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Rebuttal From Drs Colice and IdellRebuttal From Drs Colice and Idell

Gene L. Colice, MD, FCCP; Steven Idell, MD, PhD, FCCP
Author and Funding Information

From The George Washington University School of Medicine & Health Sciences (Dr Colice); Pulmonary, Critical Care and Respiratory Services (Dr Colice), Washington Hospital Center; and School of Medical Biological Sciences (Dr Idell), The University of Texas Health Science Center at Tyler.

Correspondence to: Gene L. Colice, MD, FCCP, Washington Hospital Center, 110 Irving St, NW, Washington, DC 20010; e-mail: Gene.Colice@Medstar.net


Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: Dr Idell is the unpaid Chief Scientific Officer of Lung Therapeutics, Inc, serves on its board of directors, and has an equity position in the company, which was created to develop and commercialize single chain urokinase and other agents for use in lung and pleural disease. His work on single chain urokinase and pleural injury has been supported by grants from the National Institutes of Health and philanthropy. Dr Colice has reported no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(1):21-23. doi:10.1378/chest.13-2357
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Extract

Drs Corcoran and Rahman1 emphasized that clinical use of a therapeutic agent should be determined by its risk/benefit profile. Let us consider the risk/benefit profile of intrapleural fibrinolytics. Because streptokinase and urokinase are not currently available in the United States, we will focus on the tissue plasminogen activator (tPA). Use of tPA is associated with the risk of bleeding. In a retrospective review, four of 57 patients (7%) treated with intrapleural tPA for a parapneumonic effusion (PPE) or empyema experienced bleeding complications, some of which were serious.2 Balanced against the bleeding risk with tPA, clinicians should appreciate that Rahman et al3 concluded in the second Multicenter Intrapleural Sepsis Trial (MIST2) that intrapleural administration of tPA alone was ineffective. Besides the lack of clinical benefit with tPA in this study, there was no difference in the change in intrapleural opacification between placebo and tPA. This observation indicates that tPA did not effectively cause intrapleural fibrinolysis and pleural drainage when used at an empirical intrapleural dose of 10 mg. With possible risk but no evident benefit, we do not favor routine administration of intrapleural fibrinolytics to adults with a PPE requiring drainage.

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