Reduced-Dose Tenecteplase in High-Risk Pulmonary Embolism

Pulmonary embolism (PE) is a venous thromboembolic disease occurring when thrombi detach and embolize to pulmonary arteries, causing substantial morbidity and mortality in older adults yearly. In patients experiencing hemodynamic compromise, systemically administered thrombolytic therapy followed by anticoagulation over anticoagulation alone is recommended for initial management.

This report describes successful treatment of a patient over 90 years of age presenting to the Emergency Department with an acute, high-risk PE who received low-dose, systemically administered tenecteplase followed by systemic anticoagulation with unfractionated heparin. The patient was initiated on norepinephrine 0.5 µg/kg/min for hemodynamic support. They were administered a reduced dose of tenecteplase (17.5 mg or 0.37 mg/kg) bolus followed by unfractionated heparin and subsequent transfer to the medical intensive care unit. At 1 h post-tenecteplase, norepinephrine was decreased to 0.2 µg/kg/min. At 14 h post-tenecteplase, the norepinephrine requirement was minimal at 0.02 µg/kg/min and resolved with extubation 15 h post-tenecteplase. The patient did not develop any clinically significant bleeding and was discharged to an acute rehabilitation facility on hospital day 7. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Available evidence suggests positive outcomes and dosing guidance for low-dose alteplase for PE treatment, though at the time of this report the authors identified a gap in existing literature surrounding the same concept with reduced-dose tenecteplase. Further studies are needed to investigate this intervention further.