What is the role of TPA (tissue plasminogen activator) and dornase (Pulmozyme) (deoxyribonuclease) in the management of malignant effusion?

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Last updated: May 18, 2025 • View editorial policy

From the Guidelines

Tissue plasminogen activator (TPA) and dornase alfa (DNase) should be administered at a dose of 10 mg TPA twice daily + 5 mg DNase twice daily for 3 days in patients with malignant effusion, with consideration of reduced doses in those with higher bleeding risk. When using TPA and DNase, patient consent should be obtained due to the potential risk of bleeding 1. The administration regimen is based on randomized controlled trial data, and a lower dose of 5 mg TPA twice daily + 5 mg DNase twice daily for 3 days may be considered as an alternative, as suggested by retrospective case series data 1.

Key Considerations

  • Reduced doses of TPA may be necessary in patients with a potentially higher bleeding risk, such as those on therapeutic anticoagulation that cannot be temporarily ceased 1.
  • The British Thoracic Society (BTS) Clinical Statement on Pleural Procedures should be consulted for details on the administration of intrapleural treatments 1.
  • Patient safety and potential side effects, including bleeding risk, should be carefully evaluated before and during treatment with TPA and DNase.

Administration and Monitoring

  • The treatment regimen should be carefully followed, with attention to proper chest tube positioning and functioning before administration of TPA and DNase.
  • Patients should be closely monitored for potential side effects, including chest pain, fever, and pleural bleeding, during and after treatment with TPA and DNase.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

TPA/Dornase in Malignant Effusion

  • The use of tissue plasminogen activator (t-PA) and dornase alfa (DNase) has been studied in the context of managing malignant pleural effusions (MPEs) 2, 3.
  • A case report published in 2022 described the successful use of t-PA and DNase in a patient with a multiloculated recurrent MPE, resulting in the resolution of symptoms and radiographic findings 2.
  • A retrospective review published in 2023 found that both intrapleural t-PA and combination t-PA-DNase improved pleural drainage in patients with loculated MPEs, with no significant difference in complications between the two treatments 3.
  • The safety and effectiveness of intrapleural t-PA have also been evaluated in patients with nondraining indwelling pleural catheters (IPCs), with studies showing that it can restore flow and provide symptomatic relief 4, 5.
  • Intrapleural t-PA and DNase have also been used to treat IPC-related pleural infection, with a multi-center observational study finding that this treatment approach is feasible, safe, and effective in reducing the need for surgical referrals 6.

Key Findings

  • t-PA and DNase can improve pleural drainage and provide symptomatic relief in patients with MPEs 2, 3.
  • Intrapleural t-PA can restore flow in nondraining IPCs and improve symptoms in patients with MPEs 4, 5.
  • The use of t-PA and DNase in IPC-related pleural infection is a promising treatment approach that requires further study 6.

Treatment Approaches

  • Intrapleural t-PA and DNase can be administered through an IPC to improve pleural drainage and provide symptomatic relief 2, 3.
  • The dose and administration schedule of t-PA and DNase may vary depending on the specific clinical scenario and institutional protocols 3, 4, 6.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.