50mg lyophilized powder (IV)

Dosing Summary

Acute Myocardial Infarction with ST elevation (STEMI <12hrs)

FDA approved, 2000. Indicated when anticipated STEMI diagnosis to Percutaneous Coronary Intervention-mediated reperfusion time is >120min. 

Adult dose (IV ,bolus):


Acute Ischemic Stroke (AIS <4.5hrs)

Not FDA approved. 

Adult dose (IV ,bolus):


Pulmonary Embolism (PE)

Not FDA approved. Prefer alteplase for PE fibrinolytic therapy. If unavailable, consider tenecteplase.

Adult dose (IV, bolus):

Executive Summary

(August 2021)


Emergency Medicine Executive Summary

Tenecteplase (TNK) is a modified form of the Tissue Plasminogen Activator alteplase, with enhanced fibrin affinity, diminished fibrinogenolysis (greater fibrin-specificity) and Plasminogen Activator Inhibitor-1 (PAI-1) resistance (1). These properties prolong its half-life permitting administration as a single bolus which is remarkably useful in emergency medicine. 


FDA and EMA approved its use only for emergency reperfusion in Acute Myocardial Infarction with ST elevation (STEMI)(1, 2). Compared to alteplase, it is safer due to a lower risk of non-cerebral hemorrhage and blood transfusion (13), and is easier to administer. Those advantages led TNK as the fibrinolytic of choice in STEMI (3). 


In the past decade tenecteplase has been studied to treat Acute Ischemic Stroke (AIS) with promising results (5, 7, 8, 17). Although this drug has not yet been universally adopted for the treatment of  AIS, there are relevant data that favor it:

Therefore, the use of TNK for AIS is steadily increasing among clinicians beyond research purposes; for example in 2016 tenecteplase was approved to treat AIS by the Indian health authorities (9). 


EMDrugs do not encourage its use for Pulmonary Embolism because there are no solid comparative studies of tenecteplase vs alteplase in high-risk PE (hemodynamic instability). Interestingly, when tenecteplase is compared with alteplase for PE, TNK is associated with an increased risk of major bleeding, but in myocardial infarction, the data show a reduced risk of major bleeding (10, 13). This increased risk is known to be related to the older population (significantly higher risk in patients >65 years)(11), and is probably associated with concomitant heparin administration (eg. PEITHO trial protocol)(16). 


Always consider the contraindications seriously and balance the risk of tenecteplase fibrinolysis of  intracranial hemorrhage and other major bleeding events versus the benefit of the therapy. This intervention must be decided -or at least supported- by a specialist (eg. emergency medicine, neurologist, cardiologist, intensivist). 

Contraindications to systemic fibrinolytic therapy

There isn't a definite and universally accepted list of contraindications, and it seems to be a tendency to become simpler over the years. Beware that references differ on some issues. 


Absolute contraindications (3, 4)


Relative contraindications (3, 4)

Adult dose

FDA approval in 2000. EMA approval in 2001. Indicated when anticipated STEMI diagnosis to Percutaneous Coronary Intervention-mediated reperfusion time is >120min (3).

Relevant studies: ASSENT trial, 1999 (13).

Adult dose (IV ,bolus):


Studied schemes in AIS have been conducted with 0.1, 0.25 and 0.4mg/kg, possibly 0.25mg/kg is the safer and equally effective dose, but more data is needed to reassure this (15).
Adult dose based on latest AHA/ASA Guidelines For the Early Management of Acute Ischemic Stroke 2018/2019 (4):


Adult dose (IV, bolus):

Pediatric dose

Efficacy and safety not established. Pediatric tenecteplase usage data derives mostly from case reports limited to dysfunctional central venous catheters (12). 

Prefer alteplase for fibrinolytic therapy.


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