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

1. STREPTOKINASE
NEELU ARYAL
Msc NURSING 2nd 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.

20. THANK YOU