2026 Eastern States Conference

Title
Efficacy and safety of lower dose compared to standard dose intrapleural alteplase combined with dornase for complicated pleural effusion

Authors
Sarah Thompson, PharmD, MS Siu Yan Yeung, PharmD, BCCCP Mehrnaz Pajoumand, PharmD, BCCCP

Learning Objective
At the conclusion of this presentation, participants will be able to describe the efficacy and safety of lower dose compared to standard dose intrapleural alteplase combined with dornase for complicated pleural effusion.

Background/Objective
The optimal dose of intrapleural (IP) alteplase combined with dornase for complicated pleural effusion remains unclear. This study evaluates whether a lower dose regimen provides efficacy and safety comparable to the standard dose.

Methods
This multicenter retrospective cohort study included adult patients receiving IP alteplase plus dornase for complicated pleural effusion or empyema at eight hospitals within an academic health system. Patients were categorized by IP alteplase dose received: lower dose (<10 mg) or standard dose (10 mg), with consistent dornase dosing. The primary outcome was treatment success, defined as survival without need for surgical intervention within ninety days of IP fibrinolytic therapy. Secondary outcomes included bleeding events, hospital length of stay, mortality, and need for dose escalation.

Results
Among 364 patients, treatment success is similar between groups: 82.2% of the lower-dose group (n=90) and 79.9% of the standard-dose group (n=274), with risk ratio of 1.03 (95% CI 0.91 - 1.16, p = 0.62). The results are similar with adjusted analyses (adjusted RR 1.01, 95% CI 0.89–1.14). Rates of surgery (11.1% vs 11.3%) and in-hospital mortality (6.7% vs 9.1%) were similar. The lower-dose group had higher rates of additional chest tube placement (29.2% vs 19.3%) and a longer hospital length of stay (median 18.8 vs 11.9 days). The lower-dose group had dose escalation in 16.7% of patients. Analysis of bleeding events is ongoing.

Conclusions
Lower-dose intrapleural alteplase was non-inferior to standard dosing for treatment success, with comparable surgery and mortality outcomes.

Self-Assessment Question
Which outcome defines treatment success in this study of IP alteplase dosing?
A. Radiographic improvement only
B. Survival without surgical intervention within ninety days
C. Decrease in chest tube duration
D. Reduction in hospital length of stay