Do your part as a PHARMACIST in acute strokes

Continue to use IV alteplase for all eligible patients up to 4.5 hr from symptom onset. After this, the main risk, one more symptomatic brain.....
Abdelwahab Ward, BS Pharm, PharmD

Clinicians will sort through new evidence looking for the best ways to bust clots in patients with acute ischemic stroke. Optimal stroke care is a big focus. The Joint Commission looks at whether patients get IV alteplase (Activase) appropriately and Medicare penalizes excess 30-day stroke readmissions. We know that one patient will have minimal or no disability at 3 months, for every 6 patients given IV alteplase within 3 hr of symptom onset, or every 14 patients given IV alteplase from 3 to 4.5 hr of symptom onset.

Continue to use IV alteplase for all eligible patients up to 4.5 hr from symptom onset. After this, the main risk, one more symptomatic brain bleed for every 17 treated, outweighs benefits. You will see more interest in using tenecteplase (TNKase) as an alternative. An IV bolus (0.25 mg/kg up to 25 mg) seems to have similar efficacy and safety as an IV alteplase bolus and infusion with advantages such as simpler prep and administration.

Be aware of developments with intra-arterial (IA) treatment for strokes from proximal artery clots. These cause 1 in 3 ischemic strokes and don't respond well to IV alteplase. For example, feel comfortable with mechanical clot removal plus IV alteplase. This combo seems to improve outcomes over IV alteplase without causing more intracranial hemorrhages. You may still see IA alteplase given if IV alteplase can't be used, such as 4.5 to 6 hr from symptom onset, or if IV alteplase doesn't work. It breaks down proximal clots better than IV alteplase, but doesn't lead to a greater improvement in outcomes.

  • Continue to follow the mantra "time is brain" and shoot for door-to-needle times of ≤ 60 minutes for thrombolysis.
  • Help prevent errors and delays by identifying and fixing system issues, lack of communication about en route patients or patient weights, etc.
  • Consider having a pharmacist respond to strokes to help facilitate medication availability and mixing.
  • Look for ways to help with early identification of in-hospital strokes. These patients have worse outcomes compared to those who present in the emergency department (ED) due to delays in diagnosis and treatment.

References

  1. Jauch EC, Saver JL, Adams HP Jr, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870-947.
  2. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med. 2015;372(24):2285-2295.
  3. Wardlaw JM, Murray V, Berge E, del Zoppo GJ. Thrombolysis for acute ischaemic stroke. Cochrane Database Syst Rev. 2014 Jul 29;2014(7):CD000213.
Abdelwahab Ward, BS Pharm, PharmD