Tenecteplase cuts interhospital transfer times, may avoid EVT delays

Switching from alteplase to tenecteplase led to reductions in interfacility transfer times, thus enabling earlier endovascular thrombectomy (EVT) in patients who have had a stroke, according to data presented at ISC 2021.

Evidence shows that every 15 minutes of faster EVT equated to better outcomes (ie, independent ambulation, improved functional independence, greater odds of discharge to home, lower in-hospital mortality/hospice discharge). [JAMA 2019;322:252-263] In a meta-analysis of thrombectomy trials, earlier EVT plus medical therapy correlated with reduced disability at 90 days in thrombectomy patients. [JAMA 2016;316:1279-1288]

Tenecteplase has shown noninferiority to alteplase in terms of safety and efficacy for acute ischaemic stroke management, noted Dr Samantha Miller, neurology resident at the University of Texas at Austin, Dell Medical School, Austin, Texas, US.

Administered as a single bolus, tenecteplase offers ease of administration and potentially shorter emergency department workflow times especially for interfacility transfers. Tenecteplase also has a significantly longer half-life and greater fibrin selectivity and is cheaper than alteplase.

Conversely, alteplase is given as a bolus followed by continuous infusion, which requires supervision by a nurse. The infusion must be completed prior to transfer, hence the potential transfer and EVT delays, added Miller.

“In September 2019, [our] 10-hospital network in central Texas switched from alteplase to tenecteplase [as local standard-of-care] for the treatment of ischaemic stroke,” said Miller. “[We are now faced] with the question of whether or not the [transfer time] improvements are attributable to the switch to tenecteplase, or rather a reflection of overall improvement in workflow efficiencies.”

Using a local stroke registry, the team evaluated data of 592 stroke transfer patients treated from September 1, 2017 through December 16, 2020. Of these, 344 were from the preswitch period (P1), while the remaining 248 were from the post-switch period (P2). In P1, 66 were on alteplase, of whom 14 underwent EVT. In P2, 43 received tenecteplase, 18 of whom eventually undergoing EVT. The remainder of the population were not on any lytic. [ISC 2021, abstract 5; Stroke 2021;52:A5]

The percentage of patients with a door-in-door-out (DIDO) time of ≤90 minutes was significantly greater in the tenecteplase vs the alteplase arm (37 percent vs 15 percent; p=0.0159), as well as among those on either lytic who eventually had EVT (67 percent vs 14 percent; p=0.0092).

DIDO time was shorter with tenecteplase vs alteplase (median, 113 vs 136 minutes; p=0.0497), more so among those on either lytic who had EVT (median, 83 vs 108 minutes; p=0.029). With almost half an hour of transfer time saved with tenecteplase, EVT may be facilitated early, Miller pointed out.

Furthermore, among those who had EVT, door-in-to-arterial-puncture* (DITAP) time was significantly shorter by >45 minutes with tenecteplase vs alteplase (median, 134 vs 180 minutes; p=0.015).

“[The reductions in DIDO and DITAP times] were not observed in patients not receiving a thrombolytic at the transferring hospital … [Our findings demonstrate that] switching to tenecteplase as a standard ischaemic stroke treatment reduced interfacility transfer time and time to thrombectomy,” said Miller. “This [effect] was not attributable to overall improvements in workflow.”