Can ethamsylate be given to patients with hematuria post thrombolysis with streptokinase?

Ethamsylate in Patients with Hematuria Post Thrombolysis with Streptokinase

Ethamsylate should not be given to patients with hematuria following thrombolysis with streptokinase due to lack of evidence supporting its efficacy and the risk of worsening bleeding complications.

Understanding Thrombolysis-Related Bleeding Complications

• Thrombolytic therapy with streptokinase is associated with significant bleeding risks, including major hemorrhage in approximately 13% of patients 1
• Hematuria is a recognized complication of antithrombotic therapy, with patients on anticoagulants experiencing hematuria-related complications at a rate of 140.92 events per 1000 person-years compared to 80.17 events in unexposed patients 2
• Streptokinase specifically has been associated with higher bleeding risk compared to other thrombolytic agents such as tissue plasminogen activator (tPA) 3, 4

Management of Post-Thrombolysis Hematuria

• For patients experiencing hematuria after streptokinase administration, the priority should be discontinuation of thrombolytic therapy and supportive management 3
• Management should focus on maintaining diuresis, local hemostatic measures, fluid replacement, and blood product administration if necessary 3
• For life-threatening bleeding, prothrombin complex concentrate (25 U/kg) or activated prothrombin complex concentrate may be considered 3

Why Ethamsylate is Not Recommended

• There is no evidence in current guidelines supporting the use of ethamsylate for managing hematuria following thrombolysis with streptokinase 3
• Ethamsylate is not mentioned in any of the major guidelines for management of thrombolysis-related bleeding complications 3, 5
• Adding another hemostatic agent like ethamsylate may interfere with the intended anticoagulant effect of the initial therapy, potentially increasing thrombotic risk 3

Alternative Management Approaches

• For patients with hematuria post-thrombolysis, the following approach is recommended:

  1. Discontinue thrombolytic therapy immediately 3
  2. Maintain adequate hydration and diuresis to prevent clot formation in the urinary tract 3
  3. Monitor hemoglobin levels and vital signs closely 3
  4. Consider urologic consultation for persistent or severe hematuria 2
  5. In cases of life-threatening bleeding, administer blood products as needed 3

• For patients with hematuria following streptokinase specifically:

  • Monitor fibrinogen levels, as streptokinase can cause significant fibrinogen depletion 3
  • Consider fresh frozen plasma as a plasma expander (not as a reversal agent) if needed 3
  • Tranexamic acid may be considered as an adjuvant therapy in severe cases 3

Special Considerations

• Hematuria following thrombolysis may be a sign of underlying urologic pathology - patients with hematuria while on antithrombotic medications have a higher likelihood of being diagnosed with bladder cancer (0.70% vs 0.38%) 2
• Streptokinase has largely been replaced by more fibrin-specific agents like tPA in current practice due to its higher bleeding risk profile and immunogenicity 4, 6
• Patients with pre-existing renal disease may be at higher risk for hematuria complications following thrombolysis 7

Conclusion for Clinical Practice

• Manage hematuria post-thrombolysis with supportive care rather than adding ethamsylate 3
• Consider urologic evaluation if hematuria persists after discontinuation of thrombolytic therapy 2
• For future thrombolytic needs in patients with history of bleeding complications, consider more fibrin-specific agents like tPA which may have a better safety profile than streptokinase 8, 4