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Transition to Tenecteplase for Acute Ischemic Stroke

Provider Education

April 2023

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Objectives

Learners will understand reason for change to Tenecteplase (TNKase®).
Learners will verbalize correct dosing and administration of TNKase.
Learners will describe potential adverse reactions and treatment of same.
Learners will describe care of the patient from outside facility with thrombolytic infusing.

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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Why Change to TNKase®?

More Fibrin specific lysis – reduces bleeding risk
Longer ½ life ~ 120 minutes vs 10 minutes for alteplase (tPA) (IV push vs. infusion)

Allows for bolus administration (IV push)

Easier/faster to deliver
Less dosing errors
Easier to transport – Drip-n-Ship

Limited deactivation by Plasminogen Activator Inhibitor – 1
Lower cost compared to tPA = hospital savings

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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What Does the Research Show?

Several studies have compared TNKase to tPA
A recent meta-analysis reviewed 9 RCTs from 2010-2022 comparing TNKase to tPA.

Results: There was no difference in clinical outcomes (mRS 0-1 and mRS 0-2), sICH, or mortality between TNKase and tPA
Studies have found TNKase led to early neurological improvement and higher rate of recanalization

Kobeissi et al., 2023

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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TNKase® vs tPA for Acute Ischemic Stroke (AIS) & Mechanical Endovascular Reperfusion (MER) 90-day Modified Rankin

Campbell et al, 2018

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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TNKase® vs. tPA�The process is the same

Same inclusion/exclusion criteria
Same Blood Pressure criteria/ management
Same Post-lytic thrombectomy pathway
Same patient monitoring processes
Similar risk for angioedema
Same reversal

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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The kit contains everything needed for reconstitution

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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Dosing

TNKase will be given as rapid IV push bolus
After reconstitution, the concentration is 5 mg/mL (total amount 50mg =10 mL)
Dose will be 0.25 mg/kg

Max dose is 25 mg = 5 mL

Be careful! Vial contains 50 mg!!
There will ALWAYS be a waste portion when administering for stroke!
Flush line with saline before and after TNKase administration

�**If given in IV containing dextrose, precipitation will occur!

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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Angioedema with TNKase®

Symptoms are usually mild and transient but can progress to severe airway obstruction.
Patients taking ACE-I are at increased risk for angioedema due to elevated baseline levels of Bradykinin.
Treatment for Angioedema:

IV Benadryl
IV Dexamethasone or Solumedrol
IV H2 antagonist

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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Key Points to Remember: Dosing

Patient weight is needed for accurate

dosing (0.25mg/ kg)

"Thrombolytic Orders for Acute Ischemic Stroke" which includes monitoring orders for nursing
MAX DOSE 25 mg = 5 mL

Blood Pressure Guidelines are the same

BP < 185/110 prior to administration
Nursing will manually enter the BP in MAR

Dual sign off required
Patient monitoring will remain the same!

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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Key Points to Remember: Order Set

Tenecteplase

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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Thrombolytic Infusion from Outside Hospital

Need to ensure patient receives full dose
Documentation: time of bolus, rate of tPA infusion, and NS post infusion at same rate for 1 hour
One-off order for Saline Infusion

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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Key Points to Remember!

May still receive patients during/ after tPA administration from other area hospitals!
NS infusion will need to be ordered at the same rate once tPA is completed.
The same monitoring parameters apply!
You will still need to order the Thrombolytic Order Set and uncheck TNK in order to place the appropriate monitoring orders.

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)

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Antithrombotic Administration for Other Indications

In most cases an antithrombotic medication such as aspirin, Plavix, or Brilinta should not be administered within the first 24 hours after thrombolytic administration
There may be exceptions based on individual patient needs (i.e., carotid or intracranial stent, patient participation in research studies pairing thrombolytic with antithrombotic medications)

MIDLANDS STROKE

Privileged Peer Review Document(s) pursuant to S.S.C. Code Ann. 40-71-10 and 20 and 44-7-390, 392, and 394 (As Amended)