tPA Dosing for Acute Ischemic Stroke

Acute ischemic stroke:

  • Within 3 hours of the onset of symptom onset (labeled use)
  • Within 3 to 4.5 hours of symptom onset (off-label use)
  • Recommended total dose: 0.9 mg/Kg (max 90mg)
    • ≤100 kg:
      • Load 10% as IV bolus over 1 minute, then
      • 90% as continuous infusion over 1 hour
    • >100 kg:
      • Load 9 mg as IV bolus over 1 minute, then
      • 81 mg as continuous infusion over 1 hour
  • No heparin or aspirin within 24 hours after tPA, start 24-48 hours after stroke onset.
  • SQH (<10,000 units) or LMWH for DVT prophylaxis within 24 hours did not increase ICH

Low dose alteplase (0.6mg/kg) recently shown to be “not noninferior” in a recent trial published in NEJM (06/2017) by ENCHANTED group. Whether this lower dose (which resulted in less ICH) may benefit patients who are at higher risk of post-tPA hemorrhage remains to be investigated.  [2]

 

References

[1] Uptodate: “Alteplase: Drug information.” Accessed 07/08/2016.

[2] Anderson, Craig S. et al. “Low-Dose Versus Standard-Dose Intravenous Alteplase In Acute Ischemic Stroke”. New England Journal of Medicine 374.24 (2016): 2313-2323. Web.

 

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