Alteplase

Administration

• Type: Thrombolytic
• Dosage Forms: powder for injection (reconstitute before use)
• Routes of Administration: IV
• Common Trade Names: tPA

Adult Dosing

Acute MI

• >67kg: 15mg IV over 1-2min; then 50mg IV over 30min; then 35mg over next 60min (i.e. 100mg over 1.5hr)
• ≤67kg: 15mg IV over 1-2min; then 0.75 mg/kg (max 50mg) IV over 30 min; then 0.5 mg/kg over 60min (max 35 mg)

Acute ischemic stroke

• 0.9mg/kg IV (max 90mg total)
  • 10% of dose is administered as bolus; rest is given over 60 minutes

Massive PE

• Stable Massive PE: 100mg IV over 2 hr OR 0.6mg/kg over 2 min
• Cardiac arrest: 50mg IV over 2 min followed by 50mg IV after 15 min if needed

Arterial thrombosis

• 1.5 mg/hour by transcatheter intra-arterial infusion until lysis of thrombus

Pediatric Dosing

• PE: 0.5 mg/kg/hour IV, for a maximum of 6 hours, in addition to heparin

Special Populations

• Pregnancy Rating: C
• Lactation risk: Infant risk cannot be ruled out
• Renal dosing: not defined
• Hepatic dosing: not defined

Contraindications

• Allergy to class/drug
• Bleeding diathesis
• Active internal bleeding
• Current intracranial hemorrhage, subarachnoid hemorrhage
• Intracranial neoplasm, arteriovenous malformation, aneurysm, or other conditions that may increase the risk of intracranial bleeding
• Recent (<3 mo) intracranial or intraspinal surgery
• Recent (<3 mo) serious head trauma
• Recent (<3 mo) stroke (for patients being treated for MI or PE)
• Severe uncontrolled hypertension

Adverse Reactions

Serious

• Intracranial hemorrhage - see Post-tPA Hemorrhage in CVA
• GI bleed
• Pericardial effusion, pericarditis, cardiac tamponade
• Stroke, seizure
• Pulmonary edema, pleural effusion
• Cardiac dysrhythmia
• Anaphylaxis or angioedema
  • Stop tPA immediately
  • Epinephrine 0.3 mg IM
  • Famotidine 40 mg IV
  • Diphenhydramine 50 mg IV
  • Methylprednisolone 125 mg IV
  • Consider early airway management PRN

Pharmacology

• Onset of action: 30-60 minutes
• Half-life: 26.5 to 46 minutes
• Metabolism: Liver
• Excretion:

Mechanism of Action

• Tissue plasminogen activator (TPA): binds fibrin, enhances conversion of plasminogen to plasmin thus initiating fibrinolysis

See Also

• Thrombolytics
• Thrombolysis in Acute Ischemic Stroke (tPA)
• EBQ:Thrombolysis in Pulmonary Embolism Metanalysis
• Acute arterial ischemia
• STEMI