Plasminogen
Fibrinogen
Plasmin
Fibrin
Fibrinolysis
Fibrinolysis
Injured endothelial cells
Plasminogen activators
Plasmin cleaved from plasminogen Fibrin degrades
Primary
Plasmin Plasminogen
Thrombolytic drugs dissolve blood clots by activating plasminogen, which forms a cleaved product called plasmin. Plasmin is a proteolytic enzyme that is capable of breaking cross-links between fibrin molecules, which provide the structural integrity of blood clots. Because of these actions, thrombolytic drugs are also called "plasminogen activators" and "fibrinolytic drugs."
The removal of the clot is caused by plasmin cleavage of the fibrin monomers into soluble fibrin degradation products. Plasmin is formed by the cleavage of plasminogen between Arg561 and Val562. Plasmin is a two-chain trypsin-like serine protease.
C2569H3928N746O781S40
Elimination by Hepatocyte
Fibrinolytic drug
Alteplase (Actilyse; Activase; rtPA) is a recombinant form of human tPA
Binding to fibrin
Splitting of Plasminogen
Clot-buster
Pharmacokinetics
ADME
Broken down in digestive system, so? Exercise and vasoactive substances such as epinephrine, vasopressin, desmopressin, niacin or alcohol, increase endogenous levels, so? Endogenous levels = 46 ng/mL, so?
Pharmacokinetics
ME
Metabolism poorly understood but principally hepatic with most occurring with the hepatocytes. First reading 60 Second reading 26 @ 5 minutes later Third Reading 12 @ another 5 minutes later
Half-life?
Pharmacokinetics
Rapidly cleared 550-680 mL/minute from plasma giving an initial distribution phase half life (t) <5 min and in the terminal elimination phase (t) ~40 min. Thus > 50% of t-PA is cleared from plasma within 5 minutes after discontinuance of an IV infusion and approximately 80% is cleared within 10 minutes.
Giving us
Continuous infusion. Recommended dose 0.9 mg alteplase/kg body weight (maximum of 90 mg) over 60 minutes, with 10% of the total dose administered as an initial intravenous bolus. Not indicated <18 years >80 years. ????
Risks
Plasmin breaks down fibrin = fibrin degradation products (FDPs). FDPs compete with thrombin = slow down the conversion of fibrinogen to fibrin (and thus slows down clot formation).
Risks
Lysis of normal haemostatic plugs - bleeding
Intracranial haemorrhage, absolute risk is increased 6% in patients of first 10 days, maximal during the first 36 hours after treatment. (c.f. 3 month overall risk reduction of 11% )
Other risks
Potential interactions with anticoagulants, ACE inhibitors, platelet function altering drugs etc. Cholesterol embolisms
Contraindications?
Blood glucose < 50 or > 400 mg/dl More with Dr Fotherby
Beyond that time, the efficacy diminishes and higher doses are generally required to achieve desired lysis and the great the risk of unwanted complications.
Alteplase is recommended for the treatment of acute ischaemic stroke when used by physicians trained and experienced in the management of acute stroke. It should only be administered in centres with facilities that enable it to be used in full accordance with its marketing authorisation.
Competency framework
the time of the onset of stroke has been recorded and has full understanding of the importance of this in relation to thrombolysis
Understands the pharmacodynamics and pharmacokinetics of thrombolytic treatment with rtPA Understands the potential for unwanted effects