Complications of Intravenous Tenecteplase Versus Alteplase for the Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Abstract

BACKGROUND: Prior systematic reviews have compared the efficacy of intravenous tenecteplase and alteplase in acute ischemic stroke, assigning their relative complications as a secondary objective. The objective of the present study is to determine whether the risk of treatment complications differs between patients treated with either agent. METHODS: We performed a systematic review including interventional studies and prospective and retrospective, observational studies enrolling adult patients treated with intravenous tenecteplase for ischemic stroke (both comparative and noncomparative with alteplase). We searched MEDLINE, Embase, the Cochrane Library, Web of Science, and the www.ClinicalTrials.gov registry from inception through June 3, 2022. The primary outcome was symptomatic intracranial hemorrhage, and secondary outcomes included any intracranial hemorrhage, angioedema, gastrointestinal hemorrhage, other extracranial hemorrhage, and mortality. We performed random effects meta-analyses where appropriate. Evidence was synthesized as relative risks, comparing risks in patients exposed to tenecteplase versus alteplase and absolute risks in patients treated with tenecteplase. RESULTS: Of 2226 records identified, 25 full-text articles (reporting 26 studies of 7913 patients) were included. Sixteen studies included alteplase as a comparator, and 10 were noncomparative. The relative risk of symptomatic intracranial hemorrhage in patients treated with tenecteplase compared with alteplase in the 16 comparative studies was 0.89 ([95% CI, 0.65–1.23]; I 2 =0%). Among patients treated with low dose (<0.2 mg/kg; 4 studies), medium dose (0.2–0.39 mg/kg; 13 studies), and high dose (≥0.4 mg/kg; 3 studies) tenecteplase, the RRs of symptomatic intracranial hemorrhage were 0.78 ([95% CI, 0.22–2.82]; I 2 =0%), 0.77 ([95% CI, 0.53–1.14]; I 2 =0%), and 2.31 ([95% CI, 0.69–7.75]; I 2 =40%), respectively. The pooled risk of symptomatic intracranial hemorrhage in tenecteplase-treated patients, including comparative and noncomparative studies, was 0.99% ([95% CI, 0%–3.49%]; I 2 =0%, 7 studies), 1.69% ([95% CI, 1.14%–2.32%]; I 2 =1%, 23 studies), and 4.19% ([95% CI, 1.92%–7.11%]; I 2 =52%, 5 studies) within the low-, medium-, and high-dose groups. The risks of any intracranial hemorrhage, mortality, and other studied outcomes were comparable between the 2 agents. CONCLUSIONS: Across medium- and low-dose tiers, the risks of complications were generally comparable between those treated with tenecteplase versus alteplase for acute ischemic stroke.

Efficacy and safety of intravenous tenecteplase compared to alteplase before mechanical thrombectomy in acute ischemic stroke: a meta-analysis

“…Evidence from previous meta-analyses in AIS patients consistently suggests that the efficacy and safety of TNK is not inferior to ALT [ 22 , 34 – 36 ]. However, given the substantial impact of MT on AIS outcome [ 2 ], many studies have intentionally excluded patients undergoing MT from their study cohorts [ 22 , 34 – 36 ]. As a result, patients receiving MT were underrepresented in meta-analyses.…”

Angioedema Following Tenecteplase for Acute Ischemic Stroke

“…In these 3 studies, 750 patients received A systematic review of 26 studies, including interventional, prospective, retrospective, and observational studies, evaluated complications following intravenous tenecteplase for ischemic stroke. 10 Fifteen of the 26 studies reported rates of angioedema, and among these patients, angioedema occurred in 0.56% of patients, with individual studies reporting rates of 0% to 2.8%.…”

Tenecteplase vs. Alteplase for Intravenous Thrombolytic Therapy of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

“…The efficacy of intravenous thrombolysis with tenecteplase in patients with AIS remains controversial. There are some evaluations of tenecteplase and alteplase in the treatment of AIS, e.g., a systematic review and meta-analysis by Rehman et al [ 15 ], which mainly explores different doses, and Rose et al [ 16 ], which focuses on the risk of complications associated with treatment with the two drugs. In addition, there are some network meta-analyses [ 17 , 18 ], but these include not only RCTs but also some other types of clinical studies, which will increase the publication bias of the article and thus have a certain impact on the accuracy of the results.…”