Treating Stroke with Faster-to-Administer Drug

A case study on how the change was implemented at Cedars-Sinai was published in the American Journal of Health-System Pharmacy.

"The wonderful thing about this drug (tenecteplase) is clinicians can administer it in five seconds, unlike the current standard drug, which must be given by both a syringe and long intravenous infusion done with a pump that takes more than an hour to complete," said Lydia Noh, PharmD, manager of Inpatient Adult Medicine, Women's Health and Pediatric Pharmacy Services and first author of the case study.

An occurs when an artery in a person's brain becomes blocked, impeding blood flow and causing brain cells to die. The American Heart Association and the American Stroke Association recommend people with acute ischemic stroke be given a clot-busting drug as soon as possible after a diagnosis is made.

The standard drug for treating stroke caused by blood clots is alteplase. But recent studies have shown that tenecteplase may work as well and be as safe as alteplase. In addition to being easier to administer than alteplase, tenecteplase also better attaches to proteins involved in the clotting of blood, stays longer in a person’s bloodstream and costs several thousand dollars less per dose. Researchers also believe since tenecteplase can be administered faster than alteplase it may reduce brain damage, although more research is needed to confirm this.

Cedars-Sinai is one of the first health systems to have made the switch to tenecteplase for treating strokes. The health system made the change in January 2021, and the hospitals that adopted this practice are Cedars-Sinai Medical Center, Torrance Memorial Medical Center (a Cedars-Sinai affiliate) and Cedars-Sinai Marina del Rey Hospital.

The case study describes the preparation involved in changing the standard stroke drug used at Cedars-Sinai. Physicians, nurses and pharmacists underwent several weeks of training prior to the transition. Clinicians participated in patient-case scenarios in a simulation center, and pharmacists were required to attend an online lecture and take an exam. The informatics team also played an important role by updating the electronic health record system.

To avoid confusion, Noh and colleagues trained staff to use the full brand or generic name of the two stroke drugs in all verbal and written communication. They also worked with the health system to have the full names of the drugs in all preprinted forms and electronic order sets.

Cedars-Sinai will continue to have both drugs as options for patients. Patients whose imaging results indicate they arrived at the hospital more than 4.5 hours after having an acute ischemic stroke should be given alteplase, according to the authors. This is because investigators haven't yet studied the safety of tenecteplase beyond this time window.

Noh said implementing the change was possible under the leadership of Shlee S. Song, MD, vice chair of Neurology System Integration, director of the Comprehensive Stroke Center and associate professor of Neurology, and Laurie Paletz, RN, associate director of clinical operations for the Stroke Program within the Department of Neurology. Collaboration from pharmacy departments across the health system was integral to making the change, she added.

"This is an example of several disciplines coming together to do the right thing for patients and not being afraid to be the first in line to try something new and effective," Noh said.

Song and Paletz are following up Noh's case report with the CERTAIN study, which compares stroke safety outcomes in people given tenecteplase versus alteplase. The CERTAIN collaboration is an ongoing registry of de-identified patient-level data of thrombolytic-treated ischemic stroke from various hospitals and programs in New Zealand, Australia and the U.S.