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Breaking the Block: Why Tenecteplase is a New Contender in Ischemic Stroke Therapy

Compared to alteplase (tPA), the standard thrombolytic that is used for ischemic stroke care, tenecteplase offers a few key advantages that make it unique. One, tenecteplase has a longer half-life, approximately 22 minutes, as opposed to alteplase which has a half-life of approximately 3.5 seconds. Tenecteplase’s sustained duration of treatment leads to its second advantage over alteplase such that it is easier and faster to administer in patients. In the clinics, alteplase is first administered as a single bolus, or a rapid and concentrated dose, followed by a one-hour intravenous (IV) infusion that is a slower route to fully incorporate the dose into the body. Because of the longer half-life,…

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Featured

 Replacing Alteplase with Tenecteplase: Is the Time Ripe?

TNK has emerged as a promising alternative to alteplase in the treatment of acute ischemic stroke, with compelling data from several trials regarding its relative safety and efficacy. The newer trial results have helped to address important gaps between the current state of evidence and this data may help in revising international guidelines on the use of TNK in ischemic stroke.

Articles of Interest

Tenecteplase vs Alteplase in Acute Ischemic Stroke

0.25mg/kg of tenecteplase could be the dose of choice for acute ischemic stroke that has thus far shown better recanalization rates and early neurologic improvement with a similar safety profile to alteplase, however evidence for long term neurologic outcomes still remain obscure. Hopefully, the NOR-TEST 2, Part B trial will help elucidate more patient oriented outcomes.

You Don't Have to “AcT” that Way – TNK for Acute Ischemic Stroke?

The Achilles heel of this trial is the a priori assumption that alteplase is an effective treatment for acute ischemic stroke. If you accept the claim, then you can conclude it is reasonable to use tenecteplase. If you do not accept the claim, then tenecteplase has not been demonstrated to be superior to placebo and would not necessarily be reasonable.

Making the Switch From Alteplase to Tenecteplase for Acute Ischemic Stroke

TNK was FDA-approved to reduce mortality in acute myocardial infarction in 2000. In the ensuing two decades, in randomized clinical trials and meta-analyses, the bioengineered tissue plasminogen activator has been proven to have noninferior safety and efficacy compared with alteplase in acute ischemic stroke — and a potential advantage in early recanalization.

Study of Tenecteplase (TNK) in Acute Ischemic Stroke (TNK-S2B)

To date, the only scientifically-proven and FDA-approved treatment for acute stroke is the clot-busting drug, tissue plasminogen activator (tPA). A newer clot-busting drug, tenecteplase (TNK), has chemical properties that make it a potentially safer and more effective drug for treating stroke.

Tenecteplase Feasible Up to 24 Hours After Stroke

The approach is viable and seems safe, but it’s unclear whether TNK is better than alteplase in this setting, one expert says.

Tenecteplase for Suspected Pulmonary Embolism During Cardiac Arrest

Our institution recently implemented the use of tenecteplase for acute ischemic stroke, ST-elevation myocardial infarction (STEMI), and pulmonary embolism (PE). When using tenecteplase for suspected PE during cardiac arrest, we use the same weight-based dose used for STEMIs.

The Case to Replace Alteplase

Tenecteplase (TNK) is a bioengineered variant of tPA to make it a better lytic by increasing its specificity to fibrin and more resistant to degradation by endogenous enzymes. TNK is easier to prepare and administer (a rapid, single-bolus) which may mean faster door-to-needle times and faster door-in-door-out times for transport (and hopefully translate into less disability after stroke).

Transitioning Alteplase to Tenecteplase for Acute Ischemic Stroke

Transitioning from ALT to TNK for AIS remains a widely discussed topic for many stroke programs. There are many factors involved with the transition, including implementation of safeguards to prevent dosing and administration errors, education across all disciplines comprising the stroke response team, and operational considerations that vary between ALT and TNK. A structured checklist-based approach should be considered for programs preparing to make the switch, and hopefully this article can serve as a template.

Why More Hospitals Are Switching The Medication Used To Stop A Stroke

“TNK is a modification of tPA,” says Dr. Lewandowski. “It is just as safe and effective to use and makes it easier for emergency care teams to treat stroke.”

Resources

Life in the Fastlane

It is a genetically engineered variant of alteplase with resulting: Increase in plasma half-life,, enhanced fibrin specificity, increased resistance to inactivation by plasminogen activator inhibitor 1.

StatPearls

The most widely used indications are acute myocardial infarction and acute ischemic stroke.