Recommended Dosage of Tenecteplase for Acute Ischemic Stroke
The recommended dosage of tenecteplase for acute ischemic stroke is 0.25 mg/kg administered as a single intravenous bolus (maximum dose of 25 mg). 1, 2
Dosing Guidelines
Tenecteplase should be administered as a single IV weight-based bolus with the following dosing recommendations:
Higher doses (0.40 mg/kg) have been studied but do not show significant advantages over the 0.25 mg/kg dose in terms of reperfusion rates or clinical outcomes 4
Comparison to Alteplase
Unlike alteplase (which requires a 10% bolus followed by 90% as an infusion over 60 minutes), tenecteplase is administered as a single bolus due to its longer half-life (90-130 minutes) 1
The single-bolus administration offers significant workflow advantages, particularly in centers considering endovascular therapy or patient transfer 1
Tenecteplase has been shown to be noninferior to alteplase with respect to excellent functional outcomes (mRS score of 0 or 1) at 90 days 2
Clinical Evidence Supporting Tenecteplase Use
The ORIGINAL trial demonstrated that tenecteplase at 0.25 mg/kg was noninferior to alteplase regarding excellent functional outcomes at 90 days 2
In patients with large vessel occlusion, tenecteplase (0.25 mg/kg) resulted in a higher incidence of reperfusion and better functional outcomes than alteplase among patients treated within 4.5 hours after symptom onset 3
The EXTEND-IA TNK Part 2 trial showed that increasing the dose to 0.40 mg/kg did not significantly improve cerebral reperfusion compared to 0.25 mg/kg in patients with large vessel occlusion ischemic stroke 4
Safety Considerations
Symptomatic intracerebral hemorrhage rates are similar between tenecteplase and alteplase (approximately 1% in comparative studies) 3, 2
Both agents share similar contraindications including evidence of intracranial hemorrhage, recent significant trauma or surgery, and uncontrolled hypertension 1
Guideline Recommendations
The American Heart Association/American Stroke Association suggests that tenecteplase might be considered as an alternative to alteplase in patients with minor neurological impairment and no major intracranial occlusion (Class IIb, Level of Evidence B-R) 1
The 0.25 mg/kg dose is specifically recommended for large vessel occlusions based on trials demonstrating superior recanalization and improved 3-month outcomes relative to alteplase 1, 5
Common Pitfalls and Caveats
Do not confuse the dosing protocol for stroke with that used for myocardial infarction (which is 0.5 mg/kg) 5
Careful patient selection remains critical regardless of which thrombolytic agent is chosen 1
Treatment should be initiated as soon as possible after patient arrival and CT scan, with every effort made to minimize door-to-needle times 6
While tenecteplase offers advantages in administration, it has not yet received regulatory approval in all countries for acute ischemic stroke treatment 7