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Rose D, Cavalier A, Kam W, Cantrell S, Lusk J, Schrag M, Yaghi S, Stretz C, de Havenon A, Saldanha IJ, Wu TY, Ranta A, Barber PA, Marriott E, Feng W, Kosinski AS, Laskowitz D, Poli S, Grory BM. Complications of Intravenous Tenecteplase Versus Alteplase for the Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Stroke 2023; 54:1192-1204. [PMID: 36951049 PMCID: PMC10133185 DOI: 10.1161/strokeaha.122.042335] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 02/20/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND Prior systematic reviews have compared the efficacy of intravenous tenecteplase and alteplase in acute ischemic stroke, assigning their relative complications as a secondary objective. The objective of the present study is to determine whether the risk of treatment complications differs between patients treated with either agent. METHODS We performed a systematic review including interventional studies and prospective and retrospective, observational studies enrolling adult patients treated with intravenous tenecteplase for ischemic stroke (both comparative and noncomparative with alteplase). We searched MEDLINE, Embase, the Cochrane Library, Web of Science, and the www. CLINICALTRIALS gov registry from inception through June 3, 2022. The primary outcome was symptomatic intracranial hemorrhage, and secondary outcomes included any intracranial hemorrhage, angioedema, gastrointestinal hemorrhage, other extracranial hemorrhage, and mortality. We performed random effects meta-analyses where appropriate. Evidence was synthesized as relative risks, comparing risks in patients exposed to tenecteplase versus alteplase and absolute risks in patients treated with tenecteplase. RESULTS Of 2226 records identified, 25 full-text articles (reporting 26 studies of 7913 patients) were included. Sixteen studies included alteplase as a comparator, and 10 were noncomparative. The relative risk of symptomatic intracranial hemorrhage in patients treated with tenecteplase compared with alteplase in the 16 comparative studies was 0.89 ([95% CI, 0.65-1.23]; I2=0%). Among patients treated with low dose (<0.2 mg/kg; 4 studies), medium dose (0.2-0.39 mg/kg; 13 studies), and high dose (≥0.4 mg/kg; 3 studies) tenecteplase, the RRs of symptomatic intracranial hemorrhage were 0.78 ([95% CI, 0.22-2.82]; I2=0%), 0.77 ([95% CI, 0.53-1.14]; I2=0%), and 2.31 ([95% CI, 0.69-7.75]; I2=40%), respectively. The pooled risk of symptomatic intracranial hemorrhage in tenecteplase-treated patients, including comparative and noncomparative studies, was 0.99% ([95% CI, 0%-3.49%]; I2=0%, 7 studies), 1.69% ([95% CI, 1.14%-2.32%]; I2=1%, 23 studies), and 4.19% ([95% CI, 1.92%-7.11%]; I2=52%, 5 studies) within the low-, medium-, and high-dose groups. The risks of any intracranial hemorrhage, mortality, and other studied outcomes were comparable between the 2 agents. CONCLUSIONS Across medium- and low-dose tiers, the risks of complications were generally comparable between those treated with tenecteplase versus alteplase for acute ischemic stroke.
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Affiliation(s)
- Deborah Rose
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Annie Cavalier
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Wayneho Kam
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Sarah Cantrell
- Duke University Medical Center Library & Archives, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Jay Lusk
- Duke University School of Medicine, Durham, NC, USA
| | - Matthew Schrag
- Department of Neurology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Shadi Yaghi
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Christoph Stretz
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Ian J. Saldanha
- Center for Evidence Synthesis in Health, Departments of Health Services, Policy, and Practice and of Epidemiology, Brown School of Public Health, Providence, RI, USA
| | - Teddy Y. Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Anna Ranta
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - P. Alan Barber
- Department of Medicine, University of Auckland, New Zealand
| | - Elizabeth Marriott
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Wayne Feng
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
| | - Andrzej S. Kosinski
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Daniel Laskowitz
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Sven Poli
- Department of Neurology & Stroke, University of Tübingen, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
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Dhar N, Kumar M, Tiwari A, Desai I, Madhaw G, Kumar N. Tenecteplase and Alteplase for Thrombolysis of Acute Ischemic Stroke within 4.5 Hours: An Efficacy and Safety Study. Ann Indian Acad Neurol 2022; 25:897-901. [PMID: 36561006 PMCID: PMC9764915 DOI: 10.4103/aian.aian_1127_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/10/2022] [Accepted: 05/11/2022] [Indexed: 12/25/2022] Open
Abstract
Objective To compare the efficacy and safety of thrombolysis using Tenecteplase (TNK) versus alteplase in acute ischaemic stroke (AIS) patients within 4.5-hour window period. Methods This retrospective study involved the collection of data from consecutive AIS patients who underwent thrombolysis in the Department of Neurology at a tertiary care university hospital, between May 2018 to January 2021. Data including clinical history, neurological assessment using modified Rankin score (mRS), National Institutes of Health Stroke Scale (NIHSS), brain neuroimaging, treatment, and outcome details were collected. The primary efficacy outcome was the proportion of patients with good functional recovery (mRS of 0-2) at 90 days of follow-up. Results Total of 42 patients with AIS underwent thrombolysis, of which 19 received alteplase and 23 got TNK. The median (range) onset to door time [120 (20-210) versus 120 (30-210) minutes; P = 0.823] and median (range) onset to needle time [150 (60-255) versus 160 (50-240) minutes; P = 0.779] were comparable in both alteplase and TNK groups, respectively. The primary outcome of good functional recovery (mRS ≤2) at 3 months was observed in more than half the patients in each group and was comparable (P = 0.701). Post-thrombolysis complications including cerebral haemorrhage (symptomatic or asymptomatic) were comparable between the two groups (31.6% vs 30.4%; P = 0.936), except a significantly higher proportion of patients on TNK required mechanical ventilation (10.5% v/s 43.5%; P = 0.019). Conclusions This study showed a comparable efficacy and safety profile of alteplase and TNK in thrombolysis of AIS throughout the 4.5 hours window period. Moreover, the ease of administration and better pharmacodynamic properties favors tenecteplase.
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Affiliation(s)
- Nikita Dhar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mritunjai Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ashutosh Tiwari
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Ishita Desai
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Govind Madhaw
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India,Department of Neurology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Niraj Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India,Address for correspondence: Dr. Niraj Kumar, Additional Professor, Department of Neurology, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand, India. E-mail:
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Abstract
The introduction of thrombolytic therapy in the 1990s has transformed acute ischemic stroke treatment. Thus far, intravenous recombinant tissue plasminogen activator (rt-PA) also known as alteplase is the only thrombolytic proven to be efficacious and approved by the United States Food and Drug Administration. But the thrombolytic agent tenecteplase (TNK) is emerging as a potential replacement for rt-PA. TNK has greater fibrin specificity, slower clearance, and higher resistance to plasminogen activator inhibitor-1 than rt-PA. Hence, TNK has the potential to provide superior lysis with fewer hemorrhagic complications. Also, easier bolus-only administration makes TNK a very practical rt-PA alternative. In several clinical trials, TNK has shown similar efficacy and safety to rt-PA, and the potential to be at least noninferior to rt-PA in some settings. TNK may be superior to rt-PA for reperfusing large vessel occlusions in patients with salvageable penumbra, although this has not yet translated to improved clinical outcomes. Further phase 3 studies are in progress comparing rt-PA with TNK for acute ischemic stroke during the first 4.5 hours. Studies are also in progress to evaluate the use of TNK for extended applications, such as wake-up stroke.
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Affiliation(s)
| | | | - Weijun Jin
- SUNY Downstate Medical Center, Brooklyn, New York
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