Drotrecogin alfa (activated) (Xigris, marketed by Eli Lilly and Company) is a recombinant form of human activated protein C that has anti-thrombotic, anti-inflammatory, and profibrinolytic properties. Drotrecogin alpha (activated) belongs to the class of serine proteases. Drotrecogin alfa has not been found to improve outcomes in people with severe sepsis. The manufacturer's aggressive strategies in marketing its use in severe sepsis have been criticized. On October 25, 2011, Eli Lilly & Co. withdrew Xigris from the market after a major study showed no efficacy for the treatment of sepsis. Medical uses Drotrecogin alfa does not improve mortality in severe sepsis or septic shock but does increase bleeding risks. Therefore, a 2012 Cochrane review recommended that clinicians and policymakers not recommend its use and Eli Lilly has announced the discontinuation of all clinical trials. Risks and contraindications Contraindications The following patients should not receive drotrecogin: Active internal bleeding Recent (within 3 months) hemorrhagic stroke Recent (within 2 months) intracranial/intraspinal surgery/severe head trauma Trauma patients with an increased risk of life-threatening bleeding Presence of an epidural catheter Known or suspected intracranial neoplasm or mass lesion Known hypersensitivity to drotrecogin or any component Precautions The following patients are at an increased risk for bleeding complications due to drotrecogin-alpha therapy, and a careful risk/benefit assessment should be made prior to initiating therapy. Therapeutic Heparin (>15 units/kg/h) Platelet count <30,000/mm3 Recent (within 6 weeks) gastrointestinal bleeding Recent administration (within 3 days) of thrombolytic therapy Recent administration (within 7 days) of oral anticoagulants or GP IIb/IIIa inhibitors Recent administration (within 7 days) of >650 mg/day of aspirin or other platelet inhibitors Recent (within 3 months) ischemic stroke Known or suspected intracranial AV malformation or aneurysm Known bleeding diathesis (e.g., hemophilia) except for acute coagulopathy related to sepsis Chronic severe hepatic disease HIV infection in association with a last known CD4 count of <50/mm3 Any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location Because drotrecogin-alpha is a therapeutic protein, there exists a potential for immunogenicity. Antibodies against drotrecogin have been observed. There is insufficient data at this time to quantify the risk, but extreme caution should be exercised if a patient has previously received drotrecogin-alpha. Side-effects Although patients at high risk of bleeding were excluded from the phase III clinical study (PROWESS), 25% of patients treated with drotrecogin and 18% of those receiving placebo experienced