II. Indications
- ST Elevation Myocardial Infarction (STEMI)
- Acute Ischemic Cerebrovascular Accident (off label)
- See Thrombolysis in Cerebrovascular Accident
- Tenecteplase use for CVA (instead of t-PA) has become more common due to its single, rapid IV dosing
III. Mechanism
-
Recombinant Tissue Plasminogen Activator (rt-PA)
- Serine protease that binds Fibrin and converts Fibrin-bound plasminogen to plasmin
- TNK has a higher Specificity for Fibrin than Alteplase (t-PA)
- Plasmin breaks down both Fibrin and Fibrinogen to Fibrin
- Fibrin Degradation Products result, which in turn also act to inhibit Fibrin formation
- Serine protease that binds Fibrin and converts Fibrin-bound plasminogen to plasmin
IV. Dosing
-
ST Elevation Myocardial Infarction (STEMI)
- Give a single IV bolus dose over 5 seconds
- Once reconstituted, IV solution must be used within 8 hours
- Use 1/2 dose in age >75 years
- Weight <60 kg: 30 mg IV (6000 units)
- Weight 60 to 69 kg: 35 mg IV (7000 units)
- Weight 70 to 79 kg: 40 mg IV (8000 units)
- Weight 80 to 89 kg: 45 mg IV (9000 units)
- Weight >=90 kg: 50 mg IV (10,000 units)
- Massive Pulmonary Embolism (off-label)
- Same dose as in STEMI
-
Cerebrovascular Accident (off-label but common use within 4.5 hours of CVA onset)
- Give a single 0.25 mg/kg (up to 25 mg) IV over 5 to 10 seconds
- Central venous catheter Occlusion
- Weight >30 kg
- Inject 2 mg in 2 mL into the occluded catheter
- Consider a second dose in 2 hours
- Weight <30kg
- Inject the equivalent of 110% of catheter lumen volume (up to max 2 mg in 2 ml solution)
- Weight >30 kg
- References
- Pearlman and Nickson (2024) Life in the Fastlane, accessed 10/2/2026
VI. Adverse Effects: CVA Protocol
-
Intracerebral Hemorrhage (ICH)
- Early data suggested a possible higher risk of ICH compared with t-PA
- However, ICH data was based on higher doses (0.4 mg/kg) than current dosing (0.25 mg/kg)
- Later 2023 studies at lower dose (0.25 mg/kg) supported the use of TNK over t-PA (see efficacy below)
- Marcolini and Swaminathan (2023) Neurocritical Care Mailbag, EM:Rap, December, accessed 12/1/2023
- Kvistad (2022) Lancet Neurol 21(6):511-9 +PMID: 35525250 [PubMed]
- Qureshi (2023) J Stroke Cerebrovasc Dis 32(2):106898 +PMID: 36493706 [PubMed]
VII. Safety
- Unknown safety in pregnancy
- Unknown safety in Lactation
VIII. Efficacy: CVA
- Lower mortality and Intracerebral Hemorrhage than with t-PA
- Similar outcomes (including Intracerebral Hemorrhage) as with t-PA
IX. Resources
- Tenecteplase (DailyMed)