From the Guidelines
Talc is the most effective agent for pleurodesis, with a complete success rate of 93%, and should be used as the first-line treatment for malignant pleural effusions. The choice of agent depends on availability, cost, and patient factors. Other chemical agents that can be used for pleurodesis include bleomycin (60 units), doxycycline (500mg), tetracycline (20mg/kg, maximum 1g), iodopovidone (20-100ml of 10% solution), and silver nitrate (20ml of 0.5% solution) 1. Mechanical options include autologous blood patch (50-100ml of patient's blood) and surgical abrasion of the pleural surfaces.
Key Considerations
- Talc can be administered as a slurry (4-5g mixed with saline) or by insufflation as a powder 1.
- The procedure should be performed after complete drainage of the pleural space, and adequate pain control should be provided as the procedure can be uncomfortable 1.
- Side effects may include chest pain, fever, and rarely acute respiratory distress syndrome 1.
- The decision to use talc poudrage or talc slurry should depend on several factors, including local expertise, whether additional tissue is needed for molecular-marker analysis, as well as patient-related factors 1.
Evidence Summary
The most recent and highest quality study, published in 2018, recommends the use of either talc poudrage or talc slurry for pleurodesis in patients with symptomatic malignant pleural effusions and expandable lung 1. This study found that talc is the most widely used and effective pleurodesis agent, with a complete success rate of 93% 1. Other studies have also shown that talc is superior to other agents, such as bleomycin and tetracycline, in terms of efficacy and safety 1.
From the FDA Drug Label
Malignant Pleural Effusion–60 units administered as a single dose bolus intrapleural injection Bleomycin is effective as a sclerosing agent for the treatment of malignant pleural effusion and prevention of recurrent pleural effusions. The agent used for pleurodesis is bleomycin.
- The dose for pleurodesis is 60 units administered as a single dose bolus intrapleural injection. 2 2
From the Research
Agents Used for Pleurodesis
The following agents have been studied for use in pleurodesis:
- Talc: considered to be the most effective chemical agent for pleurodesis, with a success rate of 93% 3 and 90% 4
- Bleomycin: had a success rate of 54% 3, 79% 4, and 70% 5
- Tetracycline and its derivatives (doxycycline and minocycline): had success rates of 67% 3, 72% 3, and 86% 3
- Corynebacterium parvum: had a success rate of 76% 3
- Other agents: including cisplatin, doxorubicin, etoposide, fluorouracil, interferon-beta, mitomycin-c, and methylprednisolone have been studied, but with varying success rates 3
- Alternative agents: such as oral tetracycline/doxycycline, quinacrine, silver nitrate, iodopovidone, and other talc preparations can be used when commonly used agents are not available 6
Comparison of Agents
Studies have compared the efficacy and safety of different pleurodesis agents, including: