Tenecteplase in Acute Ischemic Stroke AIS

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

IMPORTANT NOTES:

Patients should be monitored for BP > 180/105, O₂saturation <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

References:

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.