Alteplase

Thrombolytic treatment in acute myocardial infarction

- 90 minutes (accelerated) dose regimen : for patients in whom treatment can be started within 6 h after symptom onset

- 3 h dose regimen : for patients in whom treatment can be started between 6 - 12 h after symptom onset provided that the diagnosis has been clearly confirmed.

Alteplase has proven to reduce 30-day-mortality in patients with acute myocardial infarction.

Thrombolytic treatment in acute massive pulmonary embolism with haemodynamic instability

The diagnosis should be confirmed whenever possible by objective means such as pulmonary angiography or non-invasive procedures such as lung scanning. There is no evidence for positive effects on mortality and late morbidity related to pulmonary embolism.

Fibrinolytic treatment of acute ischaemic stroke

Treatment must be started as early as possible within 4.5 hours after onset of stroke symptoms and after exclusion of intracranial haemorrhage by appropriate imaging techniques (e.g. cranial computerised tomography or other diagnostic imaging method sensitive for the presence of haemorrhage). The treatment effect is time-dependent; therefore earlier treatment increases the probability of a favourable outcome.

Alteplase should be given as soon as possible after symptom onset. The following dose guidelines apply.

Acute Myocardial infarction

Posology

a) 90 minutes (accelerated) dose regimen for patients with acute myocardial infarction, in whom treatment can be started within 6 hours after symptom onset:

In patients with a body weight below 65 kg the dose should be weight adjusted according to the following table:

b) 3 h dose regimen for patients, in whom treatment can be started between 6 and 12 hours after symptom onset:

In patients with a body weight below 65 kg the total dose should not exceed 1.5 mg/kg.

The maximum dose of alteplase is 100 mg.

Adjunctive therapy: Antithrombotic adjunctive therapy is recommended according to the current international guidelines for the management of patients with ST-elevation myocardial infarction.

Method of administration

The reconstituted solution should be administered intravenously.

2 mg vials of alteplase are not indicated for use in this indication.

Pulmonary embolism

Posology

A total dose of 100 mg of alteplase should be administered in 2 hours. Most experience is available with the following dose regimen:

The total dose should not exceed 1.5 mg/kg in patients with a body weight below 65 kg.

Adjunctive therapy: After treatment with Alteplase heparin therapy should be initiated (or resumed) when aPTT values are less than twice the upper limit of normal. The infusion should be adjusted to maintain aPTT between 50 - 70 seconds (1.5 to 2.5 fold of the reference value).

Method of administration

The reconstituted solution should be administered intravenously.

2 mg vials of alteplase are not indicated for use in this indication.

Acute ischaemic stroke

Posology

The recommended dose is 0.9 mg alteplase/kg body weight (maximum of 90 mg) infused intravenously over 60 minutes with 10% of the total dose administered as an initial intravenous bolus.

Adjunctive therapy: The safety and efficacy of this regimen with concomitant administration of heparin and acetylsalicylic acid within the first 24 hours of onset of the symptoms have not been sufficiently investigated. Administration of acetylsalicylic acid or intravenous heparin should be avoided in the first 24 hours after treatment with Alteplase. If heparin is required for other indications (e.g. prevention of deep vein thrombosis) the dose should not exceed 10,000 IU per day, administered subcutaneously.

Method of administration

The reconstituted solution should be administered intravenously.

2 mg vials of alteplase are not indicated for use in this indication.

Paediatric population

The safety and efficacy of Alteplase in children and adolescents has not yet been established. Alteplase is contraindicated for the treatment of acute stroke in children and adolescents.

Additional contraindications in acute myocardial infarction, acute pulmonary embolism and acute ischaemic stroke:

Alteplase is contraindicated in cases where there is a high risk of haemorrhage such as:

- significant bleeding disorder at present or within the past 6 months

- known haemorrhagic diathesis

- patients receiving effective oral anticoagulant treatment, e.g. warfarin sodium

- manifest or recent severe or dangerous bleeding

- known history of or suspected intracranial haemorrhage

- suspected subarachnoid haemorrhage or condition after subarachnoid haemorrhage from aneurysm

- any history of central nervous system damage (i.e. neoplasm, aneurysm, intracranial or spinal surgery)

- recent (less than 10 days) traumatic external heart massage, obstetrical delivery, recent puncture of a non-compressible blood-vessel (e.g. subclavian or jugular vein puncture)

- severe uncontrolled arterial hypertension

- bacterial endocarditis, pericarditis

- acute pancreatitis

- documented ulcerative gastrointestinal disease during the last 3 months, oesophageal varices, arterial-aneurysm, arterial/venous malformations

- neoplasm with increased bleeding risk

- severe liver disease, including hepatic failure, cirrhosis, portal hypertension (oesophageal varices) and active hepatitis

- major surgery or significant trauma in past 3 months.

Additional contraindications in acute myocardial infarction:

- any known history of haemorrhagic stroke or stroke of unknown origin

- known history of ischaemic stroke or transient ischaemic attack (TIA) in the preceding 6 months except current acute ischaemic stroke within 4.5 hours.

Additional contraindications in acute pulmonary embolism:

- any known history of haemorrhagic stroke or stroke of unknown origin

- known history of ischaemic stroke or transient ischaemic attack (TIA) in the preceding 6 months except current acute ischaemic stroke within 4.5 hours.

Additional contraindications in acute ischaemic stroke:

- symptoms of ischaemic attack beginning more than 4.5 hours prior to infusion start or symptoms for which the onset time is unknown and could potentially be more than 4.5 hours ago

- minor neurological deficit or symptoms rapidly improving before start of infusion

- severe stroke as assessed clinically (e.g. NIHSS>25) and/or by appropriate imaging techniques

- seizure at onset of stroke

- evidence of intracranial haemorrhage (ICH) on the CT-scan

- symptoms suggestive of subarachnoid haemorrhage, even if CT-scan is normal

- administration of heparin within the previous 48 hours and a thromboplastin time exceeding the upper limit of normal for laboratory

- patients with any history of prior stroke and concomitant diabetes

- prior stroke within the last 3 months

- platelet count of below 100,000/mm³

- systolic blood pressure > 185 or diastolic BP > 110 mm Hg, or aggressive management (intravenous pharmacotherapy) necessary to reduce BP to these limits

- blood glucose < 50 or > 400 mg/dl.

Use in children and adolescents

Alteplase is not indicated for the treatment of acute stroke in paediatric patients under 18 years.

Use in elderly patients

Alteplase is not indicated for the treatment of acute stroke in adults over 80 years of age.

The appropriate presentation of alteplase product should be chosen carefully and in accordance with the intended use. The 2 mg presentation of alteplase is not indicated for use in acute myocardial infarction, acute pulmonary embolism or acute ischaemic stroke (due to risk of massive under dosing). Only 10, 20 or 50 mg presentations are indicated for use in these indications.

Thrombolytic/fibrinolytic treatment requires adequate monitoring. Alteplase should only be used under the responsibility and follow-up of physicians trained and experienced in the use of thrombolytic treatments and with the facilities to monitor that use. It is recommended that when Alteplase is administered standard resuscitation equipment and pharmacotherapy is available in all circumstances.

Hypersensitivity

Immune-mediated hypersensitivity reactions associated with the administration of Alteplase can be caused by the active substance alteplase, gentamicin (a trace residue from the manufacturing process), any of the excipients, or the stopper of the glass vial with Alteplase powder which contains natural rubber (a derivative of latex). No sustained antibody formation to the recombinant human tissue-type plasminogen activator molecule has been observed after treatment. There is no systematic experience with re-administration of Alteplase.

There is also a risk of hypersensitivity reactions mediated through a non-immunological mechanism.

Angio-oedema represents the most common hypersensitivity reaction reported with Alteplase. This risk may be enhanced in the indication acute ischaemic stroke and/or by concomitant treatment with ACE inhibitors. Patients treated for any authorised indication should be monitored for angio-oedema during and for up to 24h after infusion.

If a severe hypersensitivity reaction (e.g. angio-oedema) occurs, the infusion should be discontinued and appropriate treatment promptly initiated. This may include intubation.

Haemorrhages

If a potentially dangerous haemorrhage occurs, in particular cerebral haemorrhage, the fibrinolytic therapy must be discontinued. In general, however, it is not necessary to replace the coagulation factors because of the short half-life and the minimal effect on the systemic coagulation factors. Most patients who have bleeding can be managed by interruption of thrombolytic and anticoagulant therapy, volume replacement, and manual pressure applied to an incompetent vessel. Protamine should be considered if heparin has been administered within 4 hours of the onset of bleeding. In the few patients who fail to respond to these conservative measures, judicious use of transfusion products may be indicated. Transfusion of cryoprecipitate, fresh frozen plasma, and platelets should be considered with clinical and laboratory reassessment after each administration. A target fibrinogen level of 1 g/l is desirable with cryoprecipitate infusion. Antifibrinolytic agents are available as a last alternative.

The risk of intracranial haemorrhage is increased in elderly patients, therefore in these patients the risk/benefit evaluation should be carried out carefully.

As with all thrombolytic agents, the expected therapeutic benefit should be weighed up particularly carefully against the possible risk, especially in patients with

- small recent traumas, such as biopsies, puncture of major vessels, intramuscular injections, cardiac massage for resuscitation

-

The use of rigid catheters should be avoided.

Patients receiving oral anticoagulant treatment:

The use of Alteplase may be considered when dosing or time since the last intake of anticoagulant treatment makes residual efficacy unlikely confirmed by appropriate test(s) of anticoagulant activity for the product(s) concerned showing no clinically relevant activity on the coagulation system (e.g. INR≤ 1.3 for vitamin K antagonists or other relevant test(s) for other oral anticoagulants are within the respective upper limit of normal).

Paediatric population

As yet, there is only limited experience with the use of Alteplase in children and adolescents.

Additional special warnings and precautions in acute myocardial infarction and acute pulmonary embolism:

A dose exceeding 100 mg of alteplase must not be given because it has been associated with an additional increase in intracranial bleeding.

The expected therapeutic benefit should be weighed up particularly carefully against the possible risk, especially in patients with systolic blood pressure > 160 mm Hg.

GPIIb/IIIa antagonists:

Concomitant use of GPIIb/IIIa antagonists increases the risk of bleeding.

Additional special warnings and precautions in acute ischaemic stroke:

Special precautions for use:

Treatment must only be performed under the responsibility and follow-up of a physician trained and experienced in neurovascular care. For the verification of treatment indication remote diagnostic measures may be considered as appropriate.

Special warnings / conditions with a decreased benefit/risk ratio:

Compared to other indications patients with acute ischaemic stroke treated with Alteplase have a markedly increased risk of intracranial haemorrhage as the bleeding occurs predominantly into the infarcted area. This applies in particular in the following cases:

- and in general all situations involving a high risk of haemorrhage

- small asymptomatic aneurysms of the cerebral vessels

- with later time-to-treatment from onset of stroke symptoms the net clinical benefit is reduced and may be associated with a higher risk of ICH and death compared to patients treated earlier. Therefore, the administration of Alteplase should not be delayed.

- patients pre-treated with acetyl salicylic acid (ASA) may have a greater risk of intracerebral haemorrhage, particularly if Alteplase treatment is delayed.

Blood pressure (BP) monitoring during treatment administration and up to 24 hours seems justified; an intravenous antihypertensive therapy is also recommended if systolic BP > 180 mm Hg or diastolic BP > 105 mm Hg.

The therapeutic benefit is reduced in patients that had a prior stroke or in those with known uncontrolled diabetes, thus the benefit/risk ratio is considered less favourable, but still positive in these patients.

In patients with very mild stroke, the risks outweigh the expected benefit.

Patients with very severe stroke are at higher risk for intracerebral haemorrhage and death and should not be treated.

Patients with extensive infarctions are at greater risk of poor outcome including severe haemorrhage and death. In such patients, the benefit/risk ratio should be thoroughly considered.

In stroke patients the likelihood of good outcomes decreases with increasing age, increasing stroke severity and increased levels of blood glucose on admission while the likelihood of severe disability and death or relevant intracranial bleedings increases, independently from treatment. Patients over 80, patients with severe stroke (as assessed clinically and/or by appropriate imaging techniques) and patients with blood glucose levels < 50 mg/dl or > 400 mg/dl at baseline should not be treated with Alteplase.

Data available from ECASS III and the pooled analysis indicate that the net clinical benefit becomes smaller in elderly with increasing age compared to younger patients as benefit from treatment with Alteplase appears to decrease and the risk of mortality appears to increase with increasing age.

Other special warnings:

Reperfusion of the ischaemic area may induce cerebral oedema in the infarcted zone.

Due to an increased haemorrhagic risk, treatment with platelet aggregation inhibitors should not be initiated within the first 24 hours following thrombolysis with alteplase.

Not relevant.

The most frequent adverse reaction associated with Alteplase is bleeding in different forms resulting in a fall in haematocrit and/or haemoglobin values.

Adverse reactions listed below are classified according to frequency and system organ class. Frequency groupings are defined according to the following convention: Very common (>1/10), Common (>1/100 to <1/10), Uncommon (>1/1,000 to <1/100), Rare (>1/10,000 to <1/1,000), Very rare (<1/10,000), Not known (cannot be estimated from the available data).

Except for intracerebral/intracranial haemorrhage as adverse reaction in the indication stroke as well as for reperfusion arrhythmias in the indication myocardial infarction, there is no medical reason to assume that the qualitative and quantitative adverse reaction profile of Alteplase in the indications pulmonary embolism and acute ischaemic stroke is different from the profile in the indication myocardial infarction.

Table 1 Adverse reactions in myocardial infarction, pulmonary embolism and ischaemic stroke

**Cardiac disorders

As with other thrombolytic agents, the events described above under the respective section have been reported as sequelae of myocardial infarction and / or thrombolytic administration. These cardiac events can be life-threatening and may lead to death.

***Frequency calculation

This adverse reaction has been observed in post-marketing experience. With 95 % certainty, the frequency category is not greater than “rare”, but might be lower. Precise frequency estimation is not possible as the adverse drug reaction did not occur in a clinical trial database of 8299 patients.

Death and permanent disability are reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

The relative fibrin specificity notwithstanding, a clinical significant reduction in fibrinogen and other blood coagulation components may occur after overdosage. In most cases, it is sufficient to await the physiological regeneration of these factors after the Alteplase therapy has been terminated. If, however, severe bleeding results, the infusion of fresh frozen plasma is recommended and if necessary, synthetic antifibrinolytics may be administered.

Pharmacotherapeutic group: Antithrombotic agents, ATC code: B01AD02

The active ingredient of Alteplase is alteplase a recombinant human tissue-type plasminogen activator, a glycoprotein, which activates plasminogen directly to plasmin. When administered intravenously, alteplase remains relatively inactive in the circulatory system. Once bound to fibrin, it is activated, inducing the conversion of plasminogen to plasmin leading to the dissolution of the fibrin clot.

Due to its relative fibrin-specificity alteplase at a dose of 100 mg leads to a modest decrease of the circulating fibrinogen levels to about 60 % at 4 hours, which is generally reverted to more than 80 % after 24 hours. Plasminogen and alpha-2-antiplasmin decrease to about 20 % and 35 % respectively after 4 hours and increase again to more than 80 % at 24 hours. A marked and prolonged decrease of the circulating fibrinogen level is only seen in few patients.

In a study including more than 40,000 patients with an acute myocardial infarction (GUSTO) the administration of 100 mg alteplase over 90 minutes, with concomitant intravenous heparin infusion, led to a lower mortality after 30 days (6.3 %) as compared to the administration of streptokinase, 1.5 million U over 60 minutes, with subcutaneous or intravenous heparin (7.3 %). Alteplase-treated patients showed higher infarct related vessel patency rates at 60 and 90 minutes after thrombolysis than the streptokinase-treated patients. No differences in patency rates were noted at 180 minutes or longer.

30-day-mortality is reduced as compared to patients not undergoing thrombolytic therapy.

The release of alpha-hydroxybutyrate-dehydrogenase (HBDH) is reduced. Global ventricular function as well as regional wall motion is less impaired as compared to patients receiving no thrombolytic therapy.

Myocardial infarction

A placebo controlled trial with 100 mg alteplase over 3 hours (LATE) showed a reduction of 30-day-mortality compared to placebo for patients treated within 6-12 hours after symptom onset. In cases, in which clear signs of myocardial infarction are present, treatment initiated up to 24 hours after symptom onset may still be beneficial.

Pulmonary embolism

In patients with acute massive pulmonary embolism with haemodynamic instability thrombolytic treatment with Alteplase leads to a fast reduction of the thrombus size and a reduction of pulmonary artery pressure. Mortality data are not available.

Acute ischaemic stroke Patients

In two USA studies (NINDS A/B) a significant higher proportion of patients, had a favourable outcome with alteplase, compared to placebo (no or minimal disability). These findings were confirmed in the ECASS III trial (see paragraph below), after in the meantime two European studies and an additional USA study had failed to provide the respective evidence in settings essentially not compliant with the current EU product information.

The ECASS III trial was a placebo-controlled, double-blind trial conducted in patients with acute stroke in a time-window of 3 to 4.5 hours in Europe. Treatment administration in the ECASS III study was in line with the European SmPC for Alteplase in its stroke indication, except the upper end of the time of treatment window i.e. 4.5 hours. The primary end point was disability at 90 days, dichotomized for favourable (modified Rankin scale [mRS] 0 to 1) or unfavourable (mRS 2 to 6) outcome. A total of 821 patients (418 alteplase/403 placebo) were randomized. More patients achieved favourable outcome with alteplase (52.4%) vs. placebo (45.2%; odds ratio [OR] 1.34; 95% CI 1.02 - 1.76; P=0.038). The incidence of any ICH/SICH was higher with alteplase vs. placebo (any ICH 27.0% vs 17.6%, p=0.0012; SICH by ECASS III definition 2.4% versus 0.2 %, p = 0.008). Mortality was low and not significantly different between alteplase (7.7%) and placebo (8.4%; P=0.681). Subgroup results of ECASS III confirm that a longer OTT is associated with an increasing risk for mortality and symptomatic intracranial haemorrhage. The results of ECASS III show a positive net-clinical benefit for Alteplase in the 3 to 4.5 hour time window, while pooled data demonstrate that the net-clinical benefit is no longer favourable for alteplase in the time window beyond 4.5 hours.

The safety and efficacy of Alteplase for acute ischaemic stroke treatment up to 4.5 hours time stroke onset time to start of treatment (OTT) has been assessed by an ongoing registry (SITS-ISTR: The Safe Implementation of Thrombolysis in Stroke registry). In this observational study safety outcome data of 21.566 treated patients in the 0 to 3 hour time window were compared with data from 2.376 patients treated between 3 to 4.5 hours after onset of AIS. The incidence of symptomatic intracranial haemorrhage (according to the SITS-MOST definition) was found to be higher in the 3 to 4.5 hour time window (2.2%) as compared with the up to 3 hour time window (1.7%). Mortality rates at 3 months were similar comparing the 3 to 4.5 hour time window (12.0%) with the 0 to 3.0 hours time window (12.3%) with an unadjusted OR 0.97 (95% CI: 0.84-1.13, p=0.70) and an adjusted OR 1.26 (95% CI: 1.07-1.49, p=0.005. The SITS observational data support clinical trial evidence of stroke onset time to start of treatment (OTT) as an important predictor of outcome following acute stroke treatment with alteplase.

Alteplase is cleared rapidly from the circulating blood and metabolised mainly by the liver (plasma clearance 550 - 680 ml/min.). The relevant plasma half-life t_1/2 alpha is 4-5 minutes. This means that after 20 minutes less than 10 % of the initial value is present in the plasma. For the residual amount remaining in a deep compartment, a beta-half-life of about 40 minutes was measured.

In subchronic toxicity studies in rats and marmosets no unexpected undesirable effects were found. No indications of a mutagenic potential were found in mutagenic tests.

In pregnant animals no teratogenic effects were observed after intravenous infusion of pharmacologically effective doses. In rabbits embryotoxicity (embryolethality, growth retardation) was induced by more than 3 mg/kg/day. No effects on peri-postnatal development or on fertility parameters were observed in rats with doses up to 10 mg/kg/day.

The reconstituted solution may be diluted with sterile sodium chloride 9 mg/ml (0.9 %) solution for injection up to a minimal concentration of 0.2 mg alteplase per ml.

Further dilution, the use of water for injections for dilution or in general the use of carbohydrate infusion solutions, e.g. dextrose, is not recommended due to increasing formation of turbidity of the reconstituted solution.

Alteplase should not be mixed with other medicinal products neither in the same infusion vial nor the same catheter (not even with heparin).

For reconstitution to a final concentration of 1 mg alteplase per ml the full volume of solvent provided should be transferred to the vial containing the Alteplase powder. To this purpose a transfer cannula is included with the 20 mg and 50 mg presentations, which is to be used. For the 10 mg presentation a syringe should be used.

For reconstitution to a final concentration of 2 mg alteplase per ml only half of the solvent provided should be used (as per table below). In these cases always a syringe should be used to transfer the required amount of solvent to the vial containing the Alteplase powder.

Under aseptic conditions the content of an injection vial of Alteplase (10 mg or 20 mg or 50 mg) is dissolved with water for injections according to the following table to obtain either a final concentration of 1 mg alteplase/ml or 2 mg alteplase/ml:

The reconstituted solution should then be administered intravenously. The 1 mg/mL reconstituted solution may be diluted further with sterile sodium chloride 9 mg/ml (0.9 %) solution for injection up to a minimal concentration of 0.2 mg/ml. A further dilution of the 1 mg/mL reconstituted solution with sterilised water for injections or in general, the use of carbohydrate infusion solutions, e.g. dextrose is not recommended. Alteplase should not be mixed with other medicinal products in the same infusion-vial (not even with heparin).

The reconstituted solution is for single use only. Any unused solution or waste material should be disposed in accordance with the local requirements.

Instructions for reconstituting Alteplase

(*if a transfer cannula is included in the kit. The reconstitution can also be performed with a syringe and a needle.)