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Should COVID-19 Push Hospitals to Change Stroke Protocols for ED Staff Safety?

The COVID-19 pandemic has forced clinicians to re-evaluate almost everything. A recent viewpoint article suggests that hospitals consider using an alternative to the current first-line thrombolytic to reduce staff exposure to potential novel coronavirus infection. Find out what the authors suggest, as well as the downsides to the switch.

AUSTIN, TX – While efforts to reduce emergency department staff exposure to COVID-19 now primary focus on screening and use of personal protective equipment, a new article emphasizes the importance of reducing the time and intensity of interactions with patients with known or suspected infections.

The report in JAMA Neurology points out that acute stroke emergency is especially risky for exposure and transmission, since most patients are unable to provide a history to screen them for COVID-19.

Could using different drugs make a difference?

University of Texas at Austin-led researchers recount how tenecteplase was developed as a plasminogen activator with greater fibrin specificity and reduced clearance compared with alteplase, allowing single-bolus administration. The drug was approved 20 years ago by the Food and Drug Administration to reduce mortality in acute myocardial infarction.

“Since then, randomized clinical trials and meta-analyses on ischemic stroke have demonstrated that tenecteplase has noninferior safety and efficacy relative to the standard intravenous stroke thrombolytic agent alteplase and may be superior for early recanalization,” the authors write, adding that some stroke centers had switched to tenecteplase as the stroke thrombolytic agent because of its workflow advantages and potential time savings relative to alteplase.

The authors list the following workflow advantages of tenecteplase compared to alteplase that reduce staff exposure to a contagion:

• Shorter time to prepare Shorter time to administer (5 second versus 1 hour)
• Does not require that a second, dedicated intravenous catheter be inserted and maintained
• Does not require an intravenous infusion pump
• Shorter time to initiate interfacility transfer after intravenous lytic administration.

Another advantage to making the switch, according to the article, is that some published case observations have suggested that thrombolysis with alteplase might be beneficial as a treatment for the acute respiratory distress syndrome associated with COVID-19, and some facilities worldwide have been using alteplase for this potential additional indication and more rapidly consuming their supplies of alteplase.

“With COVID-19–associated supply chain disruptions also occurring, some centers and regions in the world temporarily do not have access to alteplase for its ischemic stroke indication,” the authors explain. “Accordingly, since the start of the COVID-19 pandemic, interest in using tenecteplase for stroke has increased.”

The article adds that changes should be made with caution since tenecteplase is not FDA-approved for stroke and does not currently have the highest level of recommendation for acute stroke thrombolysis in American Heart Association/American Stroke Association Guidelines, although it is recommended as an alternative to alteplase.

“The COVID-19 pandemic has forced the medical system to adapt and accept changes aimed at reducing risk,” the authors conclude. “Before the pandemic hit, tenecteplase had been recognized to be as safe and effective as alteplase in treating stroke while offering appealing workflow efficiencies at lower cost. Tenecteplase thrombolysis may also be a reasonable means of reducing risk exposure to and transmission of the COVID-19 virus during a stroke emergency in the emergency department, as well as addressing temporary shortages of alteplase that may arise from increased use in treating COVID-19– associated thrombosis.”