What are the indications for alteplase (tissue plasminogen activator, tPA) and potential complications to monitor?

From the Guidelines

Alteplase (tPA) is indicated for acute ischemic stroke patients who can be treated within 3 to 4.5 hours of symptom onset, with a dose of 0.9 mg/kg, maximum 90 mg, administered over 60 minutes. The decision to administer alteplase should be made based on careful consideration of the patient's eligibility criteria, including time of symptom onset, severity of symptoms, and presence of any contraindications 1.

Indications for Alteplase

• Acute ischemic stroke patients who can be treated within 3 hours of symptom onset, with a dose of 0.9 mg/kg, maximum 90 mg, administered over 60 minutes 1
• Acute ischemic stroke patients who can be treated within 3 to 4.5 hours of symptom onset, with careful consideration of patient eligibility criteria, including age, severity of symptoms, and presence of any contraindications 1
• Patients with severe stroke symptoms, despite increased risk of hemorrhagic transformation, as there is still proven clinical benefit 1

Contraindications for Alteplase

• Intracranial hemorrhage on CT scan 1
• Severe head trauma within 3 months 1
• Intracranial or intraspinal surgery within 3 months 1
• History of intracranial hemorrhage 1
• Subarachnoid hemorrhage 1
• GI malignancy or GI bleed within 21 days 1
• Coagulopathy, including platelets <100,000/mm3, INR >1.7, aPTT >40 s, or PT >15 s 1
• Use of thrombin inhibitors or factor Xa inhibitors within 48 hours 1

Potential Complications to Monitor

• Bleeding complications, including symptomatic intracranial bleeding, which can occur within 24 hours after administration of IV alteplase 1
• Angioedema, which can cause partial airway obstruction 1
• Hypoglycemia and hyperglycemia, which can mimic acute stroke presentations 1
• Blood pressure, which should be maintained <180/105 mm Hg for at least the first 24 hours after IV alteplase treatment 1

It is essential to carefully weigh the potential benefits and risks of alteplase administration in each patient, considering their individual clinical characteristics and medical history 1.

From the FDA Drug Label

INDICATIONS AND USAGE Cathflo® Activase® (Alteplase) is indicated for the restoration of function to central venous access devices as assessed by the ability to withdraw blood. PRECAUTIONS General Catheter dysfunction may be caused by a variety of conditions other than thrombus formation, such as catheter malposition, mechanical failure, constriction by a suture, and lipid deposits or drug precipitates within the catheter lumen. The most frequent adverse reaction associated with all thrombolytics in all approved indications is bleeding (3,4). Caution should be exercised with patients who have active internal bleeding or who have had any of the following within 48 hours: surgery, obstetrical delivery, percutaneous biopsy of viscera or deep tissues, or puncture of non‑compressible vessels Infections Cathflo Activase should be used with caution in the presence of known or suspected infection in the catheter Hypersensitivity, including urticaria, angioedema and anaphylaxis, has been reported in association with use of Cathflo Activase

The indications for alteplase (tissue plasminogen activator, tPA) are for the restoration of function to central venous access devices. Potential complications to monitor include:

• Bleeding: the most frequent adverse reaction associated with all thrombolytics
• Infections: use with caution in the presence of known or suspected infection in the catheter
• Hypersensitivity: including urticaria, angioedema, and anaphylaxis 2 2

From the Research

Indications for Alteplase (tPA)

• Alteplase is indicated for the treatment of acute ischemic stroke, with the goal of improving clinical outcomes by restoring blood flow to the affected area of the brain 3, 4.
• It is also used for the treatment of pulmonary embolism (PE), particularly in high-risk patients with hypotension or shock 5.
• The use of alteplase in acute ischemic stroke is recommended within 4.5 hours of symptom onset, with the greatest benefit gained from early treatment 3.

Potential Complications to Monitor

• Bleeding complications, including intracranial hemorrhage, are a major risk of alteplase therapy 5, 3, 6.
• Cytotoxicity and increased permeability of the neurovascular unit, leading to cerebral edema, are potential deleterious effects of tPA on the ischemic brain 6.
• Systemic administration of alteplase may lead to complications such as hemorrhagic conversion in the brain and relapse in the form of re-occlusion 7.
• Patients with contraindications, such as those aged >80 years, may require careful consideration and alternative treatment strategies 3.