Alteplase Compared to Tenecteplase in Patients With Acute Ischemic Stroke (AcT)
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|ClinicalTrials.gov Identifier: NCT03889249|
Recruitment Status : Completed
First Posted : March 26, 2019
Last Update Posted : May 12, 2023
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|Condition or disease||Intervention/treatment||Phase|
|Stroke, Acute Thromboses, Intracranial||Drug: Tenecteplase Drug: Alteplase||Phase 3|
There are two established therapies for acute ischemic stroke, namely intravenous alteplase and endovascular thrombectomy (EVT). The guiding principles behind these therapies are fast, effective and safe reperfusion of ischemic brain. Patients with acute ischemic stroke presenting within 4.5 hours from symptom onset are administered intravenous alteplase. If there is evidence of large vessel occlusion (LVO), these patients are transferred to the nearest comprehensive stroke center (CSC) for EVT.Physicians, hospitals and health systems are focused on implementing efficient triaging systems and workflow processes to improve speed and efficacy of administration of these life-saving therapies. Although efforts over the years with intravenous alteplase administration has resulted in improvement in efficiency metrics like door to needle time (DTN) and door-in-door-out (DIDO) time, these metrics are still not optimal, and the therapy is underutilized. Physicians continue to have concerns about low early reperfusion rates, increased risk of symptomatic intracerebral hemorrhage and challenges with drug administration (bolus + 60-minute infusion) with intravenous alteplase.
Recent phase II trials have shown that intravenous tenecteplase is potentially safer and may achieve higher early reperfusion rates than alteplase in patients with acute ischemic stroke. Bolus administration makes tenecteplase easier to administer than alteplase (which requires infusion pumps). Transfer of patients from primary stroke centers (PSC) to comprehensive stroke centers (CSCs) is potentially easier without infusion pumps. Moreover, depending on the province, tenecteplase either costs the same, or even less, than alteplase. It is therefore possible that the use of intravenous tenecteplase in patients with acute ischemic stroke otherwise eligible for intravenous alteplase may result in faster administration of thrombolysis and more efficient transport to CSCs, thus saving time, reducing adverse events (intracranial hemorrhage) and potentially improving patient outcomes, while saving the health system costs. For these various reasons, robust evidence that tenecteplase is non-inferior to alteplase as an intravenous thrombolytic agent in patients with acute ischemic stroke will change current clinical practice as it did in patients with myocardial infarction. The proposed trial is therefore a pragmatic, registry linked, prospective, randomized (1:1) controlled, open-label parallel group clinical trial with blinded endpoint assessment of 1600 patients to generate real world evidence whether intravenous tenecteplase (0.25 mg/kg body weight, max dose 25 mg) is non-inferior to intravenous alteplase (0.9 mg/kg body weight) in patients with acute ischemic stroke otherwise eligible for intravenous thrombolysis as per current standard of care.
|Study Type :||Interventional (Clinical Trial)|
|Actual Enrollment :||1600 participants|
|Intervention Model:||Parallel Assignment|
|Intervention Model Description:||The proposed trial is a pragmatic, registry linked, prospective, randomized (1:1) controlled, open-label parallel group clinical trial with blinded endpoint assessment of 1600 patients to test if intravenous tenecteplase (0.25 mg/kg body weight, max dose 25 mg) is non-inferior to intravenous alteplase (0.9 mg/kg body weight) in patients with acute ischemic stroke otherwise eligible for intravenous thrombolysis as per standard care.|
|Masking:||Single (Outcomes Assessor)|
|Masking Description:||90 day outcomes are assessed in a blinded manner|
|Official Title:||Alteplase Compared to Tenecteplase in Patients With Acute Ischemic Stroke: QuICR & OPTIMISE Registry Based Pragmatic Randomized Controlled Trial|
|Actual Study Start Date :||December 10, 2019|
|Actual Primary Completion Date :||April 26, 2022|
|Actual Study Completion Date :||April 30, 2023|
Active Comparator: Tenecteplase (tNK-TPA)
The intervention group will receive intravenous tenecteplase as a single bolus as per the standard manufacturers' instructions for use. The dose administered will be 0.25 mg/kg body weight (maximum dose 25 mg) over 10-20 seconds as soon as possible after randomization. Tenecteplase has a longer half-life, is more fibrin specific, produces less systemic depletion of circulating fibrinogen, and is more resistant to plasminogen activator inhibitor than alteplase.
Other Name: tNK
Active Comparator: Alteplase ( tPA)
The control group will receive standard of care dosing of intravenous alteplase (0.9 mg/kg body weight, 10% bolus and 90% infusion as per standard care, maximum dose 90 mg).
Other Name: tPA
- Modified Rankin Scale (mRS) 0-1 (freedom from disability) [ Time Frame: By telephone Follow-up between 90-120 days ]The modified Rankin Scale (mRS) is a commonly used scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability. The mRS is a range from 0-6. 0=No symptoms, 1=No significant disability. Able to carry out all usual activities, despite some symptoms 2=Slight disability. Able to look after own affairs without assistance, but unable to carry out all previous activities.3=Moderate disability. Requires some help, but able to walk unassisted4=Moderately severe disability. Unable to attend to own bodily needs without assistance, and unable to walk unassisted.5=Severe disability. Requires constant nursing care and attention, bedridden, incontinent.6=Dead
- Discharge Destination [ Time Frame: 90-120 days after randomization ]Location where the patient is living at 90-120 days from randomization. Locations include home, early supported discharge, rehabilitation facility, long term care, death.
- Home Time [ Time Frame: 90-120 days after randomization ]Defined as number of days subject spends at home after index stroke event. The home time outcome will be determined through linkage with administrative data to calculate the total time in the first 90 days after index event that a stroke patient is not an inpatient.
- Door to needle time [ Time Frame: Baseline-Day 1 ]Time from when the patient enters the Emergency Room until treatment with either tNK or tPA. Secondary outcome measures described above are all available through the QuICR and OPTIMISE registries and will be collected from those data sources.
- Door-in-door-out (DIDO) times at Primary Stroke Centres [ Time Frame: Baseline - Day 1 ]The amount of time from when the patient enters the Emergency room to the time of discharge from the same hospital is collected. Secondary outcome measures described above are all available through the QuICR and OPTIMISE registries and will be collected from those data sources.
- Recanalization [ Time Frame: Baseline- After Randomization- Day 1- ]Recanalization status (mTICI score) at first angiographic acquisition in patients taken to the angio-suite for the purpose of administering EVT.Secondary outcome measures described above are all available through the QuICR and OPTIMISE registries and will be collected from those data sources.
- Proportion of patients administered EVT [ Time Frame: After IV thrombolysis -within the first hour after randomization - baseline-Day 1 ]Patients receiving Endovascular Therapy after being treated with either tNK or tPA.Secondary outcome measures described above are all available through the QuICR and OPTIMISE registries and will be collected from those data sources.
- Door-to-groin puncture time in patients undergoing EVT [ Time Frame: During EVT administration-Baseline- after randomization ]Patients receiving Endovascular Therapy after being treated with either tNK or tPA-treatment time. Secondary outcome measures described above are all available through the QuICR and OPTIMISE registries and will be collected from those data sources.
- CT-to-puncture time in patients undergoing EVT [ Time Frame: Before EVT administration- baseline- after Randomization- Day 1 ]Patients receiving Endovascular Therapy after being treated with either tNK or tPA-treatment time. Secondary outcome measures described above are all available through the QuICR and OPTIMISE registries and will be collected from those data sources.
- % patients returning to baseline level of functioning [ Time Frame: By telephone Follow-up between 90-120 days ]Patient or surrogate reported return to baseline level of functioning
- Death within 90 days [ Time Frame: From Baseline- (Randomization) until Day 90 ]Collect if the patient died while in the trial and the cause of death.
- Number of Patients Diagnosed with a Symptomatic ICH post-acute stroke treatment by CT/MRI [ Time Frame: 24 hours days from Baseline- (Randomization) ]Assess any symptomatic ICH related to the tNK or tPA post treatment. AcT defines symptomatic ICH as intracerebral hemorrhage that in the opinion of the investigator is temporally related to and directly responsible for worsening of the neurological condition. While other factors may contribute to neurological worsening, the hemorrhage should, in the investigator's opinion, be the most important factor if there are multiple factors. Thus, the neurological worsening should not be explained better by any other patient condition such as evolution of infarct, hemodynamic alteration, hypoxia etc.
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|Ages Eligible for Study:||18 Years and older (Adult, Older Adult)|
|Sexes Eligible for Study:||All|
|Accepts Healthy Volunteers:||No|
Inclusion Criteria: Inclusion criteria is pragmatic and informed by Canadian Best Practices.
- All patients with acute ischemic stroke eligible to receive intravenous alteplase as per standard care will be eligible for enrolment in the proposed trial.
- Patients eligible for endovascular thrombectomy in addition to intravenous thrombolysis are eligible for enrolment.
- Contra-indications to intravenous thrombolysis as used by treating physicians as current standard of care apply.
- The benefits of thrombolysis with intravenous alteplase in the pediatric population is unknown. Any patient < 18 years of age may therefore not be enrolled.
- Women with pregnancy known to the investigator by history or examination, without requiring pregnancy testing, may only be enrolled in consultation with an expert stroke physician (either in person or through tele-stroke)
To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.
Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03889249
|Principal Investigator:||Bijoy K Menon, MD||University of Calgary|
|Responsible Party:||Dr. Bijoy Menon, Stroke Neurologist, Principal Investigator, University of Calgary|
|Other Study ID Numbers:||
Version 2.0 (Sponsor assigned)
|First Posted:||March 26, 2019 Key Record Dates|
|Last Update Posted:||May 12, 2023|
|Last Verified:||May 2023|
|Individual Participant Data (IPD) Sharing Statement:|
|Plan to Share IPD:||No|
|Studies a U.S. FDA-regulated Drug Product:||No|
|Studies a U.S. FDA-regulated Device Product:||No|
Central Nervous System Diseases
Nervous System Diseases
Embolism and Thrombosis
Intracranial Embolism and Thrombosis
Tissue Plasminogen Activator
Fibrin Modulating Agents
Molecular Mechanisms of Pharmacological Action