ইঙ্গিত ও ব্যবহার
S-Kinase is indicated for use in the following situations. For systemic administration, it is used in acute transmural myocardial infarction (not older than 12 hours) with persistent ST-segment elevation or recent left bundle-branch block, deep vein thromboses (not older than 14 days), acute massive pulmonary embolism, acute and subacute thromboses of peripheral arteries, chronic occlusive arterial diseases (not older than 6 weeks), and occlusion of the central retinal artery or vein (arterial occlusions not older than 6 to 8 hours, venous occlusions not older than 10 days). For local administration, it is used in acute myocardial infarction to reopen coronary vessels (not older than 12 hours), and in acute, subacute and chronic thromboses as well as embolisms of peripheral venous and arterial vessels.
ডোজ নির্দেশিকা
শুধুমাত্র নির্দেশিকা তথ্য
প্রদর্শিত ডোজগুলি সরকারি উৎসের সাধারণ নির্দেশিকা। ব্যক্তিগতকৃত ডোজের জন্য সর্বদা আপনার ডাক্তার বা ফার্মাসিস্টের পরামর্শ নিন।
Adults:
Acute evolving transmural MI: Administer as soon as possible after symptom onset. The greatest benefit in mortality reduction was observed when Streptokinase was administered within 4 hours, but statistically significant benefit has been reported up to 24 hours. For IV infusion, administer a total dose of 1500000 IU within 60 minutes. For intracoronary infusion, administer 20000 IU by bolus followed by 2000 IU per minute for 60 minutes, for a total dose of 140000 IU. PE, DVT, arterial thrombosis, or embolism: Institute treatment as soon as possible after the thrombotic event, preferably within 7 days. Any delay in starting lytic therapy in order to evaluate the effect of heparin therapy decreases the potential for optimal efficacy. Because human exposure to streptococci is common, antibodies to Streptokinase are prevalent, so a loading dose sufficient to neutralize these antibodies is required. A dose of 250000 IU Streptokinase infused into a peripheral vein over 30 minutes was found appropriate in over 90% of patients. If the thrombin time, or any other parameter of lysis, is not significantly different from the normal control level after 4 hours of therapy, Streptokinase should be discontinued, since this indicates excessive resistance. AV cannula occlusion: Before use, try to clear the cannula with the syringe technique using heparinized saline solution. If adequate flow is not re-established, Streptokinase may be used. Allow the effect of any pretreatment anticoagulants to diminish first. Slowly instill 250000 IU in 2 mL of solution into each occluded limb of the cannula, then clamp off the cannula limb(s) for 2 hours, observing closely for adverse effects. After treatment, aspirate the contents of the infused cannula limb(s), flush with saline, and reconnect the cannula. Pediatric use: Controlled clinical studies have not been conducted in children to establish safety and efficacy, so the evidence of clinical benefits and risks rests solely on anecdotal reports in patients ranging in age from under 1 month to 16 years. The largest number of reports concerns the use of Streptokinase in arterial occlusions. For arterial occlusions, the most frequently used loading dose was 1000 IU/kg, with fewer patients receiving 3000 IU/kg; loading dose durations have typically ranged from 5 to 30 minutes. Continuous infusion doses were frequently 1000 IU/kg/h, with fewer at 1500 IU/kg/h, and infusions were maintained for 12 hours or less in roughly half of the published cases, with a smaller proportion running between 12 and 24 hours. Reported adverse events in the pediatric population are similar in nature to those seen in adults. Rates of all bleeding complications have been variable, reaching as high as 50% at catheter sites in some studies, and bleeding has occasionally required transfusion, so careful monitoring of patient status is necessary.
পার্শ্বপ্রতিক্রিয়া
Potentially life-threatening effects: The unwanted effects of S-Kinase therapy fall into two categories: those resulting from bleeding and those resulting from allergy. Hypotension and arrhythmias may occur in patients with myocardial infarction.Bleeding: Major, life-threatening hemorrhage occurs in 0.2-0.3% of patients. Less severe bleeding has been reported in about 10% of patients. In the event of serious hemorrhage, S-Kinase therapy should be stopped. Antifibrinolytic therapy (tranexamic acid, aminocaproic acid, or aprotinin) should be considered if there is evidence of persistent fibrinolytic activity in the blood. Transfusions of blood (preferably fresh), cryoprecipitate, or fresh frozen plasma may be necessary. There may also be an excess incidence of cerebral hemorrhage (perhaps 2 per 1000) in patients treated with systemic thrombolytic agents, but there does not appear to be an increase in total strokes- perhaps because of a reduction in ischemic strokes.Allergic reactions: The incidence of allergic reactions appears to have fallen with the introduction of more highly purified forms of S-Kinase. The incidence of anaphylactic shock is 0.1%. Severe allergic reactions, including death, have been reported in patients with no history of previous exposure to S-Kinase. Less severe allergic phenomena. such as chills, rigors, nausea, vomiting, and high fever, have been reported in between 2 and 20% of patients. The immunological basis of allergic reactions to S-Kinase is not entirely clear. Investigation of patients who have suffered allergic reactions have demonstrated low titers of antiS-Kinase IgG and IgG1. There was no evidence of any other 1gG subclass nor of specific antiS-Kinase IgE. There is also evidence of cell-mediated immunity with at least five antigenic epitopes on the S-Kinase molecule which are recognized by human CD4+T-cell receptor αβ+T cells. Allergic reactions usually respond well to withdrawal of therapy, intravenous hydrocortisone and antihistamines. Although some authorities recommend the use of prophylactic intravenous hydrocortisone, there is no good evidence that this is of value.Acute overdosage: In view of the mode of use of S-Kinase overdosage is very unlikely and has not been reported. It would lead to hemorrhage.
সতর্কতা ও নিষেধাজ্ঞা
Warnings & Precautions
High-Risk Patients: Evaluate each patient carefully before starting therapy and weigh the expected benefits against the possible risks. In the conditions listed below, the risk of therapy may be increased and should be weighed against the expected benefits: recent (within 10 days) major surgery such as obstetrical delivery, organ biopsy, or previous puncture of noncompressible vessels; recent (within 10 days) serious gastrointestinal bleeding; recent (within 10 days) trauma including cardiopulmonary resuscitation; hypertension, meaning systolic BP above 180 mm Hg and/or diastolic BP above 110 mm Hg; likelihood of a left heart thrombus, such as mitral stenosis with atrial fibrillation; subacute bacterial endocarditis; cerebrovascular disease; hemostatic defects, including those secondary to severe hepatic or renal disease; pregnancy; age over 75 years; diabetic hemorrhagic retinopathy; septic thrombophlebitis or an occluded AV cannula at a seriously infected site; and any other condition in which bleeding would pose a significant hazard or would be particularly hard to manage because of its location. Arrhythmias: Rapid lysis of coronary thrombi has been shown to cause reperfusion atrial or ventricular dysrhythmias that require immediate treatment. Patients should be carefully monitored for arrhythmias during and immediately after S-Kinase is given for AMI. Tachycardia and bradycardia are occasionally seen. Hypotension: Sometimes severe hypotension not secondary to bleeding or anaphylaxis may occur during or soon after IV S-Kinase, in about 1% to 10% of patients. Patients should be closely monitored, and if symptomatic or alarming hypotension develops, appropriate treatment should be given, which may include slowing the IV S-Kinase infusion rate. Smaller hypotensive effects are common and usually do not require treatment. Injection sites: If an arterial puncture is needed, upper extremity vessels are preferred. Pressure should be applied for at least 30 minutes, followed by a pressure dressing, and the puncture site should be checked frequently. Respiratory: Respiratory depression has been reported in patients receiving S-Kinase. In some cases it was not possible to tell whether this was related to S-Kinase or was a symptom of the underlying illness. Where it is believed to be related to S-Kinase, the occurrence appears to be rare. Noncardiogenic pulmonary edema: This has been reported rarely in patients treated with S-Kinase. The risk appears greatest in patients with large MIs who receive thrombolytic therapy by the intracoronary route. Polyneuropathy: Polyneuropathy has rarely been linked in time to the use of S-Kinase, with some cases described as Gaillain-Barre syndrome. Anticoagulant and antiplatelet use after treatment for MI: In the treatment of AMI, aspirin has been shown to lower the rate of reinfarction and stroke. Adding aspirin to S-Kinase causes only a small increase in the risk of minor bleeding, 3.9% versus 3.1%, and does not appear to raise the rate of major bleeding. When not otherwise contraindicated, aspirin should be given together with S-Kinase in the treatment of AMI. Using anticoagulants after S-Kinase raises the risk of bleeding and has not been clearly shown to give a definite clinical benefit. So while aspirin is recommended unless contraindicated, the decision to use anticoagulants should be left to the treating physician. Anticoagulation after IV treatment for other indications: Following S-Kinase infusion for treatment of PE or DVT, continuous IV heparin without a loading dose has been recommended to help prevent rethrombosis. The effect of S-Kinase on thrombin time and activated partial thromboplastin time usually lessens within 3 to 4 hours after S-Kinase therapy ends. Heparin therapy without a loading dose can be started once the thrombin time or aPTT falls below twice the normal control value for S-Kinase. Cholesterol embolism: Cholesterol embolism has occurred rarely with all types of thrombolytic agents, and its true incidence is unknown. This serious, potentially fatal condition is also linked to invasive vascular procedures such as cardiac catheterization, angiography, or vascular surgery, and to anticoagulant therapy. Its clinical features include livedo reticularis, purple toe syndrome, acute renal failure, gangrenous digits, hypertension, pancreatitis, MI, cerebral infarction, spinal cord infarction, retinal artery occlusion, bowel infarction, and rhabdomyolysis. PE: If PE or recurrent PE occurs during S-Kinase therapy, the planned course of treatment should be completed in an attempt to lyse the embolus. PE may occasionally occur during S-Kinase treatment, but at no greater rate than in patients treated with heparin alone. Besides PE, embolization to other sites has also been observed during S-Kinase treatment. Hypersensitivity reactions: Anaphylactic and anaphylactoid reactions, ranging in severity from minor breathing difficulty to bronchospasm, periorbital swelling, or angioneurotic edema, have rarely been observed in patients treated with IV S-Kinase. Fever and shivering, occurring in 1% to 4% of patients, are the most commonly reported allergic reactions with IV S-Kinase in AMI. Other, milder allergic effects such as urticaria, itching, flushing, nausea, headache, and musculoskeletal pain have also been seen, along with delayed hypersensitivity reactions such as vasculitis and interstitial nephritis.
নিষেধাজ্ঞা
Contraindications- Bleeding diathesis or active internal bleeding Recent trauma (e.g. head injury. resuscitation) Severe uncontrollable hypertension Stroke or recent cerebrovascular accident Intracranial or intraspinal surgery Known intracranial neoplasm Severe uncontrollable hypertension Uncontrollable clotting disorders Known allergy to Streptokinase Relative contraindications- All forms of reduced blood coagulability, in particular spontaneous fibrinolysis Local lesions with risk of bleeding Recent surgery Recent abortion or delivery Diseases of the urogenital tract with existing or potential sources of bleeding Recent streptococcal infections which have produced high antistreptokinase titers Streptokinase therapy more than 5 days and less than 12 months previously Subacute bacterial endocarditis Pericarditis Severe hypertension or hypertensive retinal changes grades III/IV Disorders of cerebral blood flow or recent cerebral hemorrhage Pulmonary diseases with cavitation or severe bronchitis Acute pancreatitis Advanced age with suspicion of arteriosclerotic degeneration Septic thromboembolic disease.