AlteplaseNursing considerations

Side effects by what to assess

Sources: [1][2][3][4][5][6][7]

aPTT (partial thromboplastin time)

Why

Pretreatment coagulation check for stroke; timing anticoagulation after PE lysis

When

Before stroke treatment in patients recently on heparin; near the end of the PE infusion. Results may be unreliable while alteplase is in the sample

Act on

Discontinue for an elevated pretreatment aPTT in stroke; after PE, start anticoagulation once the PTT is twice normal or less

Normal

25 to 35 seconds when not on a blood thinner.

Sources: [1][2][3][4]

Blood pressure

Why

Bleeding risk, especially intracranial hemorrhage

When

Frequently during and after stroke treatment

Act on

Severe uncontrolled hypertension is a contraindication; weigh risk above 175/110 mm Hg

Normal

Below 120/80 mm Hg.

Sources: [1][2][3][4]

INR (prothrombin time)

Why

Pretreatment coagulation check for stroke

When

Before stroke treatment in patients recently on oral anticoagulants; otherwise treatment can start before results return

Act on

Discontinue if the pretreatment INR is above 1.7

Normal

INR 0.8 to 1.1 when not on a blood thinner. On warfarin, the usual target is 2.0 to 3.0.

Sources: [1][2]

High-alert status

High-alert medication. Thrombolytics, with alteplase named, are on the ISMP acute care high-alert list under antithrombotic agents.

Sources: [1]

Narrow therapeutic index

The label does not describe a narrow therapeutic index or direct dosing by measured blood levels of the drug.

Sources: [1]

Boxed warning

None on the current label. Bleeding, including intracranial hemorrhage, is the leading labeled warning.

Sources: [1]

Antidote or reversal

No specific reversal agent on the label. For serious bleeding, stop the infusion and treat appropriately. For hypersensitivity or angioedema, stop the infusion and give antihistamines, IV corticosteroids, or epinephrine.

Sources: [1][2]

Patient teaching

• Bleeding risk stays higher after treatment; report unusual bruising, pink or brown urine, black or tarry stools, coughing up blood, or vomit that looks like coffee grounds
• Report a headache or any new stroke symptoms, such as one-sided weakness or numbness, right away
• Report itching, hives, swelling of the face, lips, tongue, or throat, or trouble breathing during or after the infusion
• Tell the team about any recent surgery, injury, bleeding, stroke, or brain problem, and about all medicines, including blood thinners
• Tell lab staff that you received alteplase before any lab test

Sources: [1][2][3][4][5]

Sound-alike and look-alike names

• Activase and Cathflo Activase
• Activase and TNKase
• t-PA and TNKase

Sources: [1]

Adult dose

Acute ischemic stroke

0.9 mg/kg, maximum 90 mg total: 10% as an IV bolus over 1 minute, the rest infused over 60 minutes. Start within 3 hours of symptom onset.

AMI, accelerated infusion

Over 67 kg: 15 mg IV bolus, 50 mg over the first 30 minutes, then 35 mg over the next 60 minutes. 67 kg or less: 15 mg bolus, 0.75 mg/kg over 30 minutes, then 0.50 mg/kg over 60 minutes. Studied only with heparin and aspirin.

AMI, 3-hour infusion

65 kg or more: 100 mg total, 60 mg in the first hour (6 to 10 mg of it as a bolus), 20 mg in the second hour, 20 mg in the third. Under 65 kg: 1.25 mg/kg over 3 hours. Never exceed 100 mg for AMI; 150 mg or more raised intracranial bleeding.

Acute massive pulmonary embolism

100 mg by IV infusion over 2 hours. Start parenteral anticoagulation near the end of or right after the infusion, once the PTT or thrombin time is twice normal or less.

Sources: [1][2][3][4]

Renal adjustment

No renal dose adjustment on the label. Hemostatic defects from severe renal disease raise bleeding risk, and cholesterol embolization can present as acute renal failure.

Sources: [1][2]

Hepatic adjustment

No hepatic dose adjustment on the label. Clearance is mainly hepatic, and significant hepatic dysfunction or hemostatic defects from severe liver disease raise bleeding risk.

Sources: [1][2]

Mechanism

Recombinant tissue plasminogen activator (tPA), a serine protease. Bound to thrombus fibrin, it converts clot-trapped plasminogen to plasmin, producing local fibrinolysis with limited systemic proteolysis. Circulating fibrinogen falls 16% to 36% after a 100 mg dose. Cleared rapidly, mainly by the liver; initial half-life under 5 minutes.

Sources: [1][2][3][4]