Most hospitals have a policy on thrombolysis, all using some form of tPA. A lot of them have been thought to be equivalent however – until this Australian trial in the NEJM, comparing tenecteplase and alteplase.
Looking at 75 patients in a phase 2B trial (here’s a reminder of the phases), they gave either alteplase or tenecteplase less than 6 hours (on average around 3 hours) after the ischaemic stroke.
Furthermore to your average protocol, they carefully selected patients who would benefit, by looking for a perfusion lesion 20% greater than the infarct core, using CT perfusion scanning.
The outcomes were measured in a few different ways:
- improvement in NIHSS score at 24 hours
- tenecteplase 8, alteplase 3 (however it was 3+/- 6.3)
- proportion perfused on imaging (MRI based)
- tenecteplase 79%, alteplase 55% (p=0.004)
- absence of disability at 90 days
- tenecteplase 72%, alteplase 40% (p=0.02)
- ‘excellent’ recovery at 90 days
- tenecteplase 27, alteplase 10, but a non-significant p value at 0.25
- note that the ‘excellent or good recovery at 90 days’ had a more significant p value of 0.02
Overall, bleeding outcomes were similar between the two groups (small numbers however), and mortality was similar.
Interesting study and a suprisingly marked difference for two drugs of the same class. It is important to note the authors affiliations with various drug companies however, and a larger phase III randomised controlled trial will be more definitive.
Have a read over here.