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Thrombolytic — Ischaemic Stroke / Massive PE Pregnancy: Use only if clearly life-saving — high maternal and fetal bleeding risk

Alteplase (tPA)

Brand names: Actilyse

Adult dose

Dose: Stroke: 0.9 mg/kg IV (max 90 mg) — 10% as bolus, 90% over 60 min. Massive PE: 100 mg IV over 2 hours
Route: Intravenous
Frequency: Single course
Max: 90 mg (stroke); 100 mg (PE)
Stroke: treat within 4.5 hours of symptom onset per NICE NG128 (or within 3 hours without anticoagulant). PE: for massive PE with haemodynamic compromise — 100 mg over 2 hours; if cardiac arrest, 50 mg bolus

Paediatric dose

Dose: Seek specialist opinion N/A/kg
Route: IV
Frequency: Seek specialist opinion
Max: Seek specialist opinion
Seek specialist opinion — rare use in paediatric arterial thrombosis

Dose adjustments

Renal

No dose adjustment required

Hepatic

Use with caution in hepatic impairment — bleeding risk

Paediatric weight-based calculator

Seek specialist opinion — rare use in paediatric arterial thrombosis

Clinical pearls

  • Time is brain: each minute without reperfusion in ischaemic stroke causes approximately 1.9 million neuron deaths; IV thrombolysis is lifesaving and reduces disability when given within 4.5 hours
  • Orolingual angioedema occurs in 1-5% with alteplase — highest risk if patient is on ACE inhibitor; manage with adrenaline, antihistamine, airway protection
  • Contraindications checklist must be completed before administration — absolute contraindications include any prior haemorrhagic stroke, BP above 185/110 (must be treated first), blood glucose below 2.7 or above 22.2 mmol/L
  • Massive PE with cardiac arrest: 50 mg bolus alteplase can be given during CPR — continue CPR for at least 60-90 minutes after administration before stopping
  • Do not give antiplatelets or anticoagulants for 24 hours post-alteplase in stroke — risk of haemorrhagic transformation

Contraindications

  • Haemorrhagic stroke (current or within 3 months)
  • Recent major surgery or trauma (within 3 months)
  • Active internal bleeding
  • Uncontrolled severe hypertension
  • Intracranial neoplasm or AVM
  • Stroke: NIHSS above 25 (severe), age above 80 (relative for extended window)

Side effects

  • Intracranial haemorrhage (most serious — 5-6% in stroke)
  • Systemic bleeding
  • Reperfusion arrhythmias (PE/STEMI)
  • Angioedema (orolingual — especially with ACE inhibitors)
  • Hypotension

Interactions

  • Anticoagulants (significantly increased bleeding risk — heparin often withheld 24 hours post-alteplase in stroke)
  • Antiplatelet agents (increased bleeding)
  • ACE inhibitors (increased angioedema risk)

Monitoring

  • Neurological observations every 15 minutes during infusion, then hourly (stroke)
  • BP (target below 180/105 during and 24 hours post-infusion)
  • Signs of bleeding
  • Repeat CT head if neurological deterioration

Reference: BNFc; BNF 90; NICE NG128 (Stroke); NICE NG158 (Venous Thromboembolism); ESC PE Guidelines 2019; IST-3 Trial. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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