Stroke Thrombolysis With Tenecteplase to Reduce Emergency Department Spread of Coronavirus Disease 2019 and Shortages of Alteplase

Department Spread of Coronavirus Disease 2019 and Shortages of AlteplaseMeasures to reduce emergency department staff exposure to the severe acute respiratory syndrome coronavirus 2 have focused on screening and use of personal protective equipment.Reducing the time and intensity of interactions with individuals with known or suspected cases of coronavirus disease 2019 (COVID-19) is also desirable, insofar as such reductions do not compromise the quality or outcomes of care.The situation of an acute stroke emergency is a particularly vulnerable situation for exposure and transmission, since a substantial proportion of patients are unable to provide a history to screen them out for COVID-19.Tenecteplase was developed as a plasminogen activator with greater fibrin specificity and reduced clearance compared with alteplase, allowing single-bolus administration. 1In 2000, the US Food and Drug Administration approved tenecteplase to reduce mortality in acute myocardial infarction.Since then, randomized clinical trials and meta-analyses on ischemic stroke have demonstrated that tenecteplase has noninferior safety and efficacy relative to the standard intravenous stroke thrombolytic agent alteplase and may be superior for early recanalization. 2,3rior to the COVID-19 pandemic, some stroke centers, including ours at the University of Texas-Austin Dell Medical School and Ascension Texas, had switched to tenecteplase as the stroke thrombolytic agent because of its workflow advantages and potential time savings relative to alteplase, especially in the time to initiate an interfacility transfer for thrombectomy or a higher level of care (Box).Tenecteplase is given as a single, 5-second intravenous bolus that requires approximately 2 minutes to mix, prepare, and administer, whereas alteplase requires preparation of both a bolus syringe containing 10% of the weight-based dose and an intravenous pump set up for infusion of the remaining 90% of the dose over 60 minutes.The simpler tenecteplase workflow may be additionally advantageous during the COVID-19 pandemic.Eliminating the alteplase 1-hour infusion and the dedicated second intravenous catheter that it requires reduces staff time in close proximity to the patient and removes the intravenous infusion pump that accompanies the patient through other hospital departments and wards, presenting its own set of surfaces for a virus to settle on and staff to touch.In addition, after published case observations 4 suggested that thrombolysis with alteplase may be beneficial as a treatment for the acute respiratory distress syndrome associated with COVID-19, some centers worldwide have been using alteplase for this potential additional indication and more rapidly consuming their VIEWPOINT