What is the role of Tnkase (tenecteplase) in the treatment of acute ischemic stroke?

From the Guidelines

Tnkase (tenecteplase) is not recommended for routine use in stroke treatment, as the current evidence suggests it has not been proven to be superior or non-inferior to alteplase in most cases, according to the 2018 guidelines for the early management of patients with acute ischemic stroke 1. The standard thrombolytic therapy for acute ischemic stroke is alteplase (tPA), administered at 0.9 mg/kg (maximum 90 mg) with 10% given as a bolus and the remainder infused over 60 minutes, within 4.5 hours of symptom onset. While tenecteplase has been studied in clinical trials for stroke and shows some promise due to its easier administration (single bolus versus hour-long infusion), it remains investigational for this indication. Some key points to consider when evaluating the use of tenecteplase include:

• Theoretical advantages of tenecteplase, such as greater fibrin specificity, longer half-life allowing single-bolus administration, and potentially lower bleeding risk 1
• Recent evidence from the EXTEND-IA TNK trial, which suggested that intravenous tenecteplase was superior to alteplase with respect to arterial recanalization when given prior to mechanical thrombectomy, but was not powered to demonstrate an effect on clinical outcomes 1
• The need for further evidence from ongoing trials before changes to clinical practice can be recommended, as stated in the Canadian stroke best practice recommendations for acute stroke management 1
• The importance of considering the results of randomized placebo-controlled trials, such as those mentioned in the 2018 guidelines, which have not shown benefit from the administration of IV streptokinase or desmoteplase in patients with ischemic penumbra or large intracranial artery occlusion or severe stenosis 1. Overall, the current evidence does not support the routine use of Tnkase (tenecteplase) in stroke treatment, and alteplase remains the standard of care.

From the Research

Tnkase for Stroke

• Tnkase, also known as tenecteplase, is a fibrinolytic drug that has been studied as a treatment for acute ischemic stroke 2, 3, 4, 5, 6.
• It has a higher fibrin specificity and longer half-life compared to alteplase, which is the standard thrombolytic agent used for stroke treatment 3, 4, 5.
• Tenecteplase can be administered as a single bolus, making it a convenient option for patients who need to be urgently transported to a comprehensive stroke center for endovascular therapy 2.

Efficacy and Safety

• Studies have shown that tenecteplase may be similar to alteplase in terms of efficacy for patients with mild strokes, and superior to alteplase for patients with more severe strokes from large vessel occlusion 2, 3.
• The cumulative evidence currently favors the use of the 0.25 mg/kg dose of tenecteplase 2, 3.
• Tenecteplase has been shown to have a similar safety profile to alteplase, with no significant increase in symptomatic intracranial hemorrhage or mortality 3, 6.

Clinical Trials and Guidelines

• Several phase 3 trials are ongoing to compare the efficacy and safety of tenecteplase and alteplase for stroke thrombolysis 3, 5.
• Current clinical practice guidelines for stroke include intravenous tenecteplase as a second-tier option, with the 0.25 mg/kg dose recommended for large vessel occlusions 3.
• A recent open-label trial found that intravenous tenecteplase before endovascular thrombectomy improved functional independence at 90 days in patients with acute ischemic stroke due to large-vessel occlusion 6.