Tenecteplase versus alteplase for the treatment of acute ischemic stroke: a meta-analysis of randomized controlled trials

Tenecteplase, a modified variant of alteplase with greater fibrin specificity and longer plasma half-life, may have better efficacy and safety than alteplase in patients with acute ischemic stroke (AIS). We aimed to compare the benefits and risks of tenecteplase versus alteplase in the treatment of AIS. Electronic databases were searched up to 10 February 2023 for randomized controlled trials evaluating the effect of tenecteplase versus alteplase in the treatment of AIS. The primary outcome was functional outcome at 90 days, and secondary outcomes including the symptomatic intracranial haemorrhage (SICH), and major neurological improvement. Subgroup analysis was performed based on the different dosage of tenecteplase. Ten studies with a total of 5123 patients were analysed in this meta-analysis. Overall, no significant difference between tenecteplase and alteplase was observed for functional outcome at 90 days (excellent: OR 1.08, 95%CI 0.93–1.26, <i>I</i>² = 26%; good: OR 1.04, 95%CI 0.83–1.30, <i>I</i>² = 56%; poor: OR 0.95, 95%CI 0.75–1.21, <i>I</i>² = 31%), SICH (OR 1.12, 95%CI 0.79–1.59, <i>I</i>² = 0%), and early major neurological improvement (OR 1.26, 95%CI 0.80–1.96, <i>I</i>² = 65%). The subgroup analysis suggested that the 0.25 mg/kg dose of tenecteplase had potentially greater efficacy and lower symptomatic intracerebral haemorrhage risk compared with 0.25 mg/kg dose tenecteplase. Among AIS patients, there was no significant difference on clinical outcomes between tenecteplase and alteplase. Subgroup analysis demonstrated that 0.25 mg/kg doses of tenecteplase were more beneficial than 0.4 mg/kg doses of tenecteplase. Further studies are required to identify the optimal dosage of tenecteplase. Randomized controlled trials exploring comparative efficacy and safety of tenecteplase and alteplase have been yielding inconsistent results on various outcomes and merit the conduction of a meta-analysis to adequately answer these questions. Analysis of evidence from randomized studies suggests that tenecteplase is as safe as alteplase for the treatment of acute ischemic stroke and tenecteplase is potentially associated with more favourable outcomes. Tenecteplase at 0.25 mg/kg dose is more efficacious and at least as safe as alteplase for stroke thrombolysis.