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Huang J, Zheng H, Zhu X, Zhang K, Ping X. Tenecteplase versus alteplase for the treatment of acute ischemic stroke: a meta-analysis of randomized controlled trials. Ann Med 2024; 56:2320285. [PMID: 38442293 PMCID: PMC10916912 DOI: 10.1080/07853890.2024.2320285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 02/13/2024] [Indexed: 03/07/2024] Open
Abstract
OBJECTIVES Tenecteplase, a modified variant of alteplase with greater fibrin specificity and longer plasma half-life, may have better efficacy and safety than alteplase in patients with acute ischemic stroke (AIS). We aimed to compare the benefits and risks of tenecteplase versus alteplase in the treatment of AIS. METHODS Electronic databases were searched up to 10 February 2023 for randomized controlled trials evaluating the effect of tenecteplase versus alteplase in the treatment of AIS. The primary outcome was functional outcome at 90 days, and secondary outcomes including the symptomatic intracranial haemorrhage (SICH), and major neurological improvement. Subgroup analysis was performed based on the different dosage of tenecteplase. RESULTS Ten studies with a total of 5123 patients were analysed in this meta-analysis. Overall, no significant difference between tenecteplase and alteplase was observed for functional outcome at 90 days (excellent: OR 1.08, 95%CI 0.93-1.26, I2 = 26%; good: OR 1.04, 95%CI 0.83-1.30, I2 = 56%; poor: OR 0.95, 95%CI 0.75-1.21, I2 = 31%), SICH (OR 1.12, 95%CI 0.79-1.59, I2 = 0%), and early major neurological improvement (OR 1.26, 95%CI 0.80-1.96, I2 = 65%). The subgroup analysis suggested that the 0.25 mg/kg dose of tenecteplase had potentially greater efficacy and lower symptomatic intracerebral haemorrhage risk compared with 0.25 mg/kg dose tenecteplase. CONCLUSIONS Among AIS patients, there was no significant difference on clinical outcomes between tenecteplase and alteplase. Subgroup analysis demonstrated that 0.25 mg/kg doses of tenecteplase were more beneficial than 0.4 mg/kg doses of tenecteplase. Further studies are required to identify the optimal dosage of tenecteplase.
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Affiliation(s)
- Jian Huang
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Hui Zheng
- Department of Emergency Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Xianfeng Zhu
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
| | - Kai Zhang
- Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaofeng Ping
- Department of Critical Care Medicine, Hangzhou Ninth People’s Hospital, Hangzhou, China
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Silveira P, McCloskey J, Kassar M. Thrombolysis of incidental pulmonary embolism in a stroke patient. Radiol Case Rep 2024; 19:2600-2602. [PMID: 38645948 PMCID: PMC11026682 DOI: 10.1016/j.radcr.2024.03.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/09/2024] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
Both acute ischemic stroke (AIS) and pulmonary embolism (PE) are major causes of morbidity and mortality, with overlapping risk factors. Incidental or silent PE therefore may be discovered during an AIS work-up. Thrombolytic therapy is considered first-line therapy for eligible patients with AIS. We present the case of an 88-year-old man with an AIS, who was incidentally found to have a PE, and then received thrombolytic therapy leading to favorable outcomes in both conditions.
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Affiliation(s)
- Patrick Silveira
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
| | - Justin McCloskey
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
| | - Mohammad Kassar
- Department of Radiology, West Virginia University Hospital, 1 Medical Center Drive, PO Box 9235 Morgantown, WV, USA
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Geraghty JR, Testai FD. Advances in neurovascular research: Scientific highlights from the 15th world stroke congress. J Stroke Cerebrovasc Dis 2024; 33:107617. [PMID: 38307467 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 01/30/2024] [Indexed: 02/04/2024] Open
Affiliation(s)
- Joseph R Geraghty
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Fernando D Testai
- Department of Neurology & Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
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4
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Geraghty JR, Testai FD. Advances in neurovascular research: Scientific highlights from the 2024 international stroke conference. J Stroke Cerebrovasc Dis 2024; 33:107671. [PMID: 38447784 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Joseph R Geraghty
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Fernando D Testai
- Department of Neurology & Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
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Prasad S, Jones EM, Gebreyohanns M, Kwon Y, Olson DM, Anderson JA, Savitz SI, Cruz-Flores S, Warach SJ, Rhodes CE, Goldberg MP, Ifejika NL. Multicenter exploration of tenecteplase transition factors: A quantitative analysis. J Stroke Cerebrovasc Dis 2024; 33:107592. [PMID: 38266690 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/02/2024] [Accepted: 01/20/2024] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Tenecteplase (TNK) is gaining recognition as a novel therapy for acute ischemic stroke (AIS). Despite TNK offering a longer half-life, time and cost saving benefits and comparable treatment and safety profiles to Alteplase (ALT), the adoption of TNK as a treatment for AIS presents challenges for hospital systems. OBJECTIVE Identify barriers and facilitators of TNK implementation at acute care hospitals in Texas. METHODS This prospective survey used open-ended questions and Likert statements generated from content experts and informed by qualitative research. Stroke clinicians and nurses working at 40 different hospitals in Texas were surveyed using a virtual platform. RESULTS The 40 hospitals had a median of 34 (IQR 24.5-49) emergency department beds and 42.5 (IQR 23.5-64.5) inpatient stroke beds with 506.5 (IQR 350-797.5) annual stroke admissions. Fifty percent of the hospitals were Comprehensive Stroke Centers, and 18 (45 %) were solely using ALT for treatment of eligible AIS patients. Primary facilitators to TNK transition were team buy-in and a willingness of stroke physicians, nurses, and pharmacists to adopt TNK. Leading barriers were lack of clinical evidence supporting TNK safety profile inadequate evidence supporting TNK use and a lack of American Heart Association guidelines support for TNK administration in all AIS cases. CONCLUSION Understanding common barriers and facilitators to TNK adoption can assist acute care hospitals deciding to implement TNK as a treatment for AIS. These findings will be used to design a TNK adoption Toolkit, utilizing implementation science techniques, to address identified obstacles and to leverage facilitators.
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Affiliation(s)
- Sidarrth Prasad
- University of Texas Southwestern Medical Center, United States
| | - Erica M Jones
- University of Texas Southwestern Medical Center, United States
| | | | - Yoon Kwon
- University of Texas Southwestern Medical Center, United States
| | - DaiWai M Olson
- University of Texas Southwestern Medical Center, United States
| | | | - Sean I Savitz
- University of Texas Health Science Center at Houston, United States
| | | | - Steven J Warach
- Dell Medical School, The University of Texas at Austin, United States
| | - Charlotte E Rhodes
- The University of Texas Health Science Center at San Antonio, United States
| | - Mark P Goldberg
- The University of Texas Health Science Center at San Antonio, United States
| | - Nneka L Ifejika
- University of Texas Southwestern Medical Center, United States.
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Wang Y, Cai X, Fang Q, Zhu J. Efficacy and safety outcomes of Tenecteplase versus Alteplase for thrombolysis of acute ischemic stroke: A meta-analysis of 9 randomized controlled trials. J Neurol Sci 2024; 458:122912. [PMID: 38325064 DOI: 10.1016/j.jns.2024.122912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 01/20/2024] [Accepted: 02/01/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND In recent years, Tenecteplase (TNK), a genetically modified variant of alteplase, has been verified as a potential substitute for alteplase in the reperfusion therapy of acute ischemic stroke (AIS). Given the emergence of new randomized controlled trials (RCTs) of this subject, a meta-analysis was conducted to evaluate the present comparative evidence regarding the efficacy and safety outcomes of TNK and alteplase in thrombolysis for AIS. METHODS Following predefined inclusion criteria, we searched the databases of PubMed, Web of Science, and Cochrane Library. RCTs satisfying our inclusion criteria were selected for meta-analysis. Outcome indicators were categorized into efficacy outcomes (early vessel recanalization, excellent recovery, good recovery and early neurological improvement) and safety outcomes (poor recovery, symptomatic intracerebral hemorrhage, parenchymal hemorrhage type 2(PH2) post thrombolysis, and mortality). We extracted data on efficacy outcomes and safety outcomes for patients with AIS in the TNK group at a dose of 0.25 mg/kg and the alteplase group at a dose of 0.9 mg/kg, and expressed the relative risks between the 2 groups as odds ratios (ORs) and 95% confidence intervals (CIs) using the Mantel-Haenszel method. For further insight, we performed a network meta-analysis using a Bayesian framework to compare different doses of TNK (0.1, 0.25, 0.32, and 0.4 mg/kg) with alteplase (0.9 mg/kg). RESULTS A total of 2994 patients in 9 RCTs comparing efficacy and safety outcomes in patients with AIS treated with TNK and alteplase were included. In a pairwise analysis of TNK 0.25 mg/kg and alteplase 0.9 mg/kg, regarding efficacy outcomes, the aggregated results show that TNK 0.25 mg/kg statistically significant increased early vessel recanalization (N = 368, TNK vs. alteplase, OR: 2.07,95%CI: [1.19,3.59], I2 = 0%) and excellent recovery (N = 3548, TNK vs. alteplase, OR: 1.15,95%CI: [1.01,1.32], I2 = 0%). There was no significant difference in good recovery (N = 3486, TNK vs. alteplase, OR: 1.38,95%CI: [0.89,2.15], I2 = 84%) or early neurological improvement (N = 1686, TNK vs. alteplase, OR: 1.06,95%CI: [0.87,1.28], I2 = 24%) between the TNK 0.25 mg/kg group and the alteplase 0.9 mg/kg group. In the safety outcomes, pooled results showed no significant difference in poor recovery (N = 3548, TNK vs. alteplase, OR: 0.94,95%CI: [0.81,1.10], I2 = 0%) and symptomatic intracerebral hemorrhage (N = 3567, TNK vs. alteplase, OR: 1.06,95%CI: [0.70,1.60], I2 = 0%) and PH2(N = 3103, TNK vs. alteplase, OR: 1.26,95%CI:[0.39,4.07], I2 = 56%)and mortality (N = 3447, TNK vs. alteplase, OR: 0.99,95%CI: [0.80,1.23], I2 = 33%) between the TNK group and the alteplase group. In a network meta-analysis, competing treatments were not significantly different from one another (TNK 0.1 mg/kg, TNK 0.25 mg/kg, TNK 0.32 mg/kg, TNK 0.4 mg/kg, alteplase 0.9 mg/kg) in either efficacy outcomes or safety outcomes. CONCLUSION In this analysis of 9 RCTs in patients with AIS, TNK 0.25 mg/kg was comparable to alteplase 0.9 mg/kg from the perspective of efficacy outcomes and safety outcomes after thrombolysis within 4.5 h of AIS occurrence.
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Affiliation(s)
- Yue Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou 215300, China
| | - Xiuying Cai
- Department of Neurology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou 215300, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou 215300, China
| | - Juehua Zhu
- Department of Neurology, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou 215300, China.
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Amine Z, Cedric B, William B, Tae-Hee C, Benoit G, Sébastien R, Gaultier M, Caroline A, Bertrand L, David WL. Tenecteplase versus Alteplase before thrombectomy: A comprehensive evaluation of clinical and angiographic impact: Insights from the ETIS registry. J Neuroradiol 2024:S0150-9861(24)00110-X. [PMID: 38462131 DOI: 10.1016/j.neurad.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/28/2024] [Accepted: 02/29/2024] [Indexed: 03/12/2024]
Abstract
INTRODUCTION Data on prior use of Tenecteplase versus Alteplase in acute stroke management by mechanical thrombectomy are controversial. Our primary objective was to make a comprehensive comparative assessment of clinical and angiographic efficacy and safety outcomes in a large prospective observational study. METHODS We included stroke patients who were eligible for intravenous thrombolysis and endovascular thrombectomy between 2019 and 2021, from an ongoing registry in twenty comprehensive stroke centers in France. We divided patients into two groups based on the thrombolytic agent used (Alteplase vs Tenecteplase). We then compared their treatment times, and their angiographic (TICI scale), clinical (mRS at three months and sICH) and safety outcomes after controlling for potential confounders using propensity score methods. RESULTS We evaluated 1131 patients having undergone thrombectomy for the final analysis, 250 received Tenecteplase and 881 Alteplase. Both groups were of the same median age (75 vs 74 respectively), and had the same baseline NIHSS score (16) and ASPECTS (8). There was no significant difference for First Pass Effect (OR 0.93, 95 % CI 0.76-1.14, p = 0.75), time required for reperfusion (OR 0.03, 95 % CI 0.09-0.16, p = 0.49), or for final reperfusion status. Clinically, functional independence at 90 days was similar in both groups (OR 0.82, 95 % CI 0.61-1.10, p = 0.18) with the same risk of sICH (OR 1.36, 95 % CI 0.77-2.41, p = 0.28). However, Tenecteplase patients had shorter imaging-to-groin puncture times (99 vs 142 min, p < 0.05). CONCLUSIONS Tenecteplase showed no better clinical or angiographic impact on thrombectomy compared to Alteplase. Nevertheless, it appeared associated with a shorter thrombolysis-to-groin puncture time.
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Affiliation(s)
- Zarzour Amine
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France.
| | - Batot Cedric
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Boisseau William
- Stroke Unit Neurology, Hôpital Fondation A. de Rothschild, Université Paris-Cité, Université, Paris-Cité and Université Sorbonne Paris Nord (J.P.D.), INSERM, LVTS, F-75018 Paris, France
| | - Cho Tae-Hee
- From the Department of Stroke Medicine, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSA-Lyon, Hospices Civils de Lyon, Lyon, France
| | - Guillon Benoit
- Department of Neurology, Stroke Center, University Hospital of Nantes, Nantes, France
| | - Richard Sébastien
- Neurology, Stroke Unit, Université, CIC-P 1433, INSERM U1116, CHRU-Nancy, F-54000 Nancy, France
| | - Marnat Gaultier
- Department of Interventional Neuroradiology, University Hospital of Bordeaux, France
| | - Arquizan Caroline
- Department of Neurology, Stroke center, Hôpital Gui de Chauliac, Montpellier Neuroradiology, France
| | - Lapergue Bertrand
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Weisenburger Lile David
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
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Ma Y, Xiang H, Busse JW, Yao M, Guo J, Ge L, Li B, Luo X, Mei F, Liu J, Wang Y, Liu Y, Li W, Zou K, Li L, Sun X. Tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis of randomized and non-randomized studies. J Neurol 2024:10.1007/s00415-024-12243-1. [PMID: 38436679 DOI: 10.1007/s00415-024-12243-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 03/05/2024]
Abstract
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.
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Affiliation(s)
- Yu Ma
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Hunong Xiang
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jason W Busse
- Michael G. DeGroote National Pain Centre, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Anaesthesia, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Minghong Yao
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jian Guo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Long Ge
- Evidence Based Social Science Research Centre, School of Public Health, Lanzhou University, Lanzhou, 730000, China
- Department of Social Medicine and Health Management, School of Public Health, Lanzhou University, Lanzhou, 730000, China
| | - Bo Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Xiaochao Luo
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Fan Mei
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Jiali Liu
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Yuning Wang
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Yanmei Liu
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Wentao Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, China
- National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, China
| | - Kang Zou
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China
| | - Ling Li
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China.
| | - Xin Sun
- Department of Neurology and Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, 37 Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
- NMPA Key Laboratory for Real World Data Research and Evaluation in Hainan, Chengdu, 610041, China.
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, 610041, China.
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Arumugham S, Narayan SK, Aghoram R. Effect of continuous 2 MHz transcranial ultrasound as an adjunct to tenecteplase thrombolysis in acute anterior circulation ischemic stroke patients: an open labeled non-randomized clinical trial. J Thromb Thrombolysis 2024:10.1007/s11239-023-02922-7. [PMID: 38393673 DOI: 10.1007/s11239-023-02922-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/05/2023] [Indexed: 02/25/2024]
Abstract
The treatment of acute ischemic stroke has improved in last few decades. While meta-analyses of several trials have established the safety and efficacy of Intravenous (IV) Tenecteplase thrombolysis, concomitant continuous transcranial doppler (TCD) ultrasound administration has not been assessed in any clinical trial. The aim of this study was to determine the effects of continuous 2 MHz TCD ultrasound during IV Tenecteplase thrombolysis for Middle cerebral artery (MCA) stroke. A total of 19 patients were included, 13 received TCD ultrasound and 6 sham TCD with IV Tenecteplase. TCD spectrum and difference in Pre and post TCD parameters were measured. Asymptomatic hemorrhagic transformation of infarct was seen in two patients. There was no mortality or clinical worsening in the sonothrombolysis group as against sham sonothrombolysis group. Median of peak systolic velocity was increased in both the sonothrombolysis (P = 0.0002) and sham sonothrombolysis group (P-value = 0.001). The difference in change in mean flow velocity between two groups, sonothrombolysis (11 cm/sec) and sham sonothrombolysis (3.5 cm/sec) were also significantly different (P = 0.014). This pilot work has established safety of continuous 30 min TCD application along with IV Tenecteplase thrombolysis and it concludes that concomitant 2 MHz TCD ultrasound administration significantly increased the MCA blood flow compared to chemothrombolysis alone.CTRI Registered Number: CTRI/2021/02/031418.
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Affiliation(s)
- Semparuthi Arumugham
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvanthari Nagar, Puducherry, 605006, India
| | - Sunil K Narayan
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvanthari Nagar, Puducherry, 605006, India.
| | - Rajeswari Aghoram
- Department of Neurology, Jawaharlal Institute of Postgraduate Medical Education and Research, Dhanvanthari Nagar, Puducherry, 605006, India
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Nunna RS, Bains NK, Maher B, Siddiq F, Gomez CR, Qureshi AI. Intra-arterial thrombolysis with tenecteplase for the treatment of cervical spinal cord ischemia: Technical case report. J Stroke Cerebrovasc Dis 2024; 33:107507. [PMID: 38176226 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/30/2023] [Accepted: 11/18/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND In recent years, there have anecdotal reports of intra-arterial thrombolysis (IAT) for the treatment of spinal cord ischemia (SCI) with encouraging results. We describe a patient with acute cervical SCI who underwent IAT with Tenecteplase at our institution. CASE PRESENTATION A 20-year-old man presented to the emergency department with a 12-hour history of progressive onset upper and lower extremity numbness, weakness, and urinary incontinence after sustaining a fall. MRI of cervical spine demonstrated T2 and STIR hyperintensity in the ventral aspect of the spinal cord spanning the C3, C4, and C5 levels suggestive of SCI. He demonstrated progression of neurologic deficits to C4 ASIA B spinal cord injury with complete loss of motor function, diminished sensation, and absent rectal tone. Emergent angiography was performed with prominent anterior spinal supply via the left ascending cervical artery. A total of 30 mg of Tenecteplase was administered intra-arterially in the bilateral vertebral arteries, bilateral ascending cervical arteries, and bilateral inferior thyroid arteries. Two-week post-intervention neurologic examination demonstrated improvement in injury level and severity. The patient was C6 ASIA C SCI, with 2/5 strength in the distal upper and lower extremities and improved sensation. CONCLUSION IAT with Tenecteplase may be a feasible option for the treatment of acute spinal cord ischemia in carefully selected patients.
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Affiliation(s)
- Ravi S Nunna
- Department of Neurosurgery, University of Missouri, USA.
| | - Navpreet K Bains
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, USA
| | | | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, USA
| | | | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, USA
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11
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Shi FE, Yu Z, Sun C, Gao P, Zhang H, Zhu J. Comparing adverse events of tenecteplase and alteplase: a real-world analysis of the FDA adverse event reporting system (FAERS). Expert Opin Drug Saf 2024; 23:221-229. [PMID: 37554093 DOI: 10.1080/14740338.2023.2245745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/15/2023] [Accepted: 08/04/2023] [Indexed: 08/10/2023]
Abstract
OBJECTIVES The aim of this study is to monitor, identify, and compare the adverse events (AEs) related to tenecteplase and alteplase, with the objective of exploring the potential safety of tenecteplase for acute ischemic stroke (AIS) and guiding its use to enhance patient safety. METHODS In order to evaluate the disproportionality of AEs associated with tenecteplase and alteplase in real-world data, four algorithms (ROR, PRR, BCPNN, EBGM) were utilized as measures to detect signals of AEs related to both drugs. Subsequently, Breslow-Day statistical analysis was applied to compare the RORs of the main system organ classes (SOCs) and key preferred terms (PTs) between tenecteplase and alteplase. RESULTS A statistical analysis was performed utilizing data gleaned from the Food and Drug Administration Adverse Event Reporting System (FAERS) database, encompassing 19,514,140 case reports from 2004Q1 to 2023Q1. There were 1,004 cases where tenecteplase was reported as the primary suspected (PS) and 2,363 tenecteplase-related adverse drug reactions (ADRs) at the PTs level were identified, the two data of alteplase were 10,945 and 25,266, respectively. The occurrence of drug-induced ADRs was analyzed across 27 organ systems, The analysis revealed several expected ADRs, such as Haemorrhage, Hypersensitivity which were consistent with the two drug-labels. It is of note that the signal strengths of 'death,' 'ventricular fibrillation,' 'cardiogenic shock' and 'pneumonia aspiration' at the PT level were markedly higher for tenecteplase than for alteplase, whereas the signal strength of 'angioedema' at the PT level was significantly higher for alteplase in comparison to tenecteplase. Additionally, unexpected significant ADRs associated with ocular adverse reactions and pneumonia aspiration at the PT level were identified, indicating potential AEs not currently mentioned in the drug instructions. CONCLUSION This study identified and compared signals of ADRs associated with tenecteplase and alteplase, although tenecteplase is as effective as alteplase and has advantages such as ease of use and affordability, it cannot replace alteplase in the treatment of AIS until its safety profile is fully recognized. Additionally, previously unreported ocular ADRs and pneumonia were identified, providing valuable insights into the relationship between ADRs and the use of these thrombolytic drugs. These findings underscore the importance of continuous monitoring and effective detection of AEs to ultimately enhance the safety of AIS patients undergoing thrombolytic therapy.
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Affiliation(s)
- Fang-E Shi
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Zhe Yu
- Peking University Ditan Teaching Hospital, Beijing, China
| | - Chengyue Sun
- Department of Neurology, Peking University People's Hospital, Beijing, China
| | - Peiliang Gao
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Haiyan Zhang
- Department of Emergency, Peking University People's Hospital, Beijing, China
| | - Jihong Zhu
- Department of Emergency, Peking University People's Hospital, Beijing, China
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12
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Huang B, Libman R, Ballout A, DiUbaldi G, Arora R, Katz JM. A bibliometric analysis of tenecteplase research utilizing a commonly used citation index. Clin Neurol Neurosurg 2024; 237:108170. [PMID: 38354425 DOI: 10.1016/j.clineuro.2024.108170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 01/08/2024] [Accepted: 02/06/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND PURPOSE Tenecteplase is increasingly being used as a first-line treatment for acute ischemic stroke after several randomized studies demonstrated its safety and efficacy, resulting in a massive increase in the number of published studies on this topic. Our aim was to investigate the most impactful authors and relevant journals that have been instrumental in validating this treatment, in hopes of identifying objective research trends that may assist scientists, health organizations, and funding agencies to collaborate and plan future avenues of research. METHODS Using the search terms "Tenecteplase" and "Tenecteplase" AND "Stroke," 2683 and 1150 references were queried, respectively, using the abstract and citation database, Scopus. Scopus Citation Analysis was used to categorize the countries and authors who produced the most research. Metadata was retrieved and transferred to bibliographic visualization software, VOSviewer, for co-authorship and co-occurrence analyses to identify trends in tenecteplase research. RESULTS Data visualization software identified three tenecteplase research clusters - myocardial infarction, pulmonary embolism, and acute ischemic stroke. Our bibliographic analysis graphically identified that ischemic stroke currently leads both myocardial infarction and pulmonary embolism in annual publications pertaining to tenecteplase therapy, and further pinpointed perfusion imaging and wake-up strokes as the most relevant areas of study. The United States led all countries in tenecteplase publications, including exclusively stroke studies. The European Heart Journal led all journals in overall publications, while Stroke led all journals in stroke-related studies. CONCLUSIONS Through the use of bibliographic analysis and data visualization, we identified major articles and journals that reflected and shaped the current landscape of tenecteplase; recognized authors who engaged in tenecteplase research as it progressed from cardiopulmonary disease to stroke; and postulated future avenues of research.
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Affiliation(s)
- Brendan Huang
- Department of Neurology, Northwell Health, Manhasset, NY, USA.
| | - Richard Libman
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | - Ahmad Ballout
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | | | - Rohan Arora
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | - Jeffrey M Katz
- Department of Neurology, Northwell Health, Manhasset, NY, USA
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13
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Wilson JL, Waak M, Barry M, Jordan LC, Sun LR. Tenecteplase in Pediatric Stroke: Ready or Not. Pediatr Neurol 2024; 151:17-20. [PMID: 38070460 DOI: 10.1016/j.pediatrneurol.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/28/2023] [Accepted: 11/12/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Intravenous thrombolysis with tissue plasminogen activator is used for off-label treatment of acute childhood stroke. Tenecteplase (TNK) is used to treat acute stroke in adults at many institutions, although there are extremely few data about TNK use in children. We aimed to characterize pediatric stroke experts' experience and preferences with regard to TNK use in children with stroke. METHODS Online survey distributed to members of the International Pediatric Stroke Organization in April 2023. RESULTS We received 33 responses. Most (81.2%) respondents reported only being "a little familiar" or "somewhat familiar" with TNK. Only six (18%) respondents reported being "familiar" or "very familiar" with TNK. Seventy percent of respondents were willing to treat pediatric stroke with TNK, at least in some situations. In a hypothetical scenario of a child in an outside emergency room with only TNK available, 81.8% would consider recommending treatment with TNK. However, only three (9.1%) respondents had TNK in their stroke protocol and seven (21.2%) had TNK on formulary at their hospital. Two respondents reported direct awareness of a child treated with TNK. CONCLUSIONS The majority of pediatric stroke neurologists responding to this survey reported a willingness to consider TNK use in children. However, data on TNK use in children, provider experience, and pediatric hospital preparedness are limited.
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Affiliation(s)
- Jenny L Wilson
- Division of Pediatric Neurology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon.
| | - Michaela Waak
- Pediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Megan Barry
- Departments of Pediatrics and Neurology, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lisa R Sun
- Division of Pediatric Neurology, Division of Stroke, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland
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Flint AC, Eaton A, Melles RB, Hartman J, Cullen SP, Chan SL, Rao VA, Nguyen-Huynh MN, Kapadia B, Patel NU, Klingman JG. Comparative safety of tenecteplase vs alteplase for acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107468. [PMID: 38039801 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 10/20/2023] [Accepted: 11/03/2023] [Indexed: 12/03/2023] Open
Abstract
INTRODUCTION Tenecteplase has been compared to alteplase in acute stroke randomized trials, with similar outcomes and safety measures, but higher doses of tenecteplase have been associated with higher hemorrhage rates in some studies. Limited data are available on the safety of tenecteplase outside of clinical trials. METHODS We examined the safety measures of intracranial hemorrhage, angioedema, and serious extracranial adverse events in a 21-hospital integrated healthcare system that switched from alteplase (0.9 mg/kg, maximum dose 90 mg) to tenecteplase (0.25 mg/kg, maximum dose 25 mg) for acute ischemic stroke. RESULTS Among 3,689 subjects, no significant differences were seen between tenecteplase and alteplase in the rate of intracranial hemorrhage (ICH), parenchymal hemorrhage, or volume of parenchymal hemorrhage. Symptomatic hemorrhage (sICH) was not different between the two agents: sICH by NINDS criteria was 2.0 % for alteplase vs 2.3 % for tenecteplase (P = 0.57), and sICH by SITS criteria was 0.8 % vs 1.1 % (P = 0.39). Adjusted logistic regression models also showed no differences between tenecteplase and alteplase: the odds ratio for tenecteplase (vs alteplase) modeling sICH by NINDS criteria was 0.9 (95 % CI 0.33 - 2.46, P = 0.83) and the odds ratio for tenecteplase modeling sICH by SITS criteria was 1.12 (95 % CI 0.25 - 5.07, P = 0.89). Rates of angioedema and serious extracranial adverse events were low and did not differ between tenecteplase and alteplase. Elapsed door-to-needle times showed a small improvement after the switch to tenecteplase (51.8 % treated in under 30 min with tenecteplase vs 43.5 % with alteplase, P < 0.001). CONCLUSION In use outside of clinical trials, complication rates are similar between tenecteplase and alteplase. In the context of a stroke telemedicine program, the rates of hemorrhage observed with either agent were lower than expected based on prior trials and registry data. The more easily prepared tenecteplase was associated with a lower door-to-needle time.
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Affiliation(s)
- Alexander C Flint
- Division of Research, Kaiser Permanente Northern California, Department of Neuroscience, Kaiser Permanente Redwood City, 1150 Veterans Blvd, Redwood City, CA 94025, USA.
| | | | | | | | - Sean P Cullen
- Department of Neuroscience, KP Redwood City, CA, USA
| | - Sheila L Chan
- Department of Neuroscience, KP Redwood City, CA, USA
| | - Vivek A Rao
- Department of Neuroscience, KP Redwood City, CA, USA
| | | | - Brij Kapadia
- Department of Radiology, KP San Leandro, CA, USA
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Prasad S, Jones EM, Gebreyohanns M, Aguilera V, Olson DM, Anderson JA, Savitz SI, Flores SC, Warach SJ, Rhodes CE, Goldberg MP, Ifejika NL. A qualitative study of barriers and facilitators to using tenecteplase to treat acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107458. [PMID: 37956644 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107458] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/03/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Tenecteplase (TNK) is emerging as an alternative to alteplase (ALT) for thrombolytic treatment of acute ischemic stroke (AIS). Compared to ALT, TNK has a longer half-life, shorter administration time, lower cost, and similarly high efficacy in treating large vessel occlusion. Nevertheless, there are barriers to adopting TNK as a treatment for AIS. This study aimed to identify thematic barriers and facilitators to adopting TNK as an alternative to ALT as a thrombolytic for eligible AIS patients. METHODS Qualitative research methodology using hermeneutic cycling and purposive sampling was used to interview four stroke clinicians in Texas. Interviews were recorded and transcribed verbatim. Enrollment was complete when saturation was reached. All members of the research team participated in content analysis during each cycle and in thematic analysis after saturation. RESULTS Interviews were conducted between November 2022 and February 2023 with stroke center representatives from centers that either had successfully adopted TNK, or had not yet adopted TNK. Three themes and eight sub-themes were identified. The theme "Evidence" had three sub-themes: Pro-Con Balance, Fundamental Knowledge, and Pharmacotherapeutics. The theme "Process Flow" had four subthemes: Proactive, Reflective self-doubt, Change Process Barriers, and Parameter Barriers. The theme "Consensus" had one sub-theme: Getting Buy-In. CONCLUSION Clinicians experience remarkably similar barriers and facilitators to adopting TNK. The results lead to a hypothesis that providing evidence to support a practice change, and identifying key change processes, will help clinicians achieve consensus across teams that need to 'buy in' to adopting TNK for AIS treatment.
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Affiliation(s)
- Sidarrth Prasad
- University of Texas Southwestern Medical Center, United States
| | - Erica M Jones
- University of Texas Southwestern Medical Center, United States
| | | | | | - DaiWai M Olson
- University of Texas Southwestern Medical Center, United States
| | | | - Sean I Savitz
- University of Texas Health Science Center at Houston, United States
| | | | - Steven J Warach
- Dell Medical School, The University of Texas at Austin, United States
| | - Charlotte E Rhodes
- The University of Texas Health Science Center at San Antonio, United States
| | - Mark P Goldberg
- The University of Texas Health Science Center at San Antonio, United States
| | - Nneka L Ifejika
- University of Texas Southwestern Medical Center, United States.
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16
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Vo A, Hicks W, Sangha N. A case series on treatment of central and branch retinal artery occlusion with intravenous tenecteplase: Tenecteplase for retinal artery occlusions. J Stroke Cerebrovasc Dis 2024; 33:107488. [PMID: 37984044 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 10/31/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVES Central and branch retinal artery occlusions are disabling ischemic strokes of the retina for which established acute treatments are lacking. This is the first published report of the use of intravenous tenecteplase (TNK) for retinal artery occlusion, in which we describe the clinical course of four patients with central retinal artery occlusion (CRAO) and one patient with branch retinal artery occlusion (BRAO). MATERIALS AND METHODS Patients were retrospectively recruited to the study from two stroke centers. Clinical course was determined from review of electronic medical records. The primary outcomes of interest were short and long term complications as well as visual acuity at presentation and at any subsequent follow up. RESULTS There were no hemorrhagic complications. None of the four patients with CRAO experienced functional visual recovery (defined as improvement to 20/100 or better). The patient with BRAO had functional visual recovery. CONCLUSIONS Intravenous TNK may be a safe and reasonable treatment for CRAO and BRAO.
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Affiliation(s)
- Alexander Vo
- Kaiser Permanente Los Angeles, Department of Neurology 1505 N Edgemont St, Floor 5 Los Angeles, CA 90027, United States.
| | - William Hicks
- Comprehensive Stroke Program, OhioHealth Riverside Methodist Hospital, Columbus, OH, United States
| | - Navdeep Sangha
- Kaiser Permanente Los Angeles, Department of Neurology 1505 N Edgemont St, Floor 5 Los Angeles, CA 90027, United States
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17
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Oliveira DS, Sousa L. Off-label tenecteplase use in spinal cord ischemia. Acta Neurol Belg 2023; 123:2409-2412. [PMID: 36892749 DOI: 10.1007/s13760-023-02228-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/23/2023] [Indexed: 03/10/2023]
Affiliation(s)
- Daniela Santos Oliveira
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Rua Dr. Cândido Pinho, nº 5, 4520-220, Santa Maria da Feira, Portugal.
| | - Luísa Sousa
- Neurology Department, Centro Hospitalar de Entre o Douro e Vouga, Rua Dr. Cândido Pinho, nº 5, 4520-220, Santa Maria da Feira, Portugal
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Jacobsen E, Logallo N, Kvistad CE, Thomassen L, Idicula T. Characteristics and predictors of stroke mimics in young patients in the norwegian tenecteplase stroke trial (NOR-TEST). BMC Neurol 2023; 23:406. [PMID: 37968581 PMCID: PMC10647039 DOI: 10.1186/s12883-023-03425-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 10/05/2023] [Indexed: 11/17/2023] Open
Abstract
BACKGROUND Several studies have shown that stroke mimics occur more often among young patients. Our aims were to identify the common mimics in young patients under the age of 60 years who received thrombolysis, to analyze the risk of hemorrhage after treatment with thrombolysis, and to identify risk factors and clinical parameters that might identify mimics in this group. METHODS Norwegian Tenecteplase Stroke Trial was a phase-3 trial investigating safety and efficacy of tenecteplase vs. alteplase in patients with acute ischemic stroke. Patients diagnosed with either acute cerebral ischemia or transient ischemic attack were categorized as stroke group, and patients with any diagnosis other than ischemic stroke or transient ischemic attack as mimics group. Patients were grouped post-hoc into young (< 60 years) and old (≥ 60 years). Logistic regression analyses were performed with mimics vs. stroke as dependent variable to identify predictors of mimics. RESULTS Of the 1091 patients included in the trial, 211 patients (19.3%) were under the age of 60 years. Out of the 1091 patients, 434 (39.8%) were female, median age 77 years (18-99 years), and median NIHSS was 4. Sixty-nine patients (32.7%) out of the 211 patients under the age of 60 were diagnosed as mimic. Mimics were significantly more frequent among the young (OR = 3.3, 32.7% vs. 12.8%, p = < 0.001). The most frequent mimics diagnoses among patients under 60 years of age were migraine (11.8%), no definite diagnosis (11.4%) and peripheral vertigo (3.3%). Mimics were independently associated with age < 50 years (OR = 4.97, p = < 0.001), not currently working/studying (OR = 3.38, p = 0.002) and not having aphasia on admission (OR = 2.95, p = 0.025). None of the mimics under the age of 60 years had symptomatic or asymptomatic intracerebral hemorrhage as a complication to thrombolysis. CONCLUSION We found significantly more mimics in the young, of which migraine was the most predominant diagnosis. Thrombolysis with alteplase or tenecteplase did not cause ICH in any mimics under 60 years.
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Affiliation(s)
- Eskil Jacobsen
- Norwegian University of Science and Technology, Trondheim (NTNU), Trondheim, 7034, Norway.
| | - Nicola Logallo
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
| | - Christopher Elnan Kvistad
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Lars Thomassen
- Department of Neurology, Centre for Neurovascular Diseases, Haukeland University Hospital, Bergen, 5021, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Titto Idicula
- Norwegian University of Science and Technology (NTNU), Trondheim, 7034, Norway
- Department of Neurology, St Olav University Hospital, Trondheim, Norway
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Astier A, Abouqal R, Abid L, Aoudia Y, Ahid S. Biosimilarity. Do not confuse biosimilar and biocopy. Example of tenecteplase. Ann Pharm Fr 2023; 81:942-949. [PMID: 37422254 DOI: 10.1016/j.pharma.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/30/2023] [Accepted: 07/01/2023] [Indexed: 07/10/2023]
Abstract
Non-innovator biological products (NIBPs) or 'biocopies' are available in several countries at lower prices than biosimilars. These drugs, sometimes so-called 'biosimilars', may not meet all of the quality criteria expected of clinically equivalent products. NIBPs can exhibit major differences in physicochemical and pharmacological properties compared with their reference biological but may be presented to prescribers based on clinical trial data and claimed clinical equivalence. Tenecteplase (TNK-tpA) is a recombinant derivative of tissue plasminogen activator, used as a third-generation thrombolytic agent for treatment of acute myocardial infarction. A TNK-tPA presented as biosimilar to the originator (Metalyse®, Boehringer Ingelheim; TNKase®, Roche/Genentech) is now available for use in India (Elaxim®, Gennova Pharmaceuticals). Elaxim® is not approved in Europe or the USA but has been proposed in several countries as a replacement for the originator. Based on available literature, we discuss why this biocopy cannot be considered biosimilar to the originator tenecteplase. We describe clear differences in physicochemical and pharmacological properties. For example, the biocopy demonstrates clot lysis activity that is substantially lower than the originator and contains high concentrations of foreign proteins that confer potential for immunological reactions. Clinical data on the biocopy are limited; randomized trials to demonstrate the absence of difference in efficacy and safety between the biocopy and originator have not been conducted. This example demonstrates that confirmation of similarity, by close examination of pharmaceutical quality attributes, and preclinical and clinical data, is mandatory before presenting to prescribers a biological product as clinically equivalent.
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Affiliation(s)
- A Astier
- Académie nationale de pharmacie, faculté de pharmacie, 4, avenue de l'Observatoire, 75004 Paris, France.
| | - R Abouqal
- Laboratoire de biostatistique, de recherche clinique et épidémiologie, faculté de médecine et de pharmacie, université Mohammed V, avenue Mohamed Belarbi El Alaoui, BP 6203 Rabat-Institut, Rabat, Morocco.
| | - L Abid
- Hôpital Hédi Chaker, route Elain 0.5, 3029 Sfax, Tunisia.
| | - Y Aoudia
- Faculté de médecine SI Ahmed El Mahdi, université Saad Dahled Blida 1, Soumaa, Blida, Algeria.
| | - S Ahid
- Équipe de recherche pharmacoépidémiologie et pharmacoéconomie, faculté de médecine et de pharmacie, université Mohammed V, avenue Mohamed Belarbi El Alaoui, BP 6203 Rabat-Institut, Rabat, Morocco.
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Salamatullah HK, Bashrahil B, Alghamdi AM, Alsharm FS, Alkulli OA, Alzahrani Z, Alkhiri A, Alghamdi S, Makkawi S. Efficacy and safety of tenecteplase in comparison to alteplase in acute ischemic stroke: A systematic review and meta-analysis of randomized controlled trials. Clin Neurol Neurosurg 2023; 233:107961. [PMID: 37713743 DOI: 10.1016/j.clineuro.2023.107961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/01/2023] [Accepted: 09/03/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Alteplase is the standard medical therapy for acute ischemic stroke (AIS) patients who present within 4.5 h of symptom onset. Tenecteplase is a modified alteplase variant with pharmacological and practical advantages over alteplase. Many trials have investigated the efficacy and safety of tenecteplase against alteplase. This systematic review and meta-analysis aimed to compare the efficacy and safety of tenecteplase to alteplase across randomized controlled trials. METHOD Medline, Embase, and Cochrane CENTRAL were used to search the related articles until February 20, 2023. Randomized controlled trials (RCTs) that compared the effectiveness and safety of tenecteplase against alteplase for AIS patients were included. Screening, risk of bias assessment, and data extraction were performed following PRISMA guidelines. Data were pooled using a random-effect model. RESULTS Ten RCTs were included, with a total of 5123 patients. There was no significant difference between the two interventions in modified rankin scale 0-1 (mRS 0-1) (RR= 1.04, 95% CI [0.99-1.10], P = 0.11, I2 =0%) and early neurological improvement (RR= 1.06, 95% CI [0.97-1.15], P = 0.21, I2 =35). There was no difference in the rates of symptomatic intracranial hemorrhage (RR= 1.18, 95% CI [0.84-1.65], P = 0.35, I2 = 0%). Tenecteplase was associated with significantly higher complete recanalization rate compared to alteplase (RR= 1.17, 95% CI [1.00-1.36], P = 0.05, I2 =0%). For large vessel occlusion (LVO) patients assigned to tenecteplase, there was a significant improvement in mRS 0-1 (RR= 1.28, 95% CI [1.07-1.52], P = 0.006, I2 =0%). CONCLUSION Based on our meta-analysis, tenecteplase has similar efficacy and safety to alteplase, with a more promising effect in patients with LVO.
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Affiliation(s)
- Hassan K Salamatullah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Bader Bashrahil
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulaziz M Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Faisal S Alsharm
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Osama A Alkulli
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ziyad Alzahrani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Saeed Alghamdi
- Neuroscience Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Seraj Makkawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, Jeddah, Saudi Arabia; Department of Medicine, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia.
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Shen Z, Bao N, Tang M, Yang Y, Li J, Liu W, Jiang G. Tenecteplase vs. Alteplase for Intravenous Thrombolytic Therapy of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Neurol Ther 2023; 12:1553-1572. [PMID: 37552459 PMCID: PMC10444744 DOI: 10.1007/s40120-023-00530-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023] Open
Abstract
INTRODUCTION In recent years, as one of the drugs for the treatment of acute ischemic stroke (AIS), the clinical application of tenecteplase is still controversial. Therefore, we aimed to evaluate the safety and efficacy of tenecteplase versus alteplase to guide clinical practice. METHODS A search of PubMed, MEDLINE, EMBASE, Cochrane Library, and Web of Science databases until February 15, 2023 was conducted to identify eligible articles. The quality of the included studies was assessed using the Cochrane Risk of Bias tool. RevMan 5.3 and Stata 17 were used to perform the meta-analysis and detect publication bias, and risk ratios (RRs) with 95% confidence intervals (95% CIs) were reported for each outcome measure. RESULTS A total of 1326 records were retrieved in this meta-analysis. As a result of the limited reports on tenecteplase in patients with AIS and the lack of high-quality randomized controlled trials (RCTs), and considering the impact of publication bias, we did not include any of these studies published before 2015. Ultimately we included 16 RCTs with a total of 7508 patients, including 3940 patients treated with alteplase and 3568 patients treated with tenecteplase. Tenecteplase was associated with better early neurological improvement (RR 0.10; 95% CI 0.00-0.19; P = 0.04), recanalization of blood vessels (RR 0.24; 95% CI 0.07-0.40; P = 0.01), and 90-day excellent neurological recovery (RR 0.12; 95% CI 0.01-0.24; P = 0.04). In addition, there were no significant differences in other efficacy and safety outcomes between the two groups. The funnel plot and Begg's as well as Egger's tests showed no significant publication bias. CONCLUSIONS This meta-analysis showed that tenecteplase was not inferior to alteplase in early thrombolytic therapy in patients with AIS, and was even better than alteplase on some efficacy outcomes with no significant differences in safety. However, as a result of some inherent limitations of this study, more high-quality prospective clinical studies are needed to confirm these results.
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Affiliation(s)
- Ziyi Shen
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Nana Bao
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Ming Tang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Yang Yang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Jia Li
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China
| | - Wei Liu
- Department of Neurology, Nanbu County Hospital Affiliated to North Sichuan Medical College, Nanchong, Sichuan, China.
| | - Guohui Jiang
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, 1 South Maoyuan Road, Nanchong, Sichuan, 637000, China.
- Institute of Neurological Diseases, North Sichuan Medical College, Nanchong, Sichuan, China.
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Wang L, Dai YJ, Cui Y, Zhang H, Jiang CH, Duan YJ, Zhao Y, Feng YF, Geng SM, Zhang ZH, Lu J, Zhang P, Zhao LW, Zhao H, Ma YT, Song CG, Zhang Y, Chen HS. Intravenous Tenecteplase for Acute Ischemic Stroke Within 4.5-24 Hours of Onset (ROSE-TNK): A Phase 2, Randomized, Multicenter Study. J Stroke 2023; 25:371-377. [PMID: 37608533 PMCID: PMC10574303 DOI: 10.5853/jos.2023.00668] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Intravenous tenecteplase (TNK) efficacy has not been well demonstrated in acute ischemic stroke (AIS) beyond 4.5 hours after onset. This study aimed to determine the effect of intravenous TNK for AIS within 4.5 to 24 hours of onset. METHODS In this pilot trial, eligible AIS patients with diffusion-weighted imaging (DWI)-fluid attenuated inversion recovery (FLAIR) mismatch were randomly allocated to intravenous TNK (0.25 mg/kg) or standard care within 4.5-24 hours of onset. The primary endpoint was excellent functional outcome at 90 days (modified Rankin Scale [mRS] score of 0-1). The primary safety endpoint was symptomatic intracranial hemorrhage (sICH). RESULTS Of the randomly assigned 80 patients, the primary endpoint occurred in 52.5% (21/40) of TNK group and 50.0% (20/40) of control group, with no significant difference (unadjusted odds ratio, 1.11; 95% confidence interval 0.46-2.66; P=0.82). More early neurological improvement occurred in TNK group than in control group (11 vs. 3, P=0.03), but no significant differences were found in other secondary endpoints, such as mRS 0-2 at 90 days, shift analysis of mRS at 90 days, and change in National Institutes of Health Stroke Scale score at 24 hours and 7 days. There were no cases of sICH in this trial; however, asymptomatic intracranial hemorrhage occurred in 3 of the 40 patients (7.5%) in the TNK group. CONCLUSION This phase 2, randomized, multicenter study suggests that intravenous TNK within 4.5-24 hours of onset may be safe and feasible in AIS patients with a DWI-FLAIR mismatch.
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Affiliation(s)
- Lu Wang
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Ying-Jie Dai
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yu Cui
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
| | - Hong Zhang
- Department of Neurology, Liaoning Health Industry Group Fukuang General Hospital, Fushun, China
| | - Chang-Hao Jiang
- Department of Neurology, Lvshunkou Traditional Chinese Medicine Hospital, Dalian, China
| | - Ying-Jie Duan
- Department of Neurology, Liaoning Health Industry Group Fuxinkuang General Hospital, Fuxin, China
| | - Yong Zhao
- Department of Neurology, Haicheng Traditional Chinese Medicine Hospital, Haicheng, China
| | - Ye-Fang Feng
- Department of Neurology, Huludao Second People’s Hospital, Huludao, China
| | - Shi-Mei Geng
- Department of Neurology, Beipiao Central Hospital, Beipiao, China
| | - Zai-Hui Zhang
- Department of Neurology, Xiuyan County Central People’s Hospital, Anshan, China
| | - Jiang Lu
- Department of Neurology, Linghai Dalinghe Hospital, Jinzhou, China
| | - Ping Zhang
- Department of Neurology, Fuxin Central Hospital, Fuxin, China
| | - Li-Wei Zhao
- Department of Neurology, Anshan Changda Hospital, Anshan, China
| | - Hang Zhao
- Department of Neurology, General Hospital of Benxi Iron & Steel Industry Group of Liaoning Health Industry Group, Benxi, China
| | - Yu-Tong Ma
- Department of Neurology, Beipiao Central Hospital, Beipiao, China
| | | | - Yi Zhang
- Department of Neurology, Tieling County Central Hospital, Tieling, China Background
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theater Command, Shenyang, China
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23
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Wei H, Fu B, Yang C, Huang M. The efficacy and safety of intravenous thrombolysis with tenecteplase versus alteplase for acute ischemic stroke: a systematic review and meta-analysis. Neurol Sci 2023; 44:3005-3015. [PMID: 37061572 DOI: 10.1007/s10072-023-06801-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 04/03/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVES We aimed to evaluate the available evidence on the efficacy and safety outcomes of intravenous tenecteplase (TNK) compared with intravenous alteplase(ALT) for patients with acute ischemic stroke (AIS) in randomized controlled trials (RCTs). METHODS The MEDLINE/PubMed, Embase, Springer, Web of Science, Cochrane Collaboration database, China National Knowledge Infrastructure (CNKI) database, and Wanfang database were comprehensively searched for RCTs regarding the effects of TNK versus ALT among AIS patients in these English and Chinese electronic databases from inception dates to August 1, 2022. This meta-analysis followed PRISMA guidelines. Two reviewers independently retrieved RCTs and extracted relevant information. The methodological quality of the included trials was estimated using the Cochrane risk of bias tool. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) and mortality at 90 days. The secondary outcomes included successful recanalization, early neurologic improvement < 48 h, any intracranial hemorrhage (ICH), and symptomatic ICH. The follow-up time of all studies was at least 3 months. RESULTS A total of nine RCTs involving 1958 patients in TNK group and 1731 patients in ALT group were finally included. For the efficacy outcomes, there were no significant differences between the two groups in terms of mRS score 0 ~ 2 (RR 1.00; 95% CI 0.88-1.13; P = 0.96), mRS score 0 ~ 1 (RR 1.03; 95% CI 0.96-1.10; P = 0.36), successful recanalization (RR 1.25; 95% CI 0.88-1.76; P = 0.21), and early neurologic improvement < 48 h (RR 1.08; 95% CI 0.92-1.26; P = 0.37). Similar results were seen for the safety outcomes, which have no statistical differences in terms of any ICH (RR 1.01; 95% CI 0.72-1.41; P = 0.96), symptomatic ICH (RR 1.19; 95% CI 0.81-1.76; P = 0.37), and mortality at 90 days (RR 0.99; 95% CI 0.83-1.19; P = 0.94). CONCLUSION Overall, the efficacy and safety outcomes of intravenous thrombolysis with TNK versus ALT for AIS were not statistically different. However, TNK at a dose of 0.25 mg/kg may be a reasonable alternative to ALT for thrombolysis.
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Affiliation(s)
- Heng Wei
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China.
| | - Bin Fu
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China
| | - Chao Yang
- Department of Neurology, People's Hospital of Dongxihu District of Wuhan Union Hospital, Wuhan, 430040, China
| | - Ming Huang
- Department of Neurology, Hubei Provincial Hospital of Integrated Chinese and Western Medicine, Hubei University of Chinese Medicine, Wuhan, 430000, China.
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24
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Koh HP, Md Redzuan A, Mohd Saffian S, Hassan H, R Nagarajah J, Ross NT. Mortality outcomes and predictors of failed thrombolysis following STEMI thrombolysis in a non-PCI capable tertiary hospital: a 5-year analysis. Intern Emerg Med 2023; 18:1169-1180. [PMID: 36648707 PMCID: PMC9843664 DOI: 10.1007/s11739-023-03202-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/09/2023] [Indexed: 01/18/2023]
Abstract
Pharmacological reperfusion remains the primary strategy for ST-elevation myocardial infarction (STEMI) in low- and medium-income countries. Literature has reported inconsistent incidences and outcomes of failed thrombolysis (FT). This study aimed to identify the incidence, mortality outcomes and predictors of FT in STEMI pharmacological reperfusion. This single-centre retrospective cohort study analyzed data on consecutive STEMI patients who received thrombolytic therapy from 2016 to 2020 in a public tertiary hospital. Total population sampling was used in this study. Logistic regression analyses were used to assess independent predictors of the mortality outcomes and FT. We analyzed 941 patients with a mean age of 53.0 ± 12.2 years who were predominantly male (n = 846, 89.9%). The in-hospital mortality was 10.3% (n = 97). FT occurred in 86 (9.1%) patients and was one of the predictors of mortality (aOR 3.847, p < 0.001). Overall, tenecteplase use (aOR 1.749, p = 0.021), pre-existing hypertension (aOR 1.730, p = 0.024), history of stroke (aOR 4.176, p = 0.004), and heart rate ≥ 100 bpm at presentation (aOR 2.333, p < 0.001) were the general predictors of FT. The predictors of FT with streptokinase were Killip class ≥ II (aOR 3.197, p = 0.004) and heart rate ≥ 100 bpm at presentation (aOR 3.536, p = 0.001). History of stroke (aOR 6.144, p = 0.004) and heart rate ≥ 100 bpm at presentation (aOR 2.216, p = 0.015) were the predictors of FT in STEMI patients who received tenecteplase. Mortality following STEMI thrombolysis remained high in our population and was attributed to FT. Identified predictors of FT enable early risk stratification to evaluate the patients' prognosis to manage them better.
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Affiliation(s)
- Hock Peng Koh
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586, Kuala Lumpur, Malaysia.
| | - Adyani Md Redzuan
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | | | - Hasnita Hassan
- Emergency and Trauma Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Jivanraj R Nagarajah
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Jalan Pahang, 50586, Kuala Lumpur, Malaysia
| | - Noel Thomas Ross
- Medical Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
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25
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Ringleb P, Bauer G, Purrucker J. [Intravenous thrombolysis of ischemic stroke-Current status]. Nervenarzt 2023:10.1007/s00115-023-01500-9. [PMID: 37249597 DOI: 10.1007/s00115-023-01500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023]
Abstract
Intravenous thrombolysis (IVT) treatment with alteplase (rtPA) is an essential part of the routine treatment of patients with ischemic stroke since its introduction in the late 1990s. Rapid treatment is of essential importance. For patients with an unclear time window, various mismatch concepts have been established to identify salvageable brain tissue prior to IVT. Numerous official contraindications for rtPA are not evidence-based; for example, current data from observational studies show that systemic thrombolytic treatment is possible even in patients receiving direct oral anticoagulant (DOAC) treatment. Tenecteplase (TNK) is an alternative thrombolytic agent with some pharmacologic advantages. The most recent guidelines indicate that TNK is particularly advantageous over rtPA in patients treated in combination with endovascular stroke therapy (EST). The combination of IVT and EST should primarily be performed in the 4.5‑h time window in patients without contraindications; in the later time window EST alone is conceivable if it can be performed without delay.
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Affiliation(s)
- Peter Ringleb
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Gregor Bauer
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Jan Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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Toul M, Slonkova V, Mican J, Urminsky A, Tomkova M, Sedlak E, Bednar D, Damborsky J, Hernychova L, Prokop Z. Identification, characterization, and engineering of glycosylation in thrombolyticsa. Biotechnol Adv 2023; 66:108174. [PMID: 37182613 DOI: 10.1016/j.biotechadv.2023.108174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/09/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023]
Abstract
Cardiovascular diseases, such as myocardial infarction, ischemic stroke, and pulmonary embolism, are the most common causes of disability and death worldwide. Blood clot hydrolysis by thrombolytic enzymes and thrombectomy are key clinical interventions. The most widely used thrombolytic enzyme is alteplase, which has been used in clinical practice since 1986. Another clinically used thrombolytic protein is tenecteplase, which has modified epitopes and engineered glycosylation sites, suggesting that carbohydrate modification in thrombolytic enzymes is a viable strategy for their improvement. This comprehensive review summarizes current knowledge on computational and experimental identification of glycosylation sites and glycan identity, together with methods used for their reengineering. Practical examples from previous studies focus on modification of glycosylations in thrombolytics, e.g., alteplase, tenecteplase, reteplase, urokinase, saruplase, and desmoteplase. Collected clinical data on these glycoproteins demonstrate the great potential of this engineering strategy. Outstanding combinatorics originating from multiple glycosylation sites and the vast variety of covalently attached glycan species can be addressed by directed evolution or rational design. Directed evolution pipelines would benefit from more efficient cell-free expression and high-throughput screening assays, while rational design must employ structure prediction by machine learning and in silico characterization by supercomputing. Perspectives on challenges and opportunities for improvement of thrombolytic enzymes by engineering and evolution of protein glycosylation are provided.
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Affiliation(s)
- Martin Toul
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Kamenice 5/C13, 625 00 Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91 Brno, Czech Republic
| | - Veronika Slonkova
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Kamenice 5/C13, 625 00 Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91 Brno, Czech Republic
| | - Jan Mican
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Kamenice 5/C13, 625 00 Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91 Brno, Czech Republic
| | - Adam Urminsky
- Research Centre for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53 Brno, Czech Republic
| | - Maria Tomkova
- Center for Interdisciplinary Biosciences, P. J. Safarik University in Kosice, Jesenna 5, 04154 Kosice, Slovakia
| | - Erik Sedlak
- Center for Interdisciplinary Biosciences, P. J. Safarik University in Kosice, Jesenna 5, 04154 Kosice, Slovakia
| | - David Bednar
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Kamenice 5/C13, 625 00 Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91 Brno, Czech Republic
| | - Jiri Damborsky
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Kamenice 5/C13, 625 00 Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91 Brno, Czech Republic
| | - Lenka Hernychova
- Research Centre for Applied Molecular Oncology, Masaryk Memorial Cancer Institute, Zluty kopec 7, 656 53 Brno, Czech Republic.
| | - Zbynek Prokop
- Loschmidt Laboratories, Department of Experimental Biology and RECETOX, Faculty of Science, Masaryk University, Kamenice 5/C13, 625 00 Brno, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Pekarska 53, 656 91 Brno, Czech Republic.
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Miller SE, Warach SJ. Evolving Thrombolytics: from Alteplase to Tenecteplase. Neurotherapeutics 2023; 20:664-678. [PMID: 37273127 PMCID: PMC10275840 DOI: 10.1007/s13311-023-01391-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/06/2023] Open
Abstract
Alteplase has been the primary thrombolytic used in the treatment of acute ischemic stroke since thrombolysis was first established as an effective treatment of acute ischemic stroke in 1995. Tenecteplase, a genetically modified tissue plasminogen activator, has gained attention as an attractive alternative to alteplase given its practical workflow advantages and possible superior efficacy in large vessel recanalization. As more data is analyzed both from randomized trials and non-randomized patient registries, there is mounting support that tenecteplase appears to be at least equally, if not more, safe and potentially more effective than alteplase in the treatment of acute ischemic stroke. Randomized trials investigating tenecteplase in the delayed treatment window and with thrombectomy are ongoing, and their results are eagerly awaited. This paper provides an overview of completed and ongoing randomized trials and nonrandomized studies analyzing tenecteplase in the treatment of acute ischemic stroke. Results reviewed support the safe use of tenecteplase in clinical practice.
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Affiliation(s)
- Samantha E Miller
- Department of Neurology, Dell Medical School, University of Texas at Austin, 1601 Trinity St., Bldg. B, Stop Z0700, Austin, TX, 78712, USA.
| | - Steven J Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin, 1601 Trinity St., Bldg. B, Stop Z0700, Austin, TX, 78712, USA
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Olindo S, Albucher JF, Bejot Y, Berge J, Cordonnier C, Guillon B, Sablot D, Tardy J, Alamowitch S, Sibon I. Tenecteplase in acute ischemic stroke: Review of the literature and expert consensus from the French Neurovascular Society. Rev Neurol (Paris) 2023; 179:150-160. [PMID: 36369068 DOI: 10.1016/j.neurol.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 08/04/2022] [Accepted: 08/22/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intravenous alteplase is the only thrombolytic treatment approved for patients with acute ischemic stroke (AIS). Although no randomized controlled trial (RCT) has shown the superiority of tenecteplase over alteplase in AIS, tenecteplase is increasingly used off-label in Stroke Units. The purpose of the present work was to provide an up-to-date set of expert consensus statements on the use of tenecteplase in AIS. METHODS Members of the working group were selected by the French Neurovascular Society. RCTs comparing tenecteplase and alteplase in the treatment of AIS were reviewed. Recent meta-analysis and real-life experience data on tenecteplase published until 30th October 2021 were also analyzed. After a description of the available data, we tried to answer the subsequent questions about the use of tenecteplase in AIS: What dosage of tenecteplase should be preferred? How effective is tenecteplase for cerebral artery recanalization? What is the clinical effectiveness of tenecteplase? What is the therapeutic safety of tenecteplase? What are the benefits associated with tenecteplase ease of use? Then expert consensus statements for tenecteplase use were submitted. In October 2021 the working group was asked to review and revise the manuscript. In November 2021, the current version of the manuscript was approved. EXPERT CONSENSUS A set of three expert consensus statements for the use of tenecteplase within 4.5hours of symptom onset in AIS patients were issued: (1) It is reasonable to use tenecteplase 0.25mg/kg when mechanical thrombectomy (MT) is planned. (2) Tenecteplase 0.25mg/kg can be used as an alternative to alteplase 0.9mg/kg in patients with medium- or small-vessel occlusion not retrievable with MT. (3) Tenecteplase 0.25mg/kg could be considered as an alternative to alteplase 0.9mg/kg in patients without vessel occlusion. CONCLUSIONS These expert consensus statements could provide a framework to guide the clinical decision-making process for the use of tenecteplase according to admission characteristics of AIS patients. However, existing data are limited, requiring inclusions in ongoing RCTs or real-life registries.
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Affiliation(s)
- S Olindo
- Service de Neurovasculaire, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
| | - J-F Albucher
- Unité Neuro-Vasculaire, Hôpital Pierre-Paul-Riquet, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Y Bejot
- Service Hospitalo-Universitaire de Neurologie, CHU de Dijon Bourgogne, Dijon, France
| | - J Berge
- Service de Neuro-Radiologie, Hôpital Pellegrin, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - C Cordonnier
- Université Lille, Inserm, CHU Lille, U1172, LiINCog, Lille Neuroscience and Cognition, Lille, France
| | - B Guillon
- Unité Neurovasculaire, Hôpital G&R Laënnec, CHU de Nantes, Nantes, France
| | - D Sablot
- Service de Neurologie, Hôpital de Perpignan, Perpignan, France
| | - J Tardy
- Unité Neuro-Vasculaire, Clinique des Cèdres, Cornebarrieu, France
| | - S Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Salpêtrière-Saint Antoine, AP-HP, Sorbonne Université, Stare Team, iCRIN, Institut du cerveau, Inserm UMRS 938, Paris, France
| | - I Sibon
- Service de Neurovasculaire, Hôpital Pellegrin, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
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Rehman AU, Mohsin A, Cheema HA, Zahid A, Ebaad Ur Rehman M, Ameer MZ, Ayyan M, Ehsan M, Shahid A, Aemaz Ur Rehman M, Shah J, Khawaja A. Comparative efficacy and safety of tenecteplase and alteplase in acute ischemic stroke: A pairwise and network meta-analysis of randomized controlled trials. J Neurol Sci 2023; 445:120537. [PMID: 36630803 DOI: 10.1016/j.jns.2022.120537] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 12/04/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Studies on tenecteplase have been yielding mixed results for several important outcomes at different doses, thus hampering objective guideline recommendations in acute ischemic stroke management. This meta-analysis stratifies doses in order to refine our interpretation of outcomes and quantify the benefits and harms of tenecteplase at different doses. METHODS PubMed/MEDLINE, the Cochrane Library, and reference lists of the included articles were systematically searched. Several efficacy and safety outcomes were pooled and reported as risk ratios (RRs) with 95% confidence intervals (CIs). Network meta-analysis was used to find the optimal dose of tenecteplase. Meta-regression was run to investigate the impact of baseline NIHSS scores on functional outcomes and mortality. RESULTS Ten randomized controlled trials with a total of 4140 patients were included. 2166 (52.32%) patients were enrolled in the tenecteplase group and 1974 (47.68%) in the alteplase group. Tenecteplase at 0.25 mg/kg dose demonstrated significant improvement in excellent functional outcome at 3 months (RR 1.14, 95% CI 1.04-1.26), and early neurological improvement (RR 1.53, 95% CI 1.03-2.26). There was no statistically significant difference between tenecteplase and alteplase in terms of good functional outcome, intracerebral hemorrhage (ICH), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality at any dose. Meta-regression demonstrated superior tenecteplase efficacy with increasing stroke severity, however, the results were statistically nonsignificant. CONCLUSIONS Tenecteplase at 0.25 mg/kg dose is more efficacious and at least as safe as alteplase for stroke thrombolysis. Newer analyses need to focus on direct comparison of tenecteplase doses and whether tenecteplase is efficacious at longer needle times.
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Affiliation(s)
- Aqeeb Ur Rehman
- Department of Neurology, King Edward Medical University, Lahore, Pakistan
| | - Aleenah Mohsin
- Department of Neurology, King Edward Medical University, Lahore, Pakistan
| | | | - Afra Zahid
- Department of Neurology, King Edward Medical University, Lahore, Pakistan
| | | | | | - Muhammad Ayyan
- Department of Neurology, King Edward Medical University, Lahore, Pakistan
| | - Muhammad Ehsan
- Department of Neurology, King Edward Medical University, Lahore, Pakistan
| | - Abia Shahid
- Department of Neurology, King Edward Medical University, Lahore, Pakistan.
| | - Muhammad Aemaz Ur Rehman
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jaffer Shah
- New York State Department of Health, Albany, NY, USA
| | - Ayaz Khawaja
- Department of Neurology, Wayne State University-Detroit Medical Center, Detroit, MI, USA
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Abuelazm M, Seri AR, Awad AK, Ahmad U, Mahmoud A, Albazee E, Kambalapalli S, Abdelazeem B. The efficacy and safety of tenecteplase versus alteplase for acute ischemic stroke: an updated systematic review, pairwise, and network meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2023; 55:322-38. [PMID: 36449231 DOI: 10.1007/s11239-022-02730-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 12/05/2022]
Abstract
Tenecteplase (TNK) is a promising candidate to replace alteplase as the standard of care for acute ischemic stroke (AIS); however, the optimal dosage is still to be investigated. Therefore, we aim to evaluate the safety and efficacy of TNK versus alteplase and to investigate the optimal TNK dosage. A systematic review, pairwise, and network meta-analysis synthesizing randomized controlled trials (RCTs) from WOS, SCOPUS, EMBASE, and PubMed until July 26th, 2022. We used the risk ratio (RR) for dichotomous outcomes presented with the corresponding 95% confidence interval (CI). We registered our protocol in PROSPERO with ID: CRD42022352038. Nine RCTs with a total of 3,707 patients were included. TNK significantly led to complete recanalization (RR: 1.27 with 95% CI [1.02, 1.57], P = 0.03); however, we found no difference regarding early neurological improvement (RR: 1.07 with 95% CI [0.94, 1.21], P = 0.33) and excellent neurological recovery (RR: 1.03 with 95% CI [0.96, 1.10], P = 0.42). Also, TNK was similar to alteplase regarding mortality (RR: 0.99 with 95% CI [0.82, 1.18], P = 0.88), intracranial haemorrhage (RR: 1.00 with 95% CI [0.85, 1.18], P = 0.99), and parenchymal hematoma (RR: 1.13 with 95% CI [0.83, 1.54], P = 0.44). TNK in the dose of 0.25 mg is a viable candidate to displace alteplase as the standard of care in patients with an AIS within 4.5 h of presentation due to its better rate of early neurological recovery and non-inferiority in terms of safety outcomes. However, the evidence regarding TNK's role in AIS presenting after 4.5 h from symptoms onset, wake-up stroke, and minor stroke/TIA is still lacking, necessitating further double-blinded pragmatic RCTs in this regard.
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Qureshi AI, Baskett WI, Bains NK, French BR, Siddiq F, Gomez CR, Shyu CR. Outcomes with IV tenecteplase and IV alteplase for acute ischemic stroke with or without thrombectomy in real-world settings in the United States. J Stroke Cerebrovasc Dis 2023; 32:106898. [PMID: 36493706 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106898] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 10/20/2022] [Accepted: 11/10/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Although many stroke centers in United States are using intravenous (IV) tenecteplase (TNK) for acute ischemic stroke patients, there is paucity of comparative data between IV TNK and IV alteplase from real-world settings. MATERIALS AND METHODS We analyzed the data from 122 healthcare facilities in Cerner Real World Data and included patients admitted between February 2016 to April 2022 to determine the effect of IV TNK (compared with IV alteplase) on occurrence of two outcomes in acute ischemic stroke patients stratified by use of thrombectomy: non-routine discharge or death, and intracranial hemorrhage after adjusting for potential confounders. RESULTS Among 30,643 acute ischemic stroke patients analyzed, 29,480 (96.2%) and 1,163 (3.8%) patients received IV alteplase and IV TNK, respectively. The proportion of patients who received thrombectomy was significantly higher among patients who received IV TNK compared with those who received IV alteplase (16.7% versus 11.0%, p<0.001). Occurrence of intracranial hemorrhage was more common among patients treated with IV TNK in acute ischemic stroke patients who did not receive thrombectomy (7.9% versus 5.1%, p<0.001) but not in those who received thrombectomy (20.1% versus 16.8%, p = 0.234). In the logistic regression analysis, patients treated with IV TNK who did not receive thrombectomy were at higher risk of intracranial hemorrhage (OR, 1.34, 95% CI 1.05-1.72, p = 0.02) after adjusting for age (age strata), gender, race/ethnicity, hypertension, diabetes mellitus, atrial fibrillation, hyperlipidemia, malignancy, nicotine dependence, previous ischemic stroke, previous transient ischemic attack, previous intracerebral hemorrhage, previous subarachnoid hemorrhage, previous acute myocardial infarction, atherosclerosis of aorta, previous AKI, congestive heart failure, peripheral vascular disease, and hospital type, aphasia, hemiplegia, neglect, somnolence, stupor and coma, dysphagia, and homonymous hemianopsia. There was no difference in the rate of non-routine discharge or death between patients treated with IV TNK and those treated with IV alteplase in the multivariate analyses. CONCLUSIONS In an analysis of real-world data, IV TNK was associated with higher rates of intracranial hemorrhage compared with IV alteplase in patients with acute ischemic stroke who did not undergo thrombectomy.
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Alhadid K, Oliveira L, Etherton MR. Intravenous Thrombolytics in the Treatment of Acute Ischemic Stroke. Curr Treat Options Cardiovasc Med 2023; 25:15-28. [PMID: 36618509 PMCID: PMC9807245 DOI: 10.1007/s11936-022-00973-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 01/03/2023]
Abstract
Purpose of Review To review the current evidence and ongoing clinical trials evaluating the efficacy and safety of tenecteplase (TNK), an alternative tissue plasminogen activator (tPA), in the acute management of arterial ischemic stroke (AIS). To date, alteplase is the only tPA approved by the United States FDA for use in AIS. Recent Findings There have been multiple phase two and three trials investigating the safety and efficacy of TNK in AIS. In patients with AIS due to large vessel occlusion, one randomized controlled trial demonstrated superiority of TNK for vessel recanalization rates and long-term functional outcomes when compared to alteplase. A meta-analysis of all phase two and three trials evaluating TNK in AIS concluded that TNK has a comparable safety and efficacy profile to alteplase. The results of these trials prompted new recommendations in the Acute Stroke Guideline published by the AHA suggesting it may be reasonable to use as an alternative to alteplase. Furthermore, recent real-world data has also reported decreased door-to-needle time with TNK utilization. Summary In patients with AIS, use of a thrombolytic agent is standard of care and has been shown to reduce neurological disability and improve functional outcome. Randomized controlled trials have demonstrated that TNK is non-inferior to alteplase from a clinical outcome and safety standpoint. The existing data evaluating the efficacy of TNK compared to alteplase in acute AIS within 4.5 h from symptom onset showed no significant difference between these two agents with regard to functional outcome at 90 days but improved median time to treatment and large vessel recanalization in TNK-treated patients. The results from ongoing TNK trials in larger patient cohorts and in wake-up stroke populations will be instrumental to the wide-scale utilization of TNK in acute AIS management.
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Affiliation(s)
- Kenda Alhadid
- JPK Stroke Research Center, Department of Neurology, Massachusetts General Hospital (MGH) and Harvard Medical School, Suite 300, 175 Cambridge Street, Boston, MA 02114 USA
| | - Lara Oliveira
- JPK Stroke Research Center, Department of Neurology, Massachusetts General Hospital (MGH) and Harvard Medical School, Suite 300, 175 Cambridge Street, Boston, MA 02114 USA
| | - Mark R. Etherton
- JPK Stroke Research Center, Department of Neurology, Massachusetts General Hospital (MGH) and Harvard Medical School, Suite 300, 175 Cambridge Street, Boston, MA 02114 USA
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Singh N, Menon BK, Dmytriw AA, Regenhardt RW, Hirsch JA, Ganesh A. Replacing Alteplase with Tenecteplase: Is the Time Ripe? J Stroke 2023; 25:72-80. [PMID: 36746381 PMCID: PMC9911848 DOI: 10.5853/jos.2022.02880] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/15/2022] [Indexed: 02/04/2023] Open
Abstract
Thrombolysis for acute ischemic stroke has predominantly been with alteplase for over a quarter of a century. In recent years, with trials showing evidence of higher rates of successful reperfusion, similar safety profile and efficacy of tenecteplase (TNK) as compared to alteplase, TNK has now emerged as another potential choice for thrombolysis in acute ischemic stroke. In this review, we will focus on these recent advances, aiming: (1) to provide a brief overview of thrombolysis in stroke; (2) to provide comparisons between alteplase and TNK for clinical, imaging, and safety outcomes; (3) to focus on key subgroups of interest to understand if there is an advantage of using TNK over alteplase or vice-versa, to review available evidence on role of TNK in intra-arterial thrombolysis, as bridging therapy and in mobile stroke units; and (4) to summarize what to expect in the near future from recently completed trials and propose areas for future research on this evolving topic. We present compelling data from several trials regarding the safety and efficacy of TNK in acute ischemic stroke along with completed yet unpublished trials that will help provide insight into these unanswered questions.
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Affiliation(s)
- Nishita Singh
- Calgary Stroke Program, Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, and the Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada,Department of Internal Medicine-Neurology Division, Health Sciences Center, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Bijoy K. Menon
- Calgary Stroke Program, Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, and the Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Adam A. Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA,Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W. Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Joshua A. Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aravind Ganesh
- Calgary Stroke Program, Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, and the Hotchkiss Brain Institute, University of Calgary Cumming School of Medicine, Calgary, AB, Canada,Correspondence: Aravind Ganesh Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, HMRB 103, Heritage Medical Research Building, 3280 Hospital Dr. NW, Calgary, Alberta T2N 4Z6, Canada Tel: +1-403-220-3747 E-mail:
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Koh HP, Md Redzuan A, Mohd Saffian S, Nagarajah JR, Ross NT, Hassan H. Clinical profile and predictors of 30-day all-cause mortality of ST-elevation myocardial infarction (STEMI) patients receiving fibrinolytic therapy in an Asian population. Heart Lung 2022; 55:68-76. [PMID: 35489205 DOI: 10.1016/j.hrtlng.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Fibrinolysis remains the primary reperfusion strategy for ST-elevation myocardial infarction (STEMI) in many Asian countries. The outcomes and factors affecting mortality in STEMI fibrinolysis in the Asian population are lacking despite being widely used. OBJECTIVES This study aimed to assess the clinical profile of patients and predictors affecting STEMI mortality in an Asian population. METHODS This single-center retrospective study analyzed data from STEMI patients who received fibrinolytic therapy from 2016 to 2020 in a tertiary hospital. Logistic regression analysis was performed to identify the significant predictors of the 30-day all-cause mortality, the primary outcome. RESULTS A total of 859 patients were included. Their mean age was 53.6 ±12.1 years and they were predominantly male (n=769, 89.4%). The majority of them had anterior involvement STEMI (n = 477, 55.5%) and presented with Killip ≥ II (n = 424, 49.4%). The 30-day all-cause mortality was 12.0% (n = 103). The final model found six predictors for 30-day mortality: age ≥75 (aOR 4.784, p < 0.001), female gender (aOR 2.869, p = 0.001), pre-existing hypertension (aOR 1.623, p = 0.046), anterior myocardial infarction (MI) (aOR 1.947, p < 0.001), Killip class (p < 0.001) and heart rate ≥100 at presentation (aOR 1.823, p = 0.016). Following fibrinolytic therapy, five predictors were found to affect 30-day mortality, i.e. failed fibrinolysis (aOR 2.094, p = 0.041), bleeding events, congestive heart failure (aOR 3.554, p = 0.046), ventricular fibrillation/ tachycardia (aOR 5.920, p < 0.001), and atrial fibrillation/ flutter (aOR 2.968, p = 0.016). CONCLUSION Our STEMI patients were younger and more ill at presentation. The risk predictors on 30-day all-cause mortality identified in our Asian population allow the clinicians to better triage and manage STEMI patients.
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Trerayapiwat K, Jinatongthai P, Vathesatogkit P, Sritara P, Paengsai N, Dilokthornsakul P, Nathisuwan S, Le LM, Chaiyakunapruk N. Using real world evidence to generate cost-effectiveness analysis of fibrinolytic therapy in patients with ST-segment elevation myocardial infarction in Thailand. Lancet Reg Health West Pac 2022; 26:100503. [PMID: 35789828 PMCID: PMC9250039 DOI: 10.1016/j.lanwpc.2022.100503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Due to limited access to primary percutaneous coronary intervention for the management of ST-segment elevation myocardial infarction (STEMI) in low-to-middle-income countries (LMICs), fibrinolysis serves as a vital alternative reperfusion therapy. Among fibrinolytic agents, the cost-effectiveness of tenecteplase (TNK) in LMICs as compared to streptokinase (SK) for STEMI management remains unknown. METHODS Cost-effectiveness was analyzed using a hybrid model consisting of short-term analysis (30-days decision tree model) and long-term analysis (Markov model). Both health care provider and societal perspectives over a lifetime horizon with 3% discount rate were considered. Input parameters were obtained from Thailand's national health database, a network meta-analysis and literature review. Outcome measure was an incremental cost-effectiveness ratio (ICER) determined by an incremental cost per quality-adjusted life years (QALY) gain. An ICER of less than $5,590 per QALY gain is considered cost-effective. Series of sensitivity analyses were also performed. FINDINGS From the societal perspective, TNK increases cost by $827 and increases QALY by 0·173. Thus, the ICER is $4,777 per QALY gained. Similarly, the ICER from health care provider perspective is $4,664 per QALY gained. In the probabilistic sensitivity analysis, using 5,590 USD per QALY as threshold, the probability of TNK being cost-effective was 83% from both perspectives. The most influential parameters were risk ratio of death for treatment with TNK compared to SK and drug cost of TNK. INTERPRETATION In a resource-limited country like Thailand, tenecteplase is a cost-effective fibrinolytic drug for treatment of STEMI compared to streptokinase. FUNDING None.
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Affiliation(s)
- Krittimeth Trerayapiwat
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Peerawat Jinatongthai
- Pharmacy practice division, Faculty of Pharmaceutical Sciences, Ubon Ratchathani University, Ubon Ratchathani, Thailand
| | - Prin Vathesatogkit
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Piyamitr Sritara
- Department of Medicine, Faculty of Medicine, Ramathibodi hospital, Mahidol University, Bangkok, Thailand
| | - Ninutcha Paengsai
- National Health Security Office (NHSO), Fund Management Unit, Bangkok, Thailand
| | - Piyameth Dilokthornsakul
- Center for Medical and Health Technology Assessment (CM-HTA), Department of Pharmaceutical Care, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Surakit Nathisuwan
- Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Lan My Le
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah, United States of America
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Teivane A, Jurjāns K, Vētra J, Grigorjeva J, Kupcs K, Masiliūnas R, Miglāne E. Tenecteplase or Alteplase Better in Patients with Acute Ischemic Stroke Due to Large Vessel Occlusion: A Single Center Observational Study. Medicina (Kaunas) 2022; 58:1169. [PMID: 36143846 DOI: 10.3390/medicina58091169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 11/23/2022]
Abstract
Background and Objectives: The study aimed to investigate the efficacy of intravenous thrombolysis with Tenecteplase before thrombectomy for acute ischemic stroke (AIS) patients compared with previous results using Alteplase. Previous trials for Tenecteplase have indicated an increased incidence of vascular reperfusion. In April 2021, we started to primarily give Tenecteplase to patients eligible to undergo thrombectomy. Materials and Methods: In this retrospective observational single-center non-randomized study, we analyzed directly admitted patients with AIS who had occlusion of the internal carotid, middle cerebral, or basilar artery and who underwent thrombectomy, as well as the recanalization rate for these patients at the first angiographic assessment (mTICI score 2b–3), and complications. Results: We included 184 patients (demographic characteristics did not differ between Tenecteplase and Alteplase groups (mean age 68.4 vs. 73.0 years; female sex 53.3% vs. 51.1%, NIHSS 14 (IQR 4–26) vs. 15 (2–31). Forty-five patients received Tenecteplase and 139 Alteplase before endovascular treatment (EVT). Pre-EVT (endovascular treatment) recanalization was more likely to occur with Tenecteplase rather than Alteplase (22.2% vs. 8.6%, p = 0.02). Successful reperfusion (mTICI 2b–3) after EVT was achieved in 155 patients (42 (93.4%) vs. 113 (81.3), p = 0.07). Hemorrhagic imbibition occurred in 15 (33.3%) Tenecteplase-treated patients compared with 39 (28.1%) Alteplase-treated patients (p = 0.5). Patients treated with Tenecteplase had higher odds of excellent functional outcome than Alteplase-treated patients (Tenecteplase 48.6% vs. Alteplase 26.1%; OR 0.37 (95% CI 0.17–0.81), p = 0.01). Conclusions: Tenecteplase (25 mg/kg) could have superior clinical efficacy over Alteplase for AIS patients with large-vessel occlusion (LVO), administered before EVT. The improvement in reperfusion rate and the better excellent functional outcome could come without an increased safety concern.
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Koh HP, Md Redzuan A, Mohd Saffian S, R Nagarajah J, Ross NT, Hassan H. Impact of COVID-19 pandemic on STEMI thrombolysis and Emergency Department's performance in a non-PCI capable tertiary hospital. Am J Emerg Med 2022; 60:9-14. [PMID: 35872375 DOI: 10.1016/j.ajem.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/07/2022] [Accepted: 07/09/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Some guidelines had recommended “thrombolysis first” in ST-elevated myocardial infarction (STEMI) during the Coronavirus Disease 2019 (COVID-19) outbreak. The impact of COVID-19 solely on STEMI thrombolysis is lacking as most studies reported outcomes related to percutaneous coronary intervention (PCI) setting. Thus, this study aimed to assess the impact of the COVID-19 pandemic on STEMI thrombolysis outcomes and the Emergency Department's performance in a non-PCI capable centre. Methods This single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays. Results and discussion We analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02–4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic. Conclusion STEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis.
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Ma P, Zhang Y, Chang L, Li X, Diao Y, Chang H, Hui L. Tenecteplase vs. alteplase for the treatment of patients with acute ischemic stroke: a systematic review and meta-analysis. J Neurol 2022. [PMID: 35776193 DOI: 10.1007/s00415-022-11242-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND At present, studies regarding the efficacy and safety of tenecteplase for the treatment of patients with acute ischemic stroke (AIS) are still limited and inconsistent. The purpose of this systematic review and meta-analysis is to compare the efficacy and safety of tenecteplase with alteplase for the treatment of AIS patients. METHODS Literature search was conducted in PubMed, Embase, and Cochrane Library up to May 10, 2022. Primary outcomes of this study included 90-day good outcome (defined as an mRS score of 0-2) and 90-day excellent outcome (defined as an mRS score of 0-1). Risk ratios (RRs) with 95% confidence intervals (95% CIs) were calculated using a random-effect model for each outcome. RESULTS Fourteen studies with a total of 3537 patients were finally included in this meta-analysis. There was no statistical difference between patients receiving tenecteplase and those receiving alteplase in the rates of 90-day good outcome (RR 1.01; 95% CI 0.91-1.13; P = 0.79) and 90-day excellent outcome (RR 1.04; 95% CI 0.92-1.19; P = 0.50). Patients receiving tenecteplase might associated with higher incidence of early neurologic improvement compared with those receiving alteplase (RR 1.29; 95% CI 1.04-1.61; P = 0.02). In addition, no statistical difference was observed between the two groups in other outcomes. CONCLUSION This meta-analysis indicated that tenecteplase in AIS patients is as safe and effective as alteplase and might provide more benefit than alteplase. However, due to several inherent limitations of this study, more prospective studies should be conducted to confirm the above results.
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Eltoft A, Wilsgaard T, Roaldsen MB, Søyland MH, Lundström E, Petersson J, Indredavik B, Putaala J, Christensen H, Kõrv J, Jatužis D, Engelter ST, De Marchis GM, Werring DJ, Robinson T, Tveiten A, Mathiesen EB. Statistical analysis plan for the randomized controlled trial Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST). Trials 2022; 23:421. [PMID: 35590386 PMCID: PMC9118782 DOI: 10.1186/s13063-022-06301-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with wake-up ischemic stroke are frequently excluded from thrombolytic treatment due to unknown symptom onset time and limited availability of advanced imaging modalities. The Tenecteplase in Wake-up Ischaemic Stroke Trial (TWIST) is a randomized controlled trial of intravenous tenecteplase 0.25 mg/kg and standard care versus standard care alone (no thrombolysis) in patients who wake up with acute ischemic stroke and can be treated within 4.5 h of wakening based on non-contrast CT findings. OBJECTIVE To publish the detailed statistical analysis plan for TWIST prior to unblinding. METHODS The TWIST statistical analysis plan is consistent with the Consolidating Standard of Reporting Trials (CONSORT) statement and provides clear and open reporting. DISCUSSION Publication of the statistical analysis plan serves to reduce potential trial reporting bias and clearly outlines the pre-specified analyses. TRIAL REGISTRATION ClinicalTrials.gov NCT03181360 . EudraCT Number 2014-000096-80 . WHO ICRTP registry number ISRCTN10601890 .
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Affiliation(s)
- Agnethe Eltoft
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway. .,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Melinda B Roaldsen
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Clinical Research, University Hospital of North Norway, Tromsø, Norway
| | - Mary-Helen Søyland
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Neurology, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Erik Lundström
- Department of Neuroscience, Neurology, Uppsala University, Uppsala, Sweden
| | - Jesper Petersson
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
| | - Bent Indredavik
- Department of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu and Tartu University Hospital, Tartu, Estonia
| | - Dalius Jatužis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Stefan T Engelter
- Department of Neurology, University Hospital of Basel and University of Basel, Basel, Switzerland.,Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital of Basel and University of Basel, Basel, Switzerland
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Thompson Robinson
- College of Life Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Arnstein Tveiten
- Department of Neurology, Sorlandet Hospital Kristiansand, Kristiansand, Norway
| | - Ellisiv B Mathiesen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Meloni BP, Blacker DJ, Edwards AB, Knuckey NW. Impact of poly-arginine peptides R18D and R18 on alteplase and tenecteplase thrombolysis in vitro, and neuroprotective stability to proteolysis. J Thromb Thrombolysis 2022. [PMID: 35305237 DOI: 10.1007/s11239-022-02642-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2022] [Indexed: 10/26/2022]
Abstract
The poly-arginine peptides R18D and R18 represent novel potential neuroprotective treatments for acute ischaemic stroke. Here we examined whether R18D and R18 had any significant effects on the thrombolytic activity of alteplase (tPA) and tenecteplase (TNK) on clots formed from whole blood in an in vitro thrombolysis plate assay. R18D and R18 were examined at concentrations of 0.25, 0.5, 1, 2, 4, 8 and 16 µM during the 1-h thrombolytic assay. We also included the well-characterised neuroprotective NA-1 peptide as a control. R18D, R18 and NA-1 all reduced tPA or TNK percentage clot lysis by 0-9.35%, 0-3.44% and 0-4.8%, respectively. R18D, R18 and NA-1 had a modest and variable effect on the lag time, increasing the time to the commencement of thrombolysis by 0-9.9 min, 0-5.53 min and 0-7.16 min, respectively. Lastly, R18 and NA-1 appeared to increase the maximal activity of the thrombolysis reaction. In addition, the in vitro anti-excitotoxic neuroprotective efficacy of R18D and R18 was not affected by pre-incubation for 1-2 h or overnight with tPA or TNK, whereas only R18D retained high anti-excitotoxic neuroprotective efficacy when pre-incubated in a synthetic trypsin (TrypLE Express). The present in vitro findings suggest that neither R18D or R18 when co-administered with the thrombolytic inducing agents tPA or TNK are likely to have a significant impact when used clinically during clot thrombolysis and confirm the superior proteolytic stability of the R18D peptide.
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Koh HP, Md Redzuan A, Mohd Saffian S, Nagarajah JR, Ross NT, Hassan H. The outcomes of reperfusion therapy with streptokinase versus tenecteplase in ST-elevation myocardial infarction (STEMI): a propensity-matched retrospective analysis in an Asian population. Int J Clin Pharm 2022; 44:641-650. [PMID: 35243572 DOI: 10.1007/s11096-022-01383-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
Abstract
Background Fibrinolysis using streptokinase or tenecteplase remains the primary reperfusion strategy for ST-elevation myocardial infarction (STEMI) in many Asian countries, including Malaysia. Comparative outcomes of these two fibrinolytic agents in the Asian population were inconclusive despite being widely used. Aim We aimed to assess and compare the outcomes of streptokinase versus tenecteplase in STEMI reperfusion of an Asian population. Method This single-centre retrospective study analysed data on STEMI patients who received fibrinolytic therapy from 2016 to 2020 in the Emergency Department of the largest tertiary hospital in Malaysia. Total population sampling was used in this study. Based on the propensity score matching, 359 patients receiving streptokinase were matched against 359 patients receiving tenecteplase by incorporating 16 variables that potentially affect mortality. 30-day mortality, stroke and major bleeding were the primary outcome measures. Results There was no significant difference in 30-day mortality between streptokinase (n = 39, 11.2%) and tenecteplase (n = 46, 13.2%) groups (p = 0.418). The rates of ischemic strokes [streptokinase (n = 1, 0.3%) versus tenecteplase (n = 3, 0.9%), p = 0.624], intracranial haemorrhage [streptokinase (n = 3, 0.9%) versus tenecteplase (n = 1, 0.3%), p = 0.624] and major bleeding [streptokinase (n = 4, 1.1%) versus tenecteplase (n = 3, 0.9%), p = 0.624], were comparable for the two groups. The incidences of failed thrombolysis were significantly higher in the tenecteplase arm. Hypotension and allergic reaction were significantly higher in the streptokinase arm. Conclusion Streptokinase and tenecteplase are fibrinolytic agents with similar efficacy and safety in STEMI reperfusion therapy in our Asian population.
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Affiliation(s)
- Hock Peng Koh
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur Campus, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Adyani Md Redzuan
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur Campus, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia.
| | - Shamin Mohd Saffian
- Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Kuala Lumpur Campus, Jalan Raja Muda Abdul Aziz, 50300, Kuala Lumpur, Malaysia
| | - Jivanraj R Nagarajah
- Pharmacy Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Noel Thomas Ross
- Medical Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
| | - Hasnita Hassan
- Emergency and Trauma Department, Hospital Kuala Lumpur, Ministry of Health Malaysia, Kuala Lumpur, Malaysia
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Nepal G. Low-cost alternatives for the management of acute ischemic stroke in low and middle-income countries. Ann Med Surg (Lond) 2021; 72:102969. [PMID: 34992776 PMCID: PMC8712992 DOI: 10.1016/j.amsu.2021.102969] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/16/2021] [Accepted: 10/16/2021] [Indexed: 11/20/2022] Open
Abstract
Acute ischemic stroke (AIS) patients arriving within a suitable time frame are treated with recanalization therapy i.e. intravenous thrombolysis (IVT) with alteplase and/or mechanical thrombectomy (MT). IVT with alteplase is indicated in AIS patients presenting within 4.5 hours of onset regardless of vascular territory involved. MT is indicated in AIS patients presenting within 24 hours of onset with large vessel occlusion in the anterior circulation. However, MT is ludicrously expensive and requires exorbitant setup, devices, and expertise which is not currently feasible in LMICs. Therefore, in LMICs the only feasible recanalization option left for AIS patients is IVT. The cost of IVT varies across the LMICs, however, most of them cost around 2000-5000 USD. Apart from IVT, patients with AIS often have other significant medical costs including those for neuroimaging, intensive care, and prolonged rehabilitative treatment. In LMICs, these costs can only be afforded by a handful of patients. The majority of the LMICs have health insurance in their infancy and family members of AIS patients opt-out IVT due to the economic burden. In general, the current treatment guidelines for AIS are not very useful in LMICs because of cost-related issues among several other factors. In this editorial, we discuss evidence for alternative treatment strategies that can help tackle the rising epidemic of AIS in poor countries by improvising on existing clinical guidelines and seeking alternative treatment regimens.
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Affiliation(s)
- Gaurav Nepal
- Department of Internal Medicine, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, 44600, Nepal
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Chua KW, Muthuvadivelu S, Abdul Rani R, Ong SC, Hussin N, Cheah WK. Evaluation of the tolerability and effectiveness of Tenecteplase in patients with ST-Segment-Elevation Myocardial Infarction in a Secondary Hospital in Malaysia: A Retrospective Case Series. Curr Ther Res Clin Exp 2021; 95:100641. [PMID: 34539939 PMCID: PMC8435912 DOI: 10.1016/j.curtheres.2021.100641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 08/04/2021] [Accepted: 08/15/2021] [Indexed: 12/02/2022] Open
Abstract
Background In Malaysia, knowledge regarding the clinical efficacy of tenecteplase (TNK), a fibrin-specific tissue-plasminogen activator, is limited. Objectives To evaluate the effectiveness and tolerability of TNK in patients with ST-segment-elevation myocardial infarction in a secondary referral Malaysian hospital. Methods This was a single-center retrospective case series based on the medical records of patients with ST-segment-elevation myocardial infarction admitted to the cardiac care unit between January 2016 and May 2019. Data regarding the mortality status and date of death were collected from the database of the National Registration Department of Malaysia. Results Data for 30 patients with ST-segment-elevation myocardial infarction, who received weight-adjusted doses of TNK, were analyzed. The patients’ mean (SD) age was 62 (14) years, and 77% were men. The median time to treatment was 265 minutes (interquartile range = 228–660 minutes), and the clinical success rate of thrombolysis was 79%. The overall all-cause in-hospital mortality rate was 33%. The 1-year survival rates were higher in patients achieving a time to treatment ≤360 minutes (P = 0.03), with a trend toward greater survival in this group at 30 days. Similarly, a trend toward lower in-hospital all-cause mortality was observed in this group (21% vs 50%; P = 0.12). Only 1 patient (3%), who had a HAS-BLED score based on hypertension, abnormal liver/renal function, stroke history, bleeding history or predisposition, labile international normalized ratio, old age, drug/alcohol use of 5, developed major bleeding that required blood transfusion. No cases of ischemic stroke, nonmajor bleeding, in-hospital reinfarction, or TNK-induced allergic reaction were identified. Conclusions We hypothesized that the mortality-related outcomes of TNK in patients with ST-segment-elevation myocardial infarction were influenced by TTT, with TTT ≤360 minutes indicating a better prognosis than TTT >360 minutes. TNK-induced bleeding-related complications were minimal in low-risk patients. Further local studies are needed to compare TNK's profile with that of streptokinase, which is a common agent currently used in clinical practice in Malaysian public hospitals. (Curr Ther Res Clin Exp. 2021; 82:XXX–XXX)
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Affiliation(s)
- Kin Wei Chua
- Clinical Research Centre, Hospital Taiping, Ministry of Health Malaysia, Perak, Malaysia
| | - Sreevali Muthuvadivelu
- Clinical Research Centre, Hospital Taiping, Ministry of Health Malaysia, Perak, Malaysia
| | - Rosilawati Abdul Rani
- Clinical Research Centre, Hospital Taiping, Ministry of Health Malaysia, Perak, Malaysia
| | - Siew Chin Ong
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Narwani Hussin
- Clinical Research Centre, Hospital Taiping, Ministry of Health Malaysia, Perak, Malaysia
| | - Wee Kooi Cheah
- Clinical Research Centre, Hospital Taiping, Ministry of Health Malaysia, Perak, Malaysia.,Department of Medicine, Hospital Taiping, Ministry of Health Malaysia, Perak, Malaysia
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George M, Baby N, Paul R, Zabeer M, Thomas C. Comparison of thrombolytic agents in treatment of patients with acute ischemic stroke; findings from a single centre follow up study in real-life settings. J Clin Neurosci 2021; 91:299-305. [PMID: 34373043 DOI: 10.1016/j.jocn.2021.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/30/2021] [Accepted: 07/04/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Health outcome data of thrombolysis in patients with acute ischemic stroke in real life-settings in India are scarce. We studied the clinical profile, risk factors and functional outcome of patients with acute ischemic stroke (AIS) who were thrombolysed. METHODS In a single centre retrospective study from January 2017 to June 2020, we analysed the data of adult patients with AIS presented within 4.5 h of symptom onset. We included patients if they had NIHSS score ≥4, modified Rankin score of 2 or less before the stroke onset and without evidence of haemorrhage. Modified Rankin score of two or less at the end of three months was defined as the primary efficacy outcome. The development of symptomatic intracerebral haemorrhage was considered as the primary safety outcome. We tried to analyse the primary safety and efficacy outcomes between two thrombolytic agents. RESULTS Ninety patients (Tenecteplase = 61; Alteplase, n = 29) underwent stroke thrombolysis during the study period. The mean age was 64.3 years in Tenecteplase group and 63.2 years in Alteplase group. Twenty patients were aged more than 75 years. Hypertension was the most common comorbidity in both the groups (72% and 72.4%). Median mRS score at 3-months was 1 in Tenecteplase group and 0.5 in Alteplase group (p < 0.001), however there was no statistically significant difference between both treatment groups in terms of NIHS score at 24 h (70.4% vs 51.7%, p = 0.08), functional recovery calculated with mRS at 3-month (83.6% vs 79.3%, p = 0.62) or in terms of symptomatic ICH (9.8% and 17.2% p = 0.36). CONCLUSION Tenecteplase appears to have similar clinical outcomes as Alteplase for stroke thrombolysis. Given the relatively low-cost and ease of administration, Tenecteplase may be better than Alteplase for management of acute ischemic stroke.
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Bahadori M, Mowla A. Re: Tenecteplase for thrombolysis in stroke patients: Systematic review with meta-analysis. Am J Emerg Med 2021; 55:185-186. [PMID: 34116894 PMCID: PMC9010854 DOI: 10.1016/j.ajem.2021.05.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 05/29/2021] [Indexed: 11/23/2022] Open
Affiliation(s)
- Maryam Bahadori
- Glenn Biggs Institute for Alzheimer's and Neurodegenerative Diseases, University of Texas Health Science Center at San Antonio, San Antonio, TX, United States of America
| | - Ashkan Mowla
- Division of Stroke Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, United States of America.
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Kiran GR, Chandrasekhar P, Mohammad Ali S. Clinical outcomes of patients with mitral prosthetic valve obstructive thrombosis treated with streptokinase or tenecteplase. Indian Heart J 2021; 73:365-8. [PMID: 34154758 DOI: 10.1016/j.ihj.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/04/2021] [Accepted: 02/14/2021] [Indexed: 11/23/2022] Open
Abstract
Agent of choice for thrombolytic therapy (TT) in prosthetic valve thrombosis (PVT) is unknown. 84 mitral obstructive-PVT episodes treated with TT (43: Tenecteplase; 41: Streptokinase) were included in this prospective study. The incidence of primary end-point (CCS: complete clinical success, defined as complete or partial hemodynamic success with no complications or surgery) was 84.5% with recurrent PVT as a sole predictor. Bleeding and embolic manifestations were noted in 8.3% and 4.7% of episodes respectively. Tenecteplase use was associated with lower complication rate and a mitral EOA of <0.74 cm2 at presentation predicts the need for extended thrombolysis (accuracy, 78.6%).
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Roaldsen MB, Lindekleiv H, Eltoft A, Jusufovic M, Søyland MH, Petersson J, Indredavik B, Tveiten A, Putaala J, Christensen H, Kõrv J, Jatužis D, Engelter ST, Marco De Marchis G, Wilsgaard T, Werring DJ, Robinson T, Mathiesen EB, Berge E. Tenecteplase in wake-up ischemic stroke trial: Protocol for a randomized-controlled trial. Int J Stroke 2021; 16:990-994. [PMID: 33446083 PMCID: PMC8554491 DOI: 10.1177/1747493020984073] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with wake-up ischemic stroke who have evidence of salvageable tissue on advanced imaging can benefit from intravenous thrombolysis. It is not known whether patients who do not fulfil such imaging criteria might benefit from treatment, but studies indicate that treatment based on non-contrast CT criteria may be safe. Tenecteplase has shown promising results in patients with acute ischemic stroke. The aim of the Tenecteplase in Wake-up Ischemic Stroke Trial (TWIST) is to compare the effect of thrombolytic treatment with tenecteplase and standard care versus standard care alone in patients with wake-up ischemic stroke selected by non-contrast CT. METHODS/DESIGN TWIST is an international, investigator-initiated, multi-centre, prospective, randomized-controlled, open-label, blinded end-point trial of tenecteplase (n = 300) versus standard care (n = 300) in patients who wake up with an acute ischemic stroke and can be treated within 4.5 h upon awakening. Seventy-seven centres in 10 countries (Denmark, Estonia, Finland, Latvia, Lithuania, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom) participate. The primary outcome is the modified Rankin Scale on the ordinal scale (0-6) at three months. DISCUSSION TWIST aims to determine the effect and safety of thrombolytic treatment with tenecteplase in patients with wake-up ischemic stroke selected by non-contrast CT. TRIAL REGISTRATION ClinicalTrials.gov NCT03181360. EudraCT Number 2014-000096-80.
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Affiliation(s)
- Melinda B Roaldsen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Haakon Lindekleiv
- Quality and Development Centre, University Hospital of North Norway, Tromsø, Norway
| | - Agnethe Eltoft
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Mirza Jusufovic
- Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Mary-Helen Søyland
- Department of Neurology, Hospital of Southern Norway, Kristiansand, Norway
| | - Jesper Petersson
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
| | - Bent Indredavik
- Department of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Arnstein Tveiten
- Department of Neurology, Hospital of Southern Norway, Kristiansand, Norway
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanne Christensen
- Department of Neurology, Bispebjerg Hospital and University of Copenhagen, Copenhagen, Denmark
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu and Tartu University Hospital, Tartu, Estonia
| | - Dalius Jatužis
- Department of Neurology and Neurosurgery, Center for Neurology, Vilnius University, Vilnius, Lithuania
| | - Stefan T Engelter
- Department of Neurology, University Hospital of Basel and University of Basel, Basel, Switzerland.,Department of Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Switzerland
| | - Gian Marco De Marchis
- Department of Neurology, University Hospital of Basel and University of Basel, Basel, Switzerland
| | - Tom Wilsgaard
- Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, UK
| | - Thompson Robinson
- Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ellisiv B Mathiesen
- Department of Neurology, University Hospital of North Norway, Tromsø, Norway.,Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
| | - Eivind Berge
- Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Department of Internal Medicine, Oslo University Hospital, Oslo, Norway
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Ahmed HK, Logallo N, Thomassen L, Novotny V, Mathisen SM, Kurz MW. Clinical outcomes and safety profile of Tenecteplase in wake-up stroke. Acta Neurol Scand 2020; 142:475-479. [PMID: 32511749 DOI: 10.1111/ane.13296] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Tenecteplase has probably pharmacological and clinical advantages in the treatment of acute ischemic stroke. There are lacking data about safety and efficacy of tenecteplase in wake-up stroke (WUPS). AIMS To investigate safety and efficacy of tenecteplase compared to alteplase in WUPS patients included in NOR-TEST. METHODS WUPS patients in NOR-TEST were included in the study based on DWI-FLAIR mismatch. Included patients randomly assigned (1:1) to receive intravenous tenecteplase 0.4 mg/kg (to a maximum of 40 mg) or alteplase 0.9 mg/kg (to a maximum of 90 mg). Neurological improvement was defined as 1) favorable functional outcome at 90 days modified Rankin Scale (mRS) of 0 or 1 and 2) neurological improvement measured with the National Institutes of Health Stroke Scale (NIHSS) of 4 points within 24 hours as compared to admission NIHSS or NIHSS 0 at 24 hours. RESULTS Of 1100 patients from 13 stroke centers included in NOR-TEST, 45 were WUPS patients. Of these, 5 patients were stroke mimics and excluded. Of the remaining 40 patients (3.6%), 24 were treated with alteplase (60%). There was no difference in the number of patients achieving a good clinical outcome (mRS 0-1) in either treatment group. Patients treated with tenecteplase showed a better early neurological improvement (87.5% vs 54.2%, P = 0.027). No ICH was detected on MRI/CT 24-28 hours after thrombolysis. CONCLUSIONS In WUPS patients treated in NOR-TEST, there was no difference in clinical outcomes at 90 days and no ICH events or deaths were observed in either alteplase- or tenecteplase-treated patients. Clinical Trial Registration-URL: https://www.clinicaltrials.gov. Unique identifier: NCT01949948.
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Affiliation(s)
- Hassan Khan Ahmed
- Department of Neurology Stavanger University Hospital Stavanger Norway
- Neuroscience Research Group Stavanger University Hospital Stavanger Norway
| | - Nicola Logallo
- Department of Neurosurgery Haukeland University Hospital Bergen Norway
- Center for Neurovascular Diseases Haukeland University Hospital Bergen Norway
- Department of Clinical Science University of Bergen Bergen Norway
| | - Lars Thomassen
- Center for Neurovascular Diseases Haukeland University Hospital Bergen Norway
- Department of Clinical Science University of Bergen Bergen Norway
- Department of Neurology Haukeland University Hospital Bergen Norway
| | - Vojtech Novotny
- Center for Neurovascular Diseases Haukeland University Hospital Bergen Norway
- Department of Clinical Science University of Bergen Bergen Norway
| | - Sara M. Mathisen
- Department of Neurology Stavanger University Hospital Stavanger Norway
- Neuroscience Research Group Stavanger University Hospital Stavanger Norway
| | - Martin W. Kurz
- Department of Neurology Stavanger University Hospital Stavanger Norway
- Neuroscience Research Group Stavanger University Hospital Stavanger Norway
- Department of Clinical Science University of Bergen Bergen Norway
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Zia-Behbahani M, Hossein H, Kojuri J, Salesi M, Mojtaba M, Keshavarz K. Tenecteplase Versus Reteplase in Acute Myocardial Infarction: A Network Meta-Analysis of Randomized Clinical Trials. Iran J Pharm Res 2020; 18:1622-1631. [PMID: 32641969 PMCID: PMC6934957 DOI: 10.22037/ijpr.2019.1100743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Acute myocardial infarction (AMI) is the leading cause of death throughout the world. One of the standard approaches to treatment of AMI is fibrinolysis. The study was conducted to evaluate the clinical efficacy of tenecteplase versus reteplase through network meta-analysis for AMI. Randomized trials were comprehensively searched in PubMed, Scopus, Cochrane library, and Web of Science using appropriate strategies. Quality assessment was done for the papers. The primary and secondary end-points were mortality, TIMI grade 3 flow at 90 min, death or non-fatal stroke, infarction, total stroke and major bleeding. Odds ratios (OR) were computed (95% confidence intervals). After screening 27325 records, eight articles were included with total patients of 49875 to the meta-analysis. Indirect comparison of tenecteplase vs. reteplase showed no significant differences in the risk of mortality (OR = 0.98, p > 0.05), TIMI grade 3 flow at 90 min (OR = 0.77, p > 0.05), death or non-fatal stroke (OR = 1.04, p > 0.05), infarction (OR = 1.11, p > 0.05), total stroke (OR = 2.71, p > 0.05), and major bleeding (OR = 0.81, p > 0.05) (all p > 0.05). Indirect comparison suggests similar efficacy and safety of tenecteplase and reteplase. Hence, the use of each one of the two medicines depends on price, facility, and accessibility of the medicine.
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Affiliation(s)
- Majid Zia-Behbahani
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Hossein
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Javad Kojuri
- Quality Improvement in Clinical Teaching Research Center, Shiraz Education Center, Faculty of Medical Education, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmood Salesi
- Chemical Injuries Research Center, Systems Biology and Poisonins Institute, Baqiyatallah University of Medical Science, Tehran, Iran
| | - Mojtaba Mojtaba
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.,Health Human Resources Research Center and Department of Health Economic, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Khosro Keshavarz
- Health Human Resources Research Center and Department of Health Economic, School of Management and Medical Informatics, Shiraz University of Medical Sciences, Shiraz, Iran
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50
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Thommessen B, Næss H, Logallo N, Kvistad CE, Waje-Andreassen U, Ihle-Hansen H, Ihle-Hansen H, Thomassen L, Morten Rønning O. Tenecteplase versus alteplase after acute ischemic stroke at high age. Int J Stroke 2020; 16:295-299. [PMID: 32631157 DOI: 10.1177/1747493020938306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Stroke prevalence is increasing with age. Alteplase is the only agent approved for thrombolytic treatment for patients with ischemic stroke, including patients ≥80 years. In the present study, the aim was to compare efficacy and safety of tenecteplase and alteplase in patients ≥80 years. METHODS Data from the Norwegian Tenecteplase Stroke Trial, a randomized controlled trial comparing alteplase and tenecteplase, were assessed. RESULTS Of the 273 patients ≥80 years included, mean age was 85.5 years.In the intention-to-treat analyses, 43.1% receiving tenecteplase and 39.9% receiving alteplase reached excellent functional outcome (modified Rankin Scale score 0-1) after 3 months (odds ratio (OR) 1.14, 95% confidence interval (CI) 0.70-1.85, p=0.59). No significant differences among patients in the two treatment groups regarding frequency of symptomatic intracranial hemorrhage during the first 48 h were identified (11 (8.5%) in the tenecteplase group, 10 (7.0%) in the alteplase group, OR 1.23, 95% CI 0.50-3.00, p 0.65). Death within 3 months occurred in 18 patients (14.3%) in the tenecteplase group and in 21 (15.3%) in the alteplase group (p 0.84). After excluding stroke mimics, the proportion of patients with excellent functional outcome was 44.1% in the tenecteplase group and 34.4% in the alteplase group (OR 1.50 CI 0.90-2.52, p 0.12). CONCLUSION No differences in the efficacy and safety of tenecteplase versus alteplase in patients ≥80 years were identified. TRIAL REGISTRATION Clinicaltrials.gov (NCT01949948).
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Affiliation(s)
- Bente Thommessen
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lorenskog, Norway
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Center for Age-Related Medicine, Stavanger University Hospital, Stavanger, Norway
| | - Nicola Logallo
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
| | - Christopher E Kvistad
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | | | - Hege Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Drammen, Norway.,Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Håkon Ihle-Hansen
- Department of Internal Medicine, Bærum Hospital, Drammen, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Lars Thomassen
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.,Institute of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ole Morten Rønning
- Department of Neurology, Division of Medicine, Akershus University Hospital, Lorenskog, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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