What is the recommended dose and administration of Cathflo (alteplase) for clearing occlusions in a Peripherally Inserted Central (PIC) line?

Cathflo (Alteplase) Dosing for PICC Line Occlusion

For clearing occlusions in Peripherally Inserted Central (PIC) lines, administer Cathflo (alteplase) at a dose of 2 mg in 2 mL solution with a dwell time of 30-120 minutes, with the option for a second identical dose if the first is unsuccessful. 1

Recommended Administration Protocol

Dosing:

• Adult patients and children ≥30 kg: 2 mg in 2 mL solution 1
• Children <30 kg: 110% of the internal lumen volume, not to exceed 2 mg in 2 mL 1

Administration Steps:

1. First attempt: Forceful irrigation with saline (minimum flush volume should be twice the catheter volume) 2
2. If irrigation fails:
   • Reconstitute Cathflo Activase to 1 mg/mL concentration
   • Instill appropriate dose into the occluded catheter
   • Allow to dwell for 30 minutes, then assess catheter function
   • If still occluded, continue dwell time up to 120 minutes
3. If still occluded after 120 minutes: A second dose may be administered following the same procedure 1

Efficacy:

• Success rates with alteplase for catheter clearance:
  • 75% after one dose
  • 85.1% after two doses 3
  • The Cathflo Activase Pediatric Study demonstrated 82.9% cumulative success rate after two doses 4

Important Clinical Considerations

Safety Profile:

• Alteplase has demonstrated excellent safety for catheter clearance with very low rates of serious adverse events:
  • No intracranial hemorrhage events in clinical trials
  • Rare serious adverse events (0.3% gastrointestinal bleeding, 0.3% thrombosis, 0.4% sepsis) 3

Alternative Approaches for Non-Thrombotic Occlusions:

• For lipid occlusion: 70% ethanol or sodium hydroxide
• For mineral precipitates: 0.1 N hydrochloric acid
• For drug precipitates: Treatment based on pH (acidic drugs with 0.1 N HCl, basic medications with sodium bicarbonate or 0.1 N NaOH) 2

Post-Clearance Procedure:

• Once catheter function is restored, aspirate 4-5 mL of blood in patients ≥10 kg or 3 mL in patients <10 kg to remove Cathflo and residual clot
• Gently irrigate the catheter with 0.9% Sodium Chloride Injection 1

Clinical Pitfalls and Caveats

• Do not exceed recommended doses: There is no efficacy or safety information on dosing in excess of 2 mg per dose, and studies have not been performed with total doses greater than 4 mg 1
• Reconstitution timing: Cathflo contains no antibacterial preservatives and should be reconstituted immediately before use, with solution used within 8 hours when stored at 2-30°C 1
• Medication interactions: No other medication should be added to solutions containing Cathflo Activase 1
• Mechanical occlusions: Alteplase will not resolve mechanical occlusions; if catheter function is not restored after two doses, mechanical causes should be investigated 2

While lower doses (1 mg) have been studied with some success (72% clearance with one dose), the FDA-approved dose of 2 mg has demonstrated higher efficacy and is the recommended standard dose for optimal outcomes in clearing PICC line occlusions 1, 5.