Yong Chuan Chee

Among the biggest changes in intravenous thrombolysis practice in the past 5 years has been the increased use of tenecteplase over alteplase. Tenecteplase, a slightly modified form of tissue plasminogen activator, has more fibrin specificity and longer half-life than alteplase and therefore can be given more conveniently as a single bolus rather than the one-hour infusion needed for alteplase. In the past decade, tenecteplase has been tested in comparison with alteplase in patients with acute ischemic stroke. Although tenecteplase may result in higher rates of recanalization, trials have shown that clinical outcomes are essentially equivalent between the two drugs — or at least the conclusion can be made that tenecteplase is noninferior to alteplase in terms of benefit and safety. Largely on the basis of these noninferiority results, in 2025, the FDA approved the use of tenecteplase in patients with acute ischemic stroke. Although accurate patient weight is important to establish doses for both alteplase and tenecteplase, the tiered dosing of tenecteplase that was approved by the FDA (seen in table) makes rapid determination of the appropriate dose easier. Read the Review Article “Intravenous Thrombolysis for Acute Ischemic Stroke — New Directions”: nej.md/4iuL5Lr