CONy 2022 | Should tenecteplase be routinely used for thrombolysis in acute ischemic stroke?

As a background, patients who come in with an acute stroke, who come in within a certain window and the window used to be three hours and then got to be four and a half hours, but now we also look at wake up strokes also. So, the window’s been increasing. In the appropriate patients, we give them drugs that can open up their arteries. So we call it reperfusions, blocked artery it opens up.

And for reperfusion, most of the work over the years has been done with a drug called tissue plasminogen activator or alteplase. That drug is very good, it works well. There is a bit of a pain for everyone, because you have to give a little dose as a bolus and then over one hour, you give the drug. So, there’s always been this push to look for better drugs. So, TNK is a newer agent that’s more potent in a sense. It’s more specific to the clot. It’s given as a bolus. There is some evidence, not a lot of evidence, that it may be able to open up bigger clots also, not just smaller ones. So, with that data, of course there’s been an interest in centers to switch from alteplase to TNK, or tenecteplase.

Now the problem and the reason for the debate is that at any time, one agent is considered to be better than the other. There is a whole bunch of criterions that you’ve got to meet. So, first of all, you need very good studies because you’re going to make a change that’s worldwide and it’s not good to go back and forth, right? So, those studies are underway, some of them are complete, some of them will be presented in France at the European Stroke Meeting in May or June. But until those studies are presented, well the next step of course is once those studies are presented, and their guidelines, there’s European guidelines, there are North American guidelines, Canadian guidelines and American Heart Association’s guidelines. So, the data has to be interpreted outside of the investigators themselves by key opinion leaders who would then make a recommendation in the guidelines, whether it’s time that you may consider the switch or can use one or the another as per your comfort level. So, that hasn’t happened. So, long answer to your question is, why debate it? Because A, there’s a lot of evidence that tenecteplase will be better than alteplase, but we not there yet to make that recommendation. So, one of my colleagues from Norway, is going to say, “We have enough data to make a switch.” I would say not yet, hold on. Let’s wait until we get some of these studies in the public domain and let’s wait for the guidelines to make their recommendations.