Implementation of a conversion from intravenous alteplase to tenecteplase for treatment of acute ischemic stroke

Background/Purpose: In acute ischemic stroke patients meeting established criteria, thrombolytics may aid in the reperfusion of ischemic brain regions leading to improvement or resolution of neurological deficits. Alteplase is the only FDA approved thrombolytic for acute ischemic stroke. Recent evidence suggests tenecteplase is as safe and efficacious as alteplase, while providing a more favorable pharmacokinetic profile. The purpose of this project is to conduct a review of alteplase compared to tenecteplase for treatment of acute ischemic stroke, following a formulary conversion in the thrombolytic of choice across a large health system. Methodology: A multicenter, retrospective medication use evaluation was performed for patients diagnosed with acute ischemic stroke who received alteplase six months prior to formulary thrombolytic conversion, or tenecteplase six months post-transition. Patients were included if they were eighteen years and older with an acute ischemic stroke and received a thrombolytic. Primary outcomes included rate of symptomatic intracranial hemorrhagic transformation, rate of major hemorrhage other than intracranial, and door-to-needle time. Secondary outcomes included changes in National Institutes of Health Stroke Scale at 24 hours and at discharge, modified Rankin Scale at discharge, incidence of dosing errors, door-to-puncture and door-to-device times, and order-to-administration time. Results: Of the 214 patients reviewed, 105 received alteplase and 109 received tenecteplase in a period of six months pre- and post- thrombolytic conversion, respectively. The primary outcome of symptomatic intracranial hemorrhagic complications occurred in 1 patient (1%) that received alteplase compared to 3 patients (3%) that received tenecteplase (p = 0.8). No patients experienced extracranial hemorrhage. Median door-to-needle time was 26 minutes with alteplase and 24 minutes with tenecteplase comprehensive stroke centers (p = 0.22); but longer at primary stroke centers. Median change in NIHSS at 24 hours was 6 points with alteplase and 4 points with tenecteplase across all centers. Median change in NIHSS at discharge was 6 points and 4 points across all centers for alteplase and tenecteplase, respectively. Median order-to-administration time across all centers was 4 minutes with alteplase and 3 minutes with tenecteplase. Most patients, regardless of thrombolytic received, were discharged home and there was no statistically significant difference between discharge dispositions with either thrombolytic. Conclusion: Conversion from alteplase to tenecteplase across a large health system demonstrated both safe and efficacious outcomes. There was no statistical difference in symptomatic intracranial or extracranial hemorrhagic complications, and no patients experienced life-threatening or non-life-threatening extracranial hemorrhage after receiving either thrombolytic for acute ischemic stroke. Factors that could have contributed to differences in metrics include the impact of assessing a new process compared to an established workflow, staff training and turnover, as well as lower stroke volume at non-comprehensive stroke centers