(Summary Version, Updated 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:
Several randomized controlled trials (eg. 7, 17) and systematic reviews with meta-analyzes (eg. 8) show no-inferiority between tenecteplase and alteplase, as well as no differences in intracranial bleeding rates.
Based on these studies and other important literature, the latest guidelines from the American Stroke Association recommend its use as an alternative to alteplase (3).
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).