Tenecteplase dosing for MI
Tenecteplase (TNK-tPA) for STEMI is weight-based, single IV bolus:
| Weight | Dose | Max |
|---|---|---|
| <60 kg | 30 mg | - |
| 60-69 kg | 35 mg | - |
| 70-79 kg | 40 mg | - |
| 80-89 kg | 45 mg | - |
| ≥90 kg | 50 mg | 50 mg |
Given as a single IV bolus over 5-10 seconds. Half the dose (max 25 mg) is used in patients >75 years old per some guidelines to reduce bleeding risk.
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Here is the complete, verified tenecteplase dosing reference for MI (STEMI):
Tenecteplase (TNK-tPA) Dosing for STEMI
Standard Weight-Based IV Bolus Dose (0.5 mg/kg)
| Patient Weight | Dose | Volume (5 mg/mL) |
|---|---|---|
| < 60 kg | 30 mg | 6 mL |
| 60-69 kg | 35 mg | 7 mL |
| 70-79 kg | 40 mg | 8 mL |
| 80-89 kg | 45 mg | 9 mL |
| ≥ 90 kg | 50 mg | 10 mL |
Maximum dose: 50 mg
Administration
- Single IV bolus over 5-10 seconds
- IV administration only; incompatible with dextrose-containing solutions (use NS-primed line)
- Reconstitute with 10 mL sterile water for injection; final concentration = 5 mg/mL
- If not used immediately: refrigerate and use within 8 hours; do NOT freeze
- Initiate as soon as possible after symptom onset (fibrinolysis most effective in first 3 hours; indicated within 12 hours)
Age Adjustment (>75 years)
Half the standard dose (0.25 mg/kg, max 25 mg) is recommended for patients over 75 years old, based on the STREAM trial data, which showed a lower rate of intracranial hemorrhage (ICH) with half-dose tenecteplase in this age group.
When to Use (Indications)
- STEMI (ST elevation, new LBBB, or true posterior MI) within 12 hours of symptom onset
- PCI not available within 120 minutes of first medical contact
- Administer within 30 minutes of initial patient contact ("door-to-needle" goal)
- Transfer to PCI-capable center should still occur after fibrinolysis
Adjunctive Therapy
Tenecteplase must be given alongside:
- Aspirin (antiplatelet)
- Clopidogrel (antiplatelet; prasugrel and ticagrelor lack evidence with fibrinolytics)
- Anticoagulation (unfractionated heparin or enoxaparin) - goal aPTT 1.5-2.5x control
- Do NOT combine with GP IIb/IIIa inhibitors
Why Tenecteplase is Preferred
- Current agent of choice over alteplase (rt-PA) due to:
- Equivalent mortality benefit
- Simpler single-bolus dosing (fewer medication errors)
- Lower non-cerebral bleeding rates (ASSENT-2 trial)
- 14-fold greater fibrin specificity vs. alteplase
- 80-fold greater PAI-1 resistance (prolongs clot association)
- Half-life of 20-24 minutes (vs. <5 min for alteplase)
Absolute Contraindications (key ones)
- Any prior intracranial hemorrhage
- Known structural cerebral vascular lesion (e.g., AVM)
- Ischemic stroke within 3 months
- Active internal bleeding (excluding menses)
- Aortic dissection (suspected)
- Significant closed head/facial trauma within 3 months
- Prior neurosurgery within 2 months
- Intracranial/intraspinal neoplasm
Sources: Washington Manual of Medical Therapeutics (Table 4-18); Tintinalli's Emergency Medicine; ASSENT-2 trial / official TNKase prescribing information
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