A Discussion of the Use of Tenecteplase for Ischemic Stroke

Stroke Challenges held a LIVE EVENT on March 10, 2021, to discuss the use of Tenecteplase for ischemic stroke. The response to the announcement showed the keen interest of this topic in stroke programs across the US. In this blog, we share a summary of the significant talking points during our discussion from our panel and others joining the event.

Thank you to our panel who shared their experience in transitioning to Tenecteplase:

• Amanda Lamer-Rosen, Pharm.D., BCCCP, APh, Neurocritical Care Pharmacist
• Laurie Paletz, BSN PHN R.N.BC SCRN FAHA, Stroke Program Manager
• Tom Curley, MSN, RN, SCRN, NE-BC, CSC Program Manager
• Ruth Marescalco, RN, CSC Stroke Coordinator
• Vinodh Doss, DO, Vascular and Interventional Neurologist, CSC Medical Director
• Jennifer Biank, RN, MSN, CNS, Neuroscience and Cerebrovascular Clinician

1. Rationale for transitioning to Tenecteplase (TNK)
   • Discussed evidence
     • 3/2018 – Extend IA trial, 7/2019 – Meta- analysis of 5 randomized trials (Saver et al), 10/2019 – AHA Guidelines for AIS
   • High door-to-needle times
   • Ancillary benefit: cost reduction
2. Real-world implications
   • Single bolus
   • Less complex administration
     • Infusion pumps vs. IV push administration
     • Minimizes complexity when transferring intra-facility
     • Less complicated oversight of lytic prep and administration at telemedicine sites (especially nights and weekends)
   • Improved door-to-needle, door-to-groin puncture, and drip-n-ship times
   • Universal terminology (“thrombolytic”) in protocols
3. Outcomes
   • One facility shared outcome data based on one year of experience with combined thrombolytic and LVO therapy showing excellent recanalization rates and outcomes data
   • When asked about symptomatic intracranial hemorrhage rates – the group was referred to this recent article:
     • See Stroke. 2021;52:1087–1090 Routine Use of Tenecteplase for Thrombolysis in Acute Ischemic Stroke Cathy S. Zhong, et al.

4. Informed consent
   • Informed consent for TNK was discussed by each of the panelists
     • Per discussion with participants, informed consent for both TNK and alteplase seems to be organization-specific with varying norms for the use of off-label medications

5. Implementation time for new TNK protocols
   • A range of 4-12 months was reported by the panelists
     • It involved changes in policies, pathways, workflows; staff and physician education-locally and telestroke sites, etc.
     • Physician, nursing and pharmacy buy-in is critical

6. Certification reviews
   • The prevailing thought was that the focus should be on the process of implementation, staff and physician education, outcomes (if available)
7. Reversal protocols
   • Neurocritical Care Society is a good resource with their “antithrombotic reversal” guideline https://www.neurocriticalcare.org/resources/guidelines
8. Use of kits or tackle boxes
   • TNK kits are used – some with medications (and a strict time-out), others with supplies but no meds
9. Mixing/pre-mixing TNK
   • TNK takes less time to mix/dilute than alteplase
   • If mixed but not administered
     • Check with your Genentech rep for policy on replacement/reimbursement