nausea, vomiting, flushing and urticaria . Musculoskeletal pain including myalgia and back pain.

18. RARE Anaphylactic and anaohylactoid reactions ranging in severity from mild dyspnoea to bronchospasm . Anaphylactic shock and delayed hypersensitivity reactions such as arthritis, arthralgia , vasculitis and intestitial nephritis. Pulmonary embolism. Neuropathy

19. Uveitis Renal insufficiency Raised aminotransferase values. Cholesterol embolism.

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