J Stroke.  2023 Jan;25(1):72-80. 10.5853/jos.2022.02880.

Replacing Alteplase with Tenecteplase: Is the Time Ripe?

• Singh N
• Menon BK
• Dmytriw AA
• Regenhardt RW
• Hirsch JA
• Ganesh A

• KMID: 2539059
• DOI: http://doi.org/10.5853/jos.2022.02880

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data from several trials regarding the safety and efficacy of TNK in acute ischemic stroke along with completed yet unpublished trials that will help provide insight into these unanswered questions.

Keyword

Tenecteplase; Alteplase; Thrombolysis; Acute ischemic stroke

Figure

• 

  Figure 1. Timeline of the study and use of TNK in cardiology and ischemic stroke. TNK, tenecteplase; ASSENT-2, Assessment of the Safety and Efficacy of a New Thrombolytic Regimens 2; ACS, acute coronary syndrome; AIS, acute ischemic stroke; TNK2SB, Phase 2B Study of Tenecteplase in Acute Ischemic Stroke; ATTEST, Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis; NOR-TEST, Study of Tenecteplase Versus Alteplase for Thrombolysis in Acute Ischemic Stroke; EXTEND-IA TNK, Tenecteplase Versus Alteplase Before Endovascular Therapy for Ischemic Stroke; AcT, Alteplase Compared to Tenecteplase in Patients With Acute Ischemic Stroke; NOR-TEST-2, The Norwegian Tenecteplase Stroke Trial 2; TWIST, Tenecteplase in Wake-up Ischemic Stroke Trial; TASTE-A, Tenecteplase Versus Alteplase for Stroke Thrombolysis Evaluation Trial in the Ambulance.

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  Figure 2. A visual representation of the current balance and quality of evidence from meta-analyses for key outcome measures of interest in comparing alteplase (r-tPA) to tenecteplase for thrombolysis in acute ischemic stroke. EVT, endovascular treatment; LVO, large vessel occlusion; LOE, level of evidence.

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  Figure 3. A visual representation of the current balance and quality of evidence from meta-analyses for key outcome measures of interest in comparing alteplase (r-tPA) to tenecteplase (TNK) for thrombolysis in acute ischemic stroke. LVO, large vessel occlusion.

Reference

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