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# Alteplase
## Overview
Alteplase is a tissue plasminogen activator (tPA) that promotes the breakdown of fibrin clots. It is a thrombolytic agent.
## Primary Indications
* Acute ST-elevation myocardial infarction (STEMI)
* Acute ischemic stroke
* Massive pulmonary embolism (PE)
## Adult Dosing
* **STEMI:** 100 mg IV infusion over 90 minutes.
* First 15 mg IV bolus.
* Second 50 mg IV infusion over 30 minutes.
* Third 35 mg IV infusion over 60 minutes.
* Alternatively, a weight-based regimen of 1.5 mg/kg (maximum 100 mg) IV over 3 hours.
* First 10% of the total dose as an initial bolus over 1 minute.
* The remaining 90% infused over 3 hours.
* **Acute Ischemic Stroke:** 0.9 mg/kg IV infusion over 60 minutes, with the first 10% of the total dose (0.09 mg/kg) administered as an IV bolus over 1 minute.
* Maximum dose: 90 mg.
* Initiate treatment as soon as possible after symptom onset, ideally within 3 to 4.5 hours.
* **Massive Pulmonary Embolism:** 100 mg IV infusion over 2 hours.
* Consider repeat doses for severe hemodynamic compromise, but this is not standard.
## Pediatric Dosing
Dosing for pediatric patients is not well established and should be guided by specialist consultation and institutional protocols. Extrapolation from adult data may be considered in specific life-threatening situations.
## Dose Adjustments
* **Renal Impairment:** No specific dose adjustment recommended, but caution is advised due to increased bleeding risk.
* **Hepatic Impairment:** No specific dose adjustment recommended, but caution is advised due to increased bleeding risk.
## Contraindications
* Active internal bleeding
* History of intracranial hemorrhage (ICH) or recent stroke (within 3 months)
* Severe uncontrolled hypertension (systolic BP >185 mmHg or diastolic BP >110 mmHg) for acute ischemic stroke
* Known bleeding disorder
* Recent major surgery or trauma (within 3 months)
* Intracranial neoplasm or arteriovenous malformation
* Coagulopathy (e.g., platelet count <100,000/mm³, INR >1.7, PT >15 seconds)
* Recent use of oral anticoagulants
* Cardiopulmonary resuscitation with significant internal trauma
## Adverse Effects
* **Hemorrhage:** The most serious adverse effect, including intracranial hemorrhage, gastrointestinal bleeding, and urinary tract bleeding.
* Hypotension
* Arrhythmias
* Nausea and vomiting
* Fever
* Allergic reactions
## Key Drug Interactions
* **Anticoagulants (e.g., warfarin, heparin, DOACs):** Increased risk of bleeding. Discontinue prior anticoagulants before alteplase administration if possible.
* **Antiplatelet agents (e.g., aspirin, clopidogrel):** Increased risk of bleeding.
* **Other thrombolytics:** Avoid concurrent use.
* **NSAIDs:** Increased risk of bleeding.
## Monitoring
* **Hemorrhage:** Close monitoring for signs of bleeding (e.g., hematuria, melena, hematemesis, epistaxis, bruising).
* **Vital Signs:** Frequent monitoring of blood pressure, heart rate, and respiratory rate.
* **Neurological Status:** Frequent assessment for changes in mental status or focal neurological deficits, especially in stroke patients.
* **Laboratory Parameters:**
* PT/INR, aPTT, and platelet count before and during treatment.
* Hemoglobin and hematocrit.
* **Cardiac Monitoring:** For STEMI patients, monitor for reperfusion arrhythmias and recurrent ischemia.
## Clinical Pearls
* Alteplase is a high-risk medication and should only be administered by experienced healthcare professionals in a setting equipped to manage potential complications, particularly bleeding.
* Time is critical for stroke and STEMI indications. Rapid administration is essential.
* Carefully assess contraindications before administration, especially in patients with a history of bleeding or recent procedures.
* Reverse bleeding complications with appropriate blood products (e.g., cryoprecipitate, fresh frozen plasma, platelets).
* Protocols for administering alteplase vary by indication and institution. Always refer to current institutional guidelines.
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**Disclaimer:** This information is intended for healthcare professionals. It is essential to consult the most current prescribing information and institutional protocols for definitive patient care decisions.
