Tenecteplase versus alteplase for acute ischaemic stroke: a meta-analysis of phase III randomised trials

The impact of chronic kidney disease on prognosis in acute stroke: unraveling the pathophysiology and clinical complexity for optimal management

BACKGROUND

Chronic kidney disease (CKD) significantly increases stroke risk and severity, posing challenges in both acute management and long-term outcomes. CKD contributes to cerebrovascular pathology through systemic inflammation, oxidative stress, endothelial dysfunction, vascular calcification, impaired cerebral autoregulation, and a prothrombotic state, all of which exacerbate stroke risk and outcomes.

METHODS

This review synthesizes evidence from peer-reviewed literature to elucidate the pathophysiological mechanisms linking CKD and stroke. It evaluates the efficacy and safety of acute reperfusion therapies-intravenous thrombolysis and endovascular thrombectomy-in CKD patients with acute ischemic stroke. Considerations, such as renal function, drug dosage adjustments, and the risk of contrast-induced nephropathy, are critically analyzed. Evidence-based recommendations and research priorities are drawn from an analysis of current practices and existing knowledge gaps.

RESULTS

CKD influences stroke outcomes through systemic and local pathophysiological changes, necessitating tailored therapeutic approaches. Reperfusion therapies are effective in CKD patients but require careful monitoring of renal function to mitigate risks, such as contrast-induced nephropathy and thrombolytic complications. The bidirectional relationship between stroke and CKD highlights the need for integrated management strategies to address both conditions. Early detection and optimized management of CKD significantly reduce stroke-related morbidity and mortality.

CONCLUSION

Optimizing stroke care in CKD patients requires a comprehensive understanding of their pathophysiology and clinical management challenges. This article provides evidence-based recommendations, emphasizing individualized treatment decisions and coordinated care. It underscores the importance of integrating renal considerations into stroke treatment protocols and highlights the need for future research to refine therapeutic strategies, address knowledge gaps, and consider tailored interventions to improve outcomes and quality of life for this high-risk population.

Assessment of transition from use of alteplase to tenecteplase in the treatment of acute ischemic stroke in a large system of community hospitals

OBJECTIVE

Pharmacologic thrombolytic treatment for acute ischemic stroke has primarily been managed by intravenous alteplase. Tenecteplase is a variant that has been shown to be non-inferior to alteplase in clinical trials. In this study, we present a real-world assessment of patient outcomes with the facility-wide transition to the use of tenecteplase versus altepase for acute ischemic stroke in a large system of community hospitals in the United States.

METHODS

This retrospective analysis assessed adult patients who received either alteplase or tenecteplase between 1 April 2020 and 31 March 2023. Propensity matching was used to estimate the covariate-adjusted association with outcomes of discharge expired/hospice, intracranial hemorrhage and readmission to a facility in the same healthcare system within 30, 60, or 90 days.

RESULTS

Among 12,766 patients, gross mortality was 7.6% (n = 285) with tenecteplase and 8.2% (n = 739) with alteplase (p = 0.314); intracranial hemorrhage was 2.4% with either. The propensity match analysis found that the relative risk of mortality/hospice for patients given tenecteplase versus alteplase was 0.993 (95% CI: 0.848-1.162, p = 1.000). When limited to five facilities with the highest volume of thrombolytic use, there were no significant differences in outcomes. While the time from emergency department arrival to thrombolytic administration (door-to-needle) was shorter among patients receiving tenecteplase, there was no significant difference in the odds of mortality based on door-to-needle time.

CONCLUSION

In alignment with previous studies, these findings demonstrate the lack of potential harm with a transition from alteplase to tenecteplase in clinical practice for acute ischemic stroke patients treated in community hospitals.

Current gaps in acute reperfusion therapies

PURPOSE OF REVIEW

Advances in intravenous thrombolysis and endovascular thrombectomy have significantly reduced disability and improved outcomes associated with acute ischemic stroke.

RECENT FINDINGS

An expansion of indications for reperfusion therapies in select groups of patients to permit treatment in an extended time window, with large ischemic core, and with simplified imaging protocols have enabled a broader group of patients access to disability-sparing therapy. Cerebroprotection has had renewed development in the era of acute reperfusion.

SUMMARY

In this review, we highlight recent developments in stroke reperfusion research and related questions that are under study or remain unanswered.

Efficacy and Safety of Intravenous Tenecteplase Versus Alteplase in Treating Acute Ischemic Stroke With Diabetes and Admission Hyperglycemia

BACKGROUND

The aim of this study was to investigate the efficacy and safety of tenecteplase versus alteplase in patients with acute ischemic stroke, considering their diabetes history and admission hyperglycemia status.

METHODS AND RESULTS

This was a post hoc analysis of the TRACE-2 (Tenecteplase Reperfusion Therapy in Acute Ischemic Cerebrovascular Events-2) randomized clinical trial that enrolled patients in China between June 2021 and May 2022. Eligible patients with acute ischemic stroke for standard intravenous thrombolysis, but ineligible for endovascular thrombectomy, were randomly assigned (1:1) to tenecteplase or alteplase within 4.5 hours of symptom onset. Admission hyperglycemia was defined as plasma glucose >7.8 mmol/L. The primary efficacy and safety outcome were excellent functional outcome at 90 days (modified Rankin Scale score of 0-1) and symptomatic intracranial hemorrhage within 36 hours, respectively. The Cochran-Mantel-Haenszel χ2 test was used for the outcomes. Of the 1382 patients included, 369 (26.7%) had a history of diabetes, and 482 (34.9%) experienced admission hyperglycemia. The primary efficacy outcome, comparing tenecteplase to alteplase, was achieved in 93 (56.7%) versus 97 (48.3%) among patients with a history of diabetes (P=0.11) and 335 (64.6%) versus 300 (62.2%) among those without diabetes (P=0.45), respectively. The primary efficacy outcome for tenecteplase versus alteplase was comparable among patients with and without admission hyperglycemia (57.5% versus 53.9%, P = 0.44; 65.4% versus 60.4%, P=0.12, respectively). No significant difference in the risk of symptomatic intracranial hemorrhage within 36 hours was observed between tenecteplase and alteplase, regardless of diabetes history or admission hyperglycemia.

CONCLUSIONS

This study demonstrated that intravenous tenecteplase exhibits similar clinical outcomes compared with alteplase, irrespective of the patient's glucose metabolism status.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT04797013.

Intravenous Tenecteplase for Acute Ischemic Stroke During Active Menstruation

We report a case of a 51-year-old female who presented to the emergency department with stroke symptoms within the time window for intravenous (IV) thrombolytic therapy. Her initial CT head imaging showed no evidence of acute changes and her CT perfusion demonstrated an area of ischemia in the left parieto-occipital region. While she had no absolute contraindications for IV tenecteplase (TNK), she was actively menstruating at the time, which could represent a relative contraindication due to increased bleeding risk from a site that would not be easily compressible. She elected to receive TNK and did not experience any adverse events after treatment was administered. At her follow-up clinic visit, her neurological deficits were completely resolved. In the context of increasingly widespread usage of TNK, this case report highlights an uncommon but important consideration when treating acute ischemic strokes with IV thrombolytic in the female population. While no definitive conclusions should be drawn from this case, it would hopefully encourage the continued usage of TNK in menstruating females who present with stroke symptoms within the therapeutic window and with no other contraindications.

Comprehensive Review of Tenecteplase for Thrombolysis in Acute Ischemic Stroke

Although intravenous thrombolysis with alteplase remains the primary treatment for acute ischemic stroke, tenecteplase has shown potential advantages over alteplase. Animal studies have demonstrated the favorable pharmacokinetics and pharmacodynamics of tenecteplase. Moreover, it is easier to administer. Clinical trials have demonstrated that tenecteplase is not inferior to alteplase and may even be superior in cases of acute ischemic stroke with large vessel occlusion. Current evidence supports the time and cost benefits of tenecteplase, suggesting that it could potentially replace alteplase as the main option for thrombolytic therapy, especially in patients with large vessel occlusion.

Tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis of randomized and non-randomized studies

OBJECTIVE

Alteplase is the current standard of care for acute ischemic stroke. Tenecteplase is a newer fibrinolytic agent with preferable administration and lower costs; however, its comparative effectiveness to alteplase remains uncertain. We set out to perform a systematic review and meta-analysis to establish the benefits and harms of tenecteplase versus alteplase for acute ischemic stroke.

METHODS

We searched PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov from inception to April 2023 for randomized and non-randomized studies that compared tenecteplase versus alteplase for acute ischemic stroke. Paired reviewers independently assessed risk of bias and extracted data. We performed both conventional meta-analyses and Bayesian network meta-analyses (NMA) with random-effects models and used the GRADE approach to evaluate the certainty of evidence. Our primary efficacy outcome was excellent functional outcome at 3 months, defined as a score of 0-1 on the modified Rankin Scale. Our primary safety outcomes were symptomatic intracranial hemorrhage and all-cause mortality.

RESULTS

Thirty-six studies were eligible for review, including 12 randomized (n = 5533) and 24 non-randomized studies (n = 44,956). Moderate certainty evidence showed that there was no difference between tenecteplase and alteplase in increasing the proportion of patients achieving excellent functional outcome at 3 months (odds ratio [OR], 1.10; 95% CI 0.98-1.23; risk difference [RD] 2.4%, 95% CI - 0.5 to 5.2), while moderate certainty evidence from NMA suggested that 0.25 mg/kg tenecteplase significantly improved excellent functional outcome at 3 months (OR, 1.16; 95% credible interval 1.02-1.32). Moderate certainty evidence showed that, compared to alteplase, tenecteplase may make little to no difference in the prevalence of symptomatic intracranial hemorrhage (OR, 1.12; 95% CI 0.79-1.59; RD 0.3%, 95% CI - 0.5 to 1.4), and probably reduces all-cause mortality (adjusted odds ratio [aOR], 0.44; 95% CI 0.30-0.64; RD - 4.6%; 95% CI - 5.8 to - 2.9).

CONCLUSIONS

Moderate certainty evidence suggested that there was little to no difference between tenecteplase and alteplase in increasing the proportion of patients achieving excellent functional outcome at 3 months and the risk of symptomatic intracranial hemorrhage, while compared to alteplase, tenecteplase probably reduce all-cause mortality. Administration of 0.25 mg/kg tenecteplase after acute ischemic stroke is suggestive of increasing the proportion of patients that achieve excellent functional outcome at 3 months.