Monday January 30, 2006
Should we abandon Aprotinin ?
The majority of patients undergoing cardiovascular surgery routinely receive antifibrinolytic therapy - aminocaproic acid, tranexamic acid or aprotinin during and after procedure to control bleeding. Very important and large study of 4374 patients published this week in New England Journal of Medicine from Ischemia Research and Education Foundation, comparing these three agents in cardiac surgery. Study found that the use of aprotinin was associated with a dose-dependent doubling to tripling in the risk of renal failure requiring dialysis among patients undergoing primary or complex coronary-artery surgery. Probable reason of this difference is aprotinin's high affinity for the kidneys. Also, for the majority of patients undergoing primary surgery, evidence of multiorgan damage involving the heart (myocardial infarction or heart failure) and the brain (encephalopathy) in addition to the kidneys found, suggesting a generalized pattern of ischemic injury. It has been suggested in article that the replacement of aprotinin with aminocaproic acid would prevent renal failure requiring dialysis in 11,050 patients per year globally, yielding an savings of more than $1 billion per year. Also to note, Aprotinin is way more expensive than other 2 agents.
Bonus Pearl: Action of captopril may get block with concurrent use of Aprotinin.
References / suggested readings: Click to get article/abstract
1. The Risk Associated with Aprotinin in Cardiac Surgery - NEJM Jan. 26, 2006 Volume 354:353-365
2. Is Aminocaproic Acid as Effective as Aprotinin in Reducing Bleeding With Cardiac Surgery? - Circulation. 1999;99:81-89
3. Hemostatic effects of aprotinin, tranexamic acid and aminocaproic acid in primary cardiac surgery - Ann Thorac Surg 1999;68:2252-2256
4. Tranexamic acid compared with high-dose aprotinin in primary elective heart operations: Effects on perioperative bleeding and allogeneic transfusions - J Thorac Cardiovasc Surg 2000;120:520-527
5. A Study of a Weight-Adjusted Aprotinin Dosing Schedule During Cardiac Surgery - Anesth Analg 2002;94:283-289