(626) Real-World Use Trends of Alteplase Versus Tenecteplase for Acute Ischemic Stroke

Introduction: Thrombolysis is standard for acute ischemic stroke (AIS) management. Alteplase (TPA) is FDA-approved for AIS, yet use of tenecteplase (TNK) is growing based on emerging evidence. TNK is more fibrin-specific than TPA, with a longer action duration and simpler administration. Current guidelines for AIS strongly recommend TPA but suggest TNK in patients also eligible for mechanical thrombectomy. We sought to evaluate real-world utilization of TPA and TNK for AIS over a four-year period.

Methods: We analyzed de-identified data from Trisus Medication Compare (The Craneware Group, Edinburgh, UK) to identify adults with AIS (ICD-10 code I63) receiving TPA or TNK between 1/1/2019-3/31/2023. The primary objective was to evaluate yearly and quarterly use. The secondary objective was to evaluate yearly and quarterly use in those receiving mechanical thrombectomy (by ICD-10 code or Current Procedural Terminology code) versus those who did not.

Results: A total of 10,218 encounters were included (TPA, n=9,567; TNK, n=651). Hypertension, type 2 diabetes, atrial fibrillation, dyslipidemia, and ischemic heart disease were more common in those who received TNK, with similar rates of previous AIS and heart failure in both groups. Use of both agents was higher in urban settings. Increased use of TNK (39.6%) versus TPA (22.2%, p=0.0002) was seen in academic medical centers. Of all encounters, 48.6% had an NIH Stroke Scale score ICD-10 code recorded to indicate AIS severity. More patients on TNK had an NIHSS score ICD-10 code (62.7% vs 47.7%, p=0.0001). Mechanical thrombectomy was rarely reported, with higher use in the TNK group (7.7% vs 3.5%, p=0.0001). Annual trends demonstrate increasing TNK use (proportion of total use: 2019, 0.1%; 2020, 0.2%; 2021, 5.3%; 2022, 18.6%; 2023, 36.4%) and declining TPA use (proportion of total use: 2019, 99.9%; 2020, 99.8%; 2021, 94.7%; 2022, 81.4%; 2023, 63.6%). This trend was consistent when evaluating quarterly use and mechanical thrombectomy.

Conclusions: Use of TNK in adults with AIS has increased over the last four years, overall and in subgroups with and without mechanical thrombectomy.