The Great Debate: tPA vs TNK

🧠 Thrombolytics at the Crossroads: Alteplase vs. Tenecteplase in Acute Ischemic Stroke

If you've worked a code stroke in the ED, you know the feeling: heart racing, stopwatch ticking, neuro breathing down your neck, and pharmacy prepping the thrombolytic. For years, it’s been alteplase or bust. But lately, the winds are shifting — and a lot of us on the floor are asking: Is it time to start favoring tenecteplase instead?

As an emergency nurse who's mixed, hung, and pushed both drugs, I wanted to take a closer look — not just at the data, but at how this debate plays out at the bedside.

💉 Alteplase: The Veteran

We’ve had alteplase (tPA) in our crash carts and protocols for decades, ever since the NINDS trial back in the ’90s showed it could reduce disability when given quickly. It’s dosed at 0.9 mg/kg, with 10% as a bolus and the rest over 60 minutes.

That means:

  • It requires prolonged administration and monitoring.

  • There’s a risk of systemic bleeding and intracerebral hemorrhage.

  • And most importantly—it’s not as fibrin-specific as some of the newer agents.

We’ve made it work, but let’s be honest: it’s a process.

🚀 Tenecteplase: The New Contender

Tenecteplase (TNK) is a genetically modified variant of alteplase with greater fibrin specificity and a longer half-life. Originally approved for STEMI, its role in ischemic stroke has been growing—especially after some recent head-turning trials.

What makes tenecteplase appealing in the ED?

  • It’s a single IV bolus (0.25 mg/kg, max 25 mg) — no infusion pump, no waiting.

  • Easier administration = fewer delays in transfer for EVT.

  • Potentially lower cost and fewer complications.

I’ve pushed TNK during a mobile stroke alert headed straight to IR, and I have to say: it’s a nurse’s dream.

🔍 What’s the Evidence Saying?

More hospitals are switching to tenecteplase, especially for patients heading to mechanical thrombectomy. The shift is backed by solid, recent evidence:

1. EXTEND-IA TNK 2 Trial (Campbell et al., 2020)

  • Compared different TNK doses before thrombectomy

  • Found 0.25 mg/kg to be safer than 0.4 mg/kg, with similar effectiveness

  • Helped define the current preferred TNK dosing

2. NOR-TEST 2A (Logallo et al., 2023)

  • Compared TNK 0.4 mg/kg to alteplase in mild strokes

  • Was stopped early due to higher bleeding risk in the TNK group

  • Takeaway: Dose matters, and TNK might not be best for all strokes

3. AcT Trial (Menon et al., 2022)

  • Over 1,600 patients randomized to TNK or alteplase

  • Found TNK was non-inferior in terms of outcomes, with similar safety

  • Supported TNK as a real-world option

4. Meta-Analysis (Powers et al., 2024)

  • Pulled together five major studies

  • Found TNK had similar outcomes, less symptomatic bleeding, and better recanalization rates before thrombectomy

🧠 Why Nurses Should Care

Whether you’re in triage activating a stroke alert or at the bedside drawing labs and hanging meds, this decision impacts us.

DrugAlteplaseTenecteplase
Admin10% bolus + 60 min infusionSingle bolus
Set-up TimeModerate-HighMinimal
MonitoringContinuous infusionPost-bolus neuro checks
FDA Approval✅ Yes❌ Not yet (off-label)
Nursing WorkloadHighLower
ED FitOld standardFast, clean, practical

The workflow difference between a 1-hour drip and a 10-second push is huge. Especially when you’re managing a full zone, coordinating care with neuro, and prepping a patient for thrombectomy or ICU transfer.

🩺 What's the Official Word?

The 2024 AHA/ASA stroke guidelines say TNK may be considered as an alternative to alteplase — especially for patients with large vessel occlusion (LVO) who are candidates for thrombectomy. But a lot still depends on your hospital’s policy, stroke team preferences, and pharmacy approval.

Some hospitals are using TNK across the board. Others are sticking with alteplase unless the patient’s heading for IR.

👩‍⚕️ My Take

Here’s the honest truth: Tenecteplase makes my job easier. It’s faster, cleaner, and gives me more time to focus on patient care, neuro checks, and coordination — not standing there watching a drip or troubleshooting a pump during a transfer.

But it’s not just about workflow — it’s also about patient outcomes. If the data says TNK is just as effective (or better in certain patients), then why not go with the option that also streamlines our practice?

We’ve come a long way in how we handle strokes. Nurses have been right in the middle of every change — and this shift to TNK might be one of the most practical improvements we’ve seen in years.


#bloggingfromthebay

— CrashCart Kelly

📚 References

  1. Campbell BCV, et al. "Tenecteplase versus Alteplase before Thrombectomy for Ischemic Stroke." N Engl J Med. 2020.

  2. Logallo N, et al. "Tenecteplase vs Alteplase in Acute Ischemic Stroke: NOR-TEST 2A." JAMA Neurology. 2023.

  3. Menon BK, et al. "Efficacy of Tenecteplase compared to Alteplase in Stroke (AcT)." The Lancet. 2022.

  4. Powers WJ, et al. “Tenecteplase vs Alteplase for Acute Ischemic Stroke: A Meta-Analysis.” Stroke. 2024.

  5. American Heart Association/American Stroke Association Guidelines, 2024 Update.

Comments

Post a Comment

Popular posts from this blog

Welcome!

  🩺 Welcome to The Medic Minute Your Source for Emergency Medicine Practice Updates By a CEN Who Lives It Hi there, and welcome to the blog! I'm a Certified Emergency Nurse (CEN) with years of frontline experience in the controlled chaos we call the Emergency Department. If you’ve ever triaged a patient, started compressions in seconds flat, or had to make a clinical decision with limited information and even less time — you’re in the right place. I started this blog with a simple goal:  to keep emergency medicine professionals sharp, current, and connected . Guidelines change. Evidence evolves. And as much as we live in the thick of it, it’s not always easy to carve out time to stay updated. That’s where this space comes in. Here’s what you can expect: 🔄  Practice Guideline Updates  — from trauma protocols to airway algorithms. 🧠  Clinical Pearls & Pitfalls  — quick takeaways that could make or break a shift. 🛠  Real-World Application  — ...
Read more

Blood, Belmonts, and the Back of the Rig: A Guide to Mass Transfusion

“Activate MTP!”  That phrase has become one of the most defining moments of modern emergency and trauma nursing. We’ve come a long way from the days of blindly hanging fluids and praying for a stable pressure. Today, we have coordinated  massive transfusion protocols (MTPs) ,  Belmont rapid infusers , and—thanks to some bold EMS systems— prehospital blood products  already dripping before the stretcher even hits the door. But with new tools and protocols comes new responsibility—and a need to stay sharp on the  why , not just the  how . 🩸 What  Is  a Massive Transfusion Protocol? Massive transfusion  is usually defined as: >10 units of PRBCs within 24 hours , or >4 units in 1 hour with ongoing need , or Replacement of >50% of blood volume in 3 hours But practically? If your trauma team’s activating MTP, you know you're in the thick of it. MTPs are designed to: Restore  oxygen-carrying capacity  and  coagulation functi...
Read more

Poking Holes in Your Practice Methods

  🚑 Prehospital Needle Decompression: What EMS Providers Need to Know in 2025 By CrashCart Kelly Tension pneumothorax is a killer. Without quick intervention, it can rapidly progress to obstructive shock and cardiac arrest. In the field,  needle decompression  remains one of the most critical—and time-sensitive—skills an EMS provider can perform. But like everything in medicine, our approach to this procedure has evolved. This post breaks down the  latest, evidence-based guidance  on how to perform needle decompression  right —from site selection to needle length, and when you should (and shouldn’t) do it. 🎯 When Should You Decompress? Needle decompression isn’t for every trauma patient with low sats. According to recent studies, overuse leads to  iatrogenic pneumothorax, vascular injury, and poor outcomes . ✅ Perform needle decompression  only  if your patient has: Chest trauma or barotrauma  and Severe respiratory distress or hypoxia...
Read more