Intravenous (IV) tenecteplase works just as well as IV alteplase in patients with large-vessel occlusion (LVO) stroke who are eligible for thrombolysis, new research shows.
In a prespecified secondary analysis of the ACT randomized clinical trial, IV tenecteplase conferred similar reperfusion, safety, and functional outcomes compared to alteplase among patients with LVO stroke.
“Given the ease of administration of tenecteplase versus alteplase and the comparable safety and efficacy between both thrombolytics shown in this study, tenecteplase could be used as a first-line thrombolytic agent for patients with LVO stroke,” the investigators write.
The study was published online July 10 in JAMA Neurology.
Practice Changing?
The Intravenous Tenecteplase Compared With Alteplase for Acute Ischemic Stroke in Canada (ACT) randomized controlled trial was conducted at 22 primary and comprehensive stroke centers across Canada.
A total of 1577 adults with a disabling ischemic stroke within 4.5 hours of symptom onset were randomly allocated to IV tenecteplase (0.25 mg/kg of body weight) or IV alteplase (0.9 mg/kg of body weight).
As previously reported by Medscape Medical News, the overall results of the trial showed tenecteplase was noninferior to alteplase.
Results of the prespecified secondary analysis are based on 520 patients with LVO: 263 (51%) in the tenecteplase group and 257 (49%) in the alteplase group.
Mirroring the overall trial results, there was no between-group difference in the primary outcome of modified Rankin Score (mRS) 0-1 at 90 days, which was achieved in 86 adults (32.7%) in the tenecteplase group and 76 (29.6%) in the alteplase group (adjusted risk ratio, 1.15; 95% CI, 0.98 – 1.35; P = .08).
There were also no differences between tenecteplase and alteplase in rates of mRS 0-2 (49.0% vs 51.0%), symptomatic intracerebral hemorrhage (6.1% vs 4.3%), and mortality (19.9% vs 18.1%).
Among 405 patients who underwent thrombectomy, no difference between tenecteplase and alteplase was noted in successful reperfusion rates in the first (9.2% vs 10.5%) and final angiogram (84.5% vs 88.9%).
“The bottom line of this paper is that among patients with LVO stroke who are eligible for thrombolysis, tenecteplase was at least as safe and effective as alteplase,” corresponding author Mohammed Almekhlafi, MD, interventional stroke neurologist, Calgary Stroke Program and University of Calgary, Alberta, Canada, told Medscape Medical News.
This prespecified secondary analysis “further substantiates evidence from the ACT trial by showing that in patients presenting with LVO who were candidates for endovascular therapy, tenecteplase at a dose of 0.25 mg/kg showed similar safety and efficacy compared to alteplase,” the authors write in their article.
“These results support the transition to tenecteplase (0.25 mg/kg) as a first-choice thrombolytic in patients with LVO stroke,” they add.
Almekhlafi told Medscape Medical News that the pharmacologic properties of tenecteplase “suggest it will fare better than alteplase, especially among patients with LVO. Therefore, the lack of clear advantages to using tenecteplase was somewhat surprising.”
“It is worth noting,” he added, “that almost 95% of patients in this research presented directly to comprehensive stroke centers and were treated in relatively fast times. These factors may have influenced the reperfusion rates seen in our research.”
The study was supported by the Canadian Stroke Consortium, the Canadian Institutes of Health Research, the Alberta Strategy for Patient Oriented Research Support Unit, Alberta Innovates, Heart & Stroke Foundation, and the University of Calgary. A complete list of author disclosures is available with the original article.
JAMA Neurol. Published online July 10, 2023. Abstract
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