Tenecteplase Dosing
For acute myocardial infarction, tenecteplase is dosed based on body weight using a tiered regimen: 30 mg for patients <60 kg, 35 mg for 60-69 kg, 40 mg for 70-79 kg, 45 mg for 80-89 kg, and 50 mg for ≥90 kg, administered as a single IV bolus over 5 seconds. 1, 2, 3
Standard Weight-Based Dosing for STEMI
The weight-tiered dosing regimen is straightforward and does not require dose adjustment for renal impairment:
- <60 kg: 30 mg (6 mL) 1, 2, 3
- 60 to <70 kg: 35 mg (7 mL) 1, 2, 3
- 70 to <80 kg: 40 mg (8 mL) 1, 2, 3
- 80 to <90 kg: 45 mg (9 mL) 1, 2, 3
- ≥90 kg: 50 mg (10 mL) 1, 2, 3
The dose is administered as a single intravenous bolus over 5-10 seconds. 2, 3
Critical Consideration for Renal Impairment
Tenecteplase dosing does NOT require adjustment for impaired renal function. 3, 4 The drug exhibits primarily hepatic metabolism with a clearance of 99-119 mL/min that is independent of renal function. 3, 4 Body weight accounts for only 19% of clearance variability, and renal function does not significantly impact tenecteplase pharmacokinetics. 4
This contrasts sharply with adjunctive anticoagulation, where dose modifications are mandatory for renal impairment. For example, enoxaparin requires dose reduction in patients with creatinine clearance <30 mL/min. 1
Dosing for Ischemic Stroke
For acute ischemic stroke with large vessel occlusion, the recommended dose is 0.25 mg/kg (maximum 25 mg) administered as a single IV bolus. 2, 5, 6 This lower dose has demonstrated superior recanalization compared to alteplase without increased bleeding risk. 5, 6
A higher dose of 0.40 mg/kg was tested but showed no advantage over 0.25 mg/kg in achieving reperfusion before thrombectomy and was associated with numerically higher symptomatic intracranial hemorrhage (4.7% vs 1.3%). 7, 8
Age-Related Considerations
For patients >75 years with STEMI, use the standard weight-based dose without reduction. 1 The 2024 European Society of Cardiology guidelines note that half-dosing should be considered in elderly patients only in the context of increased bleeding risk, but this is not a blanket recommendation. 1
For stroke patients >75 years, the 0.25 mg/kg dose remains appropriate without age-based reduction. 5, 6
Obesity Considerations
In patients with class ≥2 obesity (BMI ≥35) or body weight >90 kg, the maximum dose is capped at 50 mg for STEMI. 1, 2, 3 For stroke, the maximum is 25 mg when using the 0.25 mg/kg regimen. 5, 6
The 2024 ESC consensus statement emphasizes measuring actual body weight to avoid underdosing in obese patients, as higher body weight is associated with worse artery patency if underdosed. 1
History of Prior Stroke or MI
Prior ischemic stroke or myocardial infarction does NOT require dose adjustment of tenecteplase. 1, 3 However, recent ischemic stroke within 3-6 months is an absolute contraindication to fibrinolytic therapy. 2
Unlike streptokinase, tenecteplase can be re-administered if clinically indicated, as it does not induce antibody formation. 2
Common Pitfalls to Avoid
Do not reduce the tenecteplase dose for renal impairment – this is a critical error that would lead to underdosing and treatment failure. 3, 4 The confusion likely arises because adjunctive enoxaparin DOES require dose reduction in renal dysfunction (no IV bolus and 0.75 mg/kg subcutaneous every 12 hours in patients ≥75 years; dose reduction for creatinine clearance <30 mL/min). 1, 2
Do not use the 0.5 mg/kg dose approved for STEMI in stroke patients – stroke trials consistently used lower doses (0.25 mg/kg), and higher doses showed no benefit with potential harm. 7, 5, 8
Do not delay administration to calculate precise weight – estimated weight is acceptable for the weight-tiered regimen, as the dose bands provide a margin of safety. 3