Tenecteplase Dosing for Acute Ischemic Stroke
The recommended dose of tenecteplase for acute ischemic stroke is 0.25 mg/kg (maximum 25 mg) administered as a single intravenous bolus. 1, 2
Standard Dosing Protocol
Tenecteplase should be given as 0.25 mg/kg up to a maximum of 25 mg as a single IV bolus, which differs fundamentally from alteplase's bolus-plus-infusion regimen. 1, 2 This single-bolus administration offers significant workflow advantages over alteplase's 1-hour infusion, particularly when endovascular therapy or patient transfer is being considered. 1
Weight-Based Dosing Breakdown
For practical administration, the American College of Cardiology provides the following weight-based dosing:
However, the 0.25 mg/kg dose (maximum 25 mg) is specifically recommended for large vessel occlusions based on trials demonstrating superior recanalization and improved 3-month outcomes relative to alteplase. 2
Guideline Status and Recommendations
The American Heart Association/American Stroke Association suggests 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, 2 This represents a conditional recommendation rather than a first-line endorsement. 1
The 2007 AHA/ASA guidelines explicitly state that intravenous administration of tenecteplase outside the setting of a clinical trial is not recommended (Class III, Level of Evidence C). 3 However, this older guidance has been superseded by more recent evidence supporting the 0.25 mg/kg dose. 1, 2
Evidence Supporting the 0.25 mg/kg Dose
The 0.25 mg/kg dose has emerged as the preferred regimen based on:
- Superior reperfusion rates compared to alteplase (22% vs 10% substantial reperfusion) when used before mechanical thrombectomy 1
- The EXTEND-IA TNK trial demonstrated higher reperfusion rates with this dose 1
- Meta-analyses of 1,585 patients point to tenecteplase superiority in recanalization of large vessel occlusions and noninferiority in disability-free 3-month outcomes, without increases in symptomatic intracranial hemorrhage or mortality 4
Higher Dose Not Recommended
A higher dose of 0.40 mg/kg (maximum 40 mg) was tested but showed no advantage over 0.25 mg/kg. 5 The EXTEND-IA TNK Part 2 trial randomized 300 patients and found that 0.40 mg/kg compared with 0.25 mg/kg did not significantly improve cerebral reperfusion prior to endovascular thrombectomy (19.3% vs 19.3%, P=0.89). 5 There was also a non-significant trend toward more symptomatic intracranial hemorrhage with the higher dose (4.7% vs 1.3%). 5
Critical Caveats
Both tenecteplase and alteplase share similar contraindications, including evidence of intracranial hemorrhage, recent significant trauma or surgery, and uncontrolled hypertension. 1, 2 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. 2 The target remains a door-to-needle time of less than 60 minutes in 90% of treated patients. 3
The dosing of tenecteplase for stroke (0.25 mg/kg, max 25 mg) differs from its myocardial infarction dosing (0.5 mg/kg), so clinicians must be careful not to confuse these protocols. 3, 4