Thrombolytic — Peripheral Arterial Occlusion / DVT (Historical) Pregnancy: Contraindicated — maternal and fetal bleeding risk

Streptokinase

Brand names: Streptase

Adult dose

Dose: Loading dose: 250,000 units IV over 30 minutes; maintenance: 100,000 units/hour for 24–72 hours (peripheral arterial); DVT: 250,000 units loading then 100,000 units/hour for 72 hours

Route: Intravenous infusion

Frequency: Continuous infusion

Max: Titrated by clinical response and fibrinogen monitoring

Now rarely used — largely superseded by alteplase (catheter-directed) and mechanical thrombectomy. Streptokinase is antigenic — forms complex with plasminogen to activate fibrinolysis (indirect mechanism). Pre-treat with hydrocortisone and antihistamine to reduce allergic reactions. Cannot be re-used within 12 months (antibodies). Not suitable for STEMI anymore (superseded by alteplase/tenecteplase).

Paediatric dose

Route:

Seek specialist opinion — very rarely used in paediatrics; alteplase preferred

Dose adjustments

Renal

No dose adjustment — not renally cleared

Hepatic

Use with caution in severe hepatic impairment

Clinical pearls

Streptokinase is a bacterial protein (streptococcal) — generates antibodies after first exposure; second course within 12 months risks anaphylaxis and therapeutic failure
Indirect thrombolytic: streptokinase + plasminogen → streptokinase-plasminogen complex → activates plasminogen → plasmin; unlike alteplase (direct tPA)
Historical significance: first thrombolytic to demonstrate MI mortality reduction (GISSI-1 trial, 1986); now replaced by tenecteplase/alteplase in STEMI and catheter-directed alteplase in peripheral vascular
Pre-medication: hydrocortisone 100 mg IV + chlorphenamine 10 mg IV before infusion to reduce allergic reactions
Fibrinogen monitoring every 4 hours — stop if <1 g/L

Contraindications

Recent streptokinase or anistreplase use (<12 months)
Streptococcal infection within 6 months
Active internal bleeding
Recent surgery/trauma (<10 days)
Stroke history
Uncontrolled hypertension
Coagulopathy

Side effects

Allergic reactions (urticaria, fever, chills — premedicate)
Anaphylaxis
Bleeding
Hypotension
Reperfusion arrhythmias
Intracranial haemorrhage

Interactions

Anticoagulants — additive bleeding
Antiplatelets — additive bleeding
Antifibrinolytics (TXA, aminocaproic acid) — antagonise thrombolysis

Monitoring

Fibrinogen every 4 hours (stop <1 g/L)
aPTT
FBC
Blood pressure
Signs of bleeding and anaphylaxis

Reference: BNFc; BNF 90; GISSI-1 Trial 1986; MHRA SPC Streptase; ESC/ESVS Peripheral Vascular Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways