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IMPLEMENTATION OF INTRAVITREAL TISSUE PLASMINOGEN ACTIVATOR INJECTION INTO PRACTICE (submitted in 2019)
European Statement
Production and Compounding
Author(s)
Liisa Eesmaa, Katrin Sõnajalg, Ülle Helena Meren
Why was it done?
Intravitreal tissue plasminogen activator (tPA) injection is a guideline recommendation for patients with medium, large or thick submacular haemorrhage mainly due to exudative age-related macular degeneration (AMD). This treatment hasn´t been available: off-label use, rare demand, high price (generic unavailable, the cost uncovered by health insurance).
What was done?
Ophthalmologists contacted the pharmacy to work out a plan for emergent cases of patients with large submacular haemorrhage in the better seeing eye. The pharmacists worked out the logistically simplest, economical affordable solution to prepare the injection in a cleanroom setting.
How was it done?
The pharmacy came up with two models: 1. Compound intravitreal injection (50 μg/dose) from Actilyse 50mg vial (€375) containing substance for intravenous infusion. The rest of the vial would possibly be used in the neurology department during the next 24 hours. The costs would be shared based on microgram use. 2. Use unregistered Actilyse cathflo 2mg vial. Application for permission and delivery would take up to 6 weeks and drug shortages would be usual. The price for 50 μg would be €65. For the first two patients the first model was used. It was logistically complicated for the neurology department as they needed to change their everyday practice. The second model has now been introduced into practice and used for another two cases. It is accepted by the doctors and pharmacists.
What has been achieved?
Four patients have received new treatment with intravitreal tPA in addition to the common practice of pneumatic displacement of the haemorrhage with intravitreal anti-VEGF (vascular endothelial growth factor) injections or intravitreal anti-VEGF monotherapy. The treatment was well tolerated by the patients with some benefit to visual function. The pharmacy is ready to prepare tPA injections during working days. The price of the injection is acceptable.
What next?
The University hospital became interested to start the same treatment. The second model was presented to their hospital pharmacy. Our ophthalmology department is now equipped to inject tPA into the subretinal space during vitrectomy to increase the efficacy of the procedure and improve patients’ visual outcome.