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Review of Dornase Alfa Use for Suspected Airway Plugs

This review assesses the use of Dornase Alfa (DNase) on pediatric intensive care units (PICU) and other ward areas against current formulary guidelines. The study analyzes the indication, dose, route of administration, and time to physiotherapy for patients prescribed DNase. The results show a discrepancy between current use and formulary recommendations, highlighting the need for further research to provide safe and cost-effective treatment.

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Review of Dornase Alfa Use for Suspected Airway Plugs

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  1. A REVIEW OF DORNASE ALFA USE FOR SUSPECTED AIRWAY PLUGS Joanne Hood Paediatric Pharmacist Evelina Children’s Hospital Guys and St Thomas Foundation Trust

  2. Introduction • Recombinant human Dornase (DNase): genetically engineered mucolytic agent • Licensed for use in Cystic Fibrosis patients • There is limited information of use DNase outside CF • Since 2002 DNase used on PICU in children with suspected airway plugs secondary to acute severe asthma refactory to treatment • Recent Use of DNase within PICU and other ward areas increased

  3. Objectives -Assess the use of Dornase Alfa on PICU against current formulary guidelines -Identify usage in other paediatric ward areas

  4. Formulary Guidelines Dornase Alpha *Paediatric intensive care unit (PICU) only -patients should be ventilated with high ventilatory pressures (Peak Airway Pressure (PAP) >28cm/H2O)

  5. Methods • Patients prescribed rhDNase from April 2006-07 were retrospectively identified from pharmacy dispensing records • Data was collected from medical notes including; - Indication of rhDNase - Dose • Route of administration • Ward location • Time to physiotherapy

  6. Results-PICU • N= 20 patients, median age 5.5 years • PICU, N= 9 patients (45%): 2 patients met formulary guidelines

  7. Results-Other ward areas • 55% (11/20) patients were outside PICU

  8. Discussion • Indication -100% mucous plugging secondary causes variable -Current practice is based on limited evidence for use of DNase via ETT in ventilated patients with acute severe asthma, secondary to mucous plugs -Extrapolated success to other indications with no clinical evidence- small studies have shown it doesn’t work -Limited information for chronic use in plastic bronchitis • Dose -No information re efficacy of reconstitution -CF patients may have different pharmacokinetics to non CF patients

  9. Discussion cont… • Route -?safety of ETT -?efficacy of nebulised dose • Physiotherapy -In Cystic Fibrosis patients DNase is nebulised, the recommended time to physiotherapy is one hour post inhalation -No evidence to suggest best time for physiotherapy post ETT administration or for non CF patients-15 minutes seems the natural timing -Change of documentation method lead to unclear results

  10. Conclusions • Current use of rhDNase does not reflect the formulary recommendations • RhDNase is an expensive therapy, our small clinical experience on PICU so far is encouraging • There are still many unclear areas regarding safety and efficacy of this drug • Further research is needed in order to provide safe and cost effective treatment • The guidelines need to be reviewed to reflect future research findings

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  12. Acknowledgementsand References • Thank you to all the ECH paediatric pharmacists, especially Sara Arenas Lopez. Steve Colthurst, Senior Physiotherapist PICU, and Andrew Durward, Senior consultant PICU, for all your help and advice • References • Patel A, Harrison E, Durward A et al. Intratracheal recombinant human deoxyribonuclease in acute life-threatening asthma refractory to conventional treatment, Br J Anaesth 2000;84:505-7 • Guy’s and St Thomas’, King’s College and University of Lewisham Hospitals, Paediatric Formulary, seventh edition, GSTFT, London, 2005

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