Alteplase

Uses

Acute Ischemic Stroke: Alteplase is used for the treatment of acute ischemic stroke. Exclude intracranial hemorrhage as the primary cause of stroke signs and symptoms prior to initiation of treatment. Initiate treatment as soon as possible but within 3 hours after symptom onset.

Acute Myocardial Infarction: Alteplase is used for use in acute myocardial infarction (AMI) for the reduction of mortality and the reduction of the incidence of heart failure.

• Acute pulmonary emboli obstructing blood flow to a lobe or multiple lung segments.
• Acute pulmonary emboli accompanied by unstable hemodynamics, e.g., failure to maintain blood pressure without supportive measures.

Alteplase is also used to associated treatment for these conditions: Acute Ischemic Stroke (AIS), Acute Myocardial Infarction (AMI), Acute massive pulmonary embolism, Central venous access device thrombosis

How Alteplase works

Alteplase binds to fibrin rich clots via the fibronectin finger-like domain and the Kringle 2 domain. The protease domain then cleaves the Arg/Val bond in plasminogen to form plasmin. Plasmin in turn degrades the fibrin matrix of the thrombus, thereby exerting its thrombolytic action.

Dosage

Alteplase dosage

Acute Ischemic Stroke: Administer Alteplase as soon as possible but within 3 hours after onset of symptoms. The recommended dose is 0.9 mg/kg (not to exceed 90 mg total dose), with 10% of the total dose administered as an initial intravenous bolus over 1 minute and the remainder infused over 60 minutes. During and following Alteplase administration for the treatment of acute ischemic stroke, frequently monitor and control blood pressure. In patients without recent use of oral anticoagulants or heparin, Alteplase treatment can be initiated prior to the availability of coagulation study results. Discontinue Alteplase if the pretreatment International Normalized Ratio (INR) is greater than 1.7 or the activated partial thromboplastin time (aPTT) is elevated.

Acute Myocardial Infarction: Administer Alteplase as soon as possible after the onset of symptoms. The recommended total doses for acute myocardial infarction (AMI) is based on patient weight, not to exceed 100 mg, regardless of the selected administration regimen (accelerated or 3 hour). There are two Alteplase dose regimens (accelerated and 3-hour) for use in the management of AMI; there are no controlled studies to compare clinical outcomes with these regimens

Pulmonary Embolism (PE): The recommended dose is 100 mg administered by IV infusion over 2 hours. Institute parenteral anticoagulation near the end of or immediately following the Alteplase infusion when the partial thromboplastin time or thrombin time returns to twice normal or less.

• 50 mg vials: administer using either a polyvinyl chloride bag or glass vial and infusion set.
• 100 mg vials: remove from the vial any quantity of drug in excess of that specified for patient treatment. Insert the spike end of an infusion set through the same puncture site created by the transfer device in the stopper of the vial of reconstituted Alteplase. Peel the clear plastic hanger from the vial label. Hang the Alteplase vial from the resulting loop.

Alteplase is for intravenous administration only. Extravasation of Alteplase infusion can cause ecchymosis or inflammation. If extravasation occurs, terminate the infusion at that IV site and apply local therapy. Do not add any other medication to infusion solutions containing Alteplase.

Pediatric Use: Safety and effectiveness of Alteplase in pediatric patients have not been established.

• Acute Ischemic Stroke: In exploratory, multivariate analyses of Studies 1 and 2, age greater than 77 years was one of several interrelated baseline characteristics associated with an increased risk of intracranial hemorrhage. Efficacy results suggest a reduced but still favorable clinical outcome for Alteplase-treated elderly.
• Acute Myocardial Infarction: In a large trial of accelerated-infusion Alteplase that enrolled 41,021 patients with AMI to one of four thrombolytic regimens [see Clinical Studies (14.2)], patients over 75 years of age, a predefined subgroup, comprised 12% of enrolment. In these patients, the incidence of stroke was 4.0% for the Alteplase accelerated infusion group, 2.8% for streptokinase IV [SK (IV)], and 3.2% for streptokinase SQ [SK (SQ)]. The incidence of combined 30-day mortality or nonfatal stroke was 20.6% for accelerated infusion of Alteplase, 21.5% for SK (IV), and 22.0% for SK (SQ).

Side Effects

• Bleeding
• Orolingual Angioedema
• Cholesterol Embolization
• Reembolization of Deep Venous Thrombi during Treatment for Acute Massive Pulmonary
• Embolism.

Precaution

• Increases the risk of bleeding. Avoid intramuscular injections. Monitor for bleeding. If serious bleeding occurs, discontinue Alteplase.
• Monitor patients during and for several hours after infusion for orolingual angioedema. If angioedema develops, discontinue Alteplase.
• Cholesterol embolism has been reported rarely in patients treated with thrombolytic agents.
• Consider the risk of reembolization from the lysis of underlying deep venous thrombi in patients with pulmonary embolism.

Food Interaction

• Avoid herbs and supplements with anticoagulant/antiplatelet activity. Examples include garlic, ginger, bilberry, danshen, piracetam, and ginkgo biloba.

Alteplase Hypertension interaction

[Major] The use of thrombolytics is contraindicated in patients with an active bleed (internal), trauma

Risk versus benefit should be carefully considered in the following conditions and thrombolytic therapy administered with caution in patients with recent (10 days) serious GI bleed or recent (10 days) surgical procedure (coronary bypass graft, obstetrical delivery, organ biopsy, puncture of noncompressible vessel), left heart thrombus, subacute bacterial endocarditis, hemostatic defect, CV disease, diabetic hemorrhagic retinopathy, or pregnancy.

Clinical monitoring of hematopoietic, bleeding and coagulation functions is recommended prior to initiation of thrombolytic therapy.

Measures of fibrinolytic activity and

Alteplase Drug Interaction

Major: heparin, heparinModerate: aspirin, aspirin, clopidogrel, clopidogrelUnknown: charcoal, charcoal, epinephrine, epinephrine, amoxicillin, amoxicillin, lorazepam, lorazepam, acetaminophen, acetaminophen, acetaminophen, acetaminophen, ondansetron, ondansetron

Alteplase Disease Interaction

Major: bleeding risks

Pregnancy & Breastfeeding use

Pregnancy Category C. Alteplase is embryocidal in rabbits when intravenously administered in doses of approximately two times (3 mg/kg) the human dose for AMI. No maternal or fetal toxicity was evident at 0.65 times (1 mg/kg) the human dose in pregnant rats and rabbits dosed during the period of organogenesis. There are no adequate and well-controlled studies in pregnant women. It is not known whether Alteplase is excreted in human milk. Many drugs are excreted in human milk.

Storage Condition

Store lyophilized Alteplase at controlled room temperature not to exceed 30°C, or under refrigeration (2-8°C). Protect the lyophilized material during extended storage from excessive exposure to light. If stored between 2-30°C, Alteplase may be used within 8 hours following reconstitution. Discard any unused solution after administration is complete. Do not use beyond the expiration date stamped on the vial.

Innovators Monograph

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