Confirming Tenecteplase Over Alteplase for Acute Ischemic Stroke

Volume 24, Issue 4

Acute ischemic stroke remains a significant cause of morbidity and mortality in the United States. The mainstay of therapy for acute ischemic stroke has been pharmacologic reperfusion of the occluded artery with some form of tissue plasminogen activator (TPA). Historically, this has been done with alteplase. 

Tenecteplase is a more fibrin-specific fibrinolytic agent that was originally designed for and used in patients with acute myocardial infarction. The drug has a much easier administration as a single intravenous bolus, whereas alteplase is dosed with both a bolus followed by continuous infusion. Because tenecteplase is more fibrin-specific, it may also convey some additional protection against collateral hemorrhage vs nonspecific lytics like alteplase. 

In this week’s issue of Talking Therapeutics, we explore a new study evaluating tenecteplase vs alteplase in the setting of acute ischemic stroke. 

Point 1: No Major Benefit Seen With Tenecteplase

The TRACE-2 trial randomized 1430 patients with acute ischemic stroke to either tenecteplase or alteplase within 4.5 hours of symptom onset. Importantly, patients were excluded if they were eligible to receive endovascular thrombectomy. 

The primary outcome, which was the stroke-related disability according to the Modified Rankin Scale, was similar between tenecteplase and alteplase. Rates of intracranial hemorrhage at 36 hours were also similarly low (2%) in both groups. 

Finally, mortality at 90 days was also low, with no significant difference noted between tenecteplase (7%) vs alteplase (5%). 

Point 2: Tenecteplase Take Over?

This study adds to several other randomized and nonrandomized analyses that have suggested tenecteplase is either just as good as or slightly better than alteplase in preventing disability after acute ischemic stroke. 

Given the ease of administration of tececteplase, I would not be surprised if this agent slowly phases out alteplase and becomes the golden-standard lytic for treating acute ischemic stroke.