Alteplase (tPA) will no longer be used for AIS, but will be available for other indications.
WHY THE SWITCH?
- Tenecteplase was added as an option for thrombolytic therapy in AIS in the 2019 AHA Guideline Update.
- Tenecteplase is given as a single IV bolus while alteplase is an IV bolus PLUS an infusion.
- Studies have shown that tenecteplase has comparable neurological outcomes and adverse event occurrences when compared to alteplase in AIS.
TENECTEPLASE AIS DOSING:
- 0.25 mg/kg (Max 25 mg) IV bolus over 5 seconds
- Administer within 4.5 hours of symptom onset
WHO CAN ORDER? WHERE?
- May be ordered by an emergency physician, teleneurologist, advanced practice provider or hospitalist
- May be initiated in the ED, any critical care unit, or in a telemetry-monitored bed with monitoring by a critical care nurse
ORDERING TENECTEPLASE IN EPIC:
1. Open patient’s profile
2. Click Manage Orders tab and type in search bar “tenecteplase”
3. Click Thrombolytic Therapy for Ischemic Stroke
4. Click Tenecteplase and check appropriate weight-based dosing
- Patients should be monitored for BP > 180/105, O2 saturation <94%, change in mental status, new or severe headache, seizures, any signs of symptoms of bleeding, or nausea/vomiting.
- No antiplatelets or anticoagulants x 24 hours after administration of tenecteplase.
- Avoid central lines, nasogastric tube placements, or urinary catheter placement in the first 24 hours after tenecteplase.
TENECTEPLASE REVERSAL GUIDELINES:
For thrombolytic-related symptomatic intracranial hemorrhage in patients who have received tenecteplase in the previous 24 hours:
- First Line: Cryoprecipitate 10 units; check fibrinogen and may repeat dose if fibrinogen < 200 mg/dL
- Alternative Agents:
- Aminocaproic acid (Amicar) 5 g in 250 mL NS IV over 1 hour followed by 1 g/hr infusion until bleeding controlled, or
- Tranexamic acid 10-15 mg/kg in 100 mL NS IV over 20 minutes
- Labs: Monitor fibrinogen levels and platelets
- Transfusion: May consider platelet transfusion, however, there is insufficient data supporting the benefit
- Coagulation Effects: Time to normal coagulation activity after drug administration is 24-48 hours
1. Campbell BCV, et al. Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke. N Engl J Med. 2018;378(17):1573-1582.
2. Parsons M, Spratt N, Bivard A, et al. A randomized trial of tenecteplase versus alteplase for acute ischemic stroke. N Engl J Med. 2012;366(12):1099-1107.
3. Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2019 Dec;50(12):e440-e441]. Stroke. 2019;50(12):e344-e418.