Study of Tenecteplase Versus Alteplase for Thrombolysis (Clot Dissolving) in Acute Ischemic Stroke

Ischemic Stroke Clinical Trial

— NOR-TEST  

Official title:

Randomised Trial of Tenecteplase vs. Alteplase for Recanalisation in Acute Ischemic Stroke

Clinical Trial Details — Status: Completed

Administrative data

• NCT number: NCT01949948
• Other study ID #: REK 2011/2435
• Status: Completed
• Phase: Phase 3
• First received: September 21, 2013
• Last updated: May 5, 2017
• Start date: September 2012
• Est. completion date: December 31, 2016

Study information

• Verified date: May 2017
• Source: Haukeland University Hospital
• Contact: n/a
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

BACKGROUND: Alteplase dissolves blood vessel clots in acute ischemic stroke and is the only approved acute drug treatment <4½ hours of stroke onset. The overall benefit from alteplase is substantial, but up to 2/3 of patients with large artery clots may not achieve reopening of the vessel and up to 40% of the patients may remain severely disabled or die, leaving substantial room for improvement. Tenecteplase, widely used in coronary heart disease, may be more effective and may have less bleeding complications than alteplase, and may be the drug of choice also in stroke.

HYPOTHESIS: Tenecteplase may be given safely to patients with acute ischemic stroke at a dose that is associated with improved clinical outcome compared with existing treatment options.

AIMS: To compare efficacy and safety of tenecteplase vs. alteplase given <4½ hours after symptom onset.

STUDY ENDPOINTS: The primary study endpoint is excellent clinical outcome at 3 months (effect). Secondary study endpoints are major early clinical improvement (effect) and bleeding complications (safety).

Description:

HYPOTHESIS: 1) Tenecteplase 0.4 mg/kg may be given safely to patients with acute ischaemic stroke <4½ hours after stroke onset. 2) Tenecteplase 0,4 mg/kg (single bolus)has superior efficacy and safety compared with alteplase 0.9 mg/kg (10% bolus + 90% infusion/60 minutes) when given within 4 ½ hours after stroke onset.

DESIGN: NOR-TEST is a multi-centre PROBE (prospective randomised, open-label, blinded endpoint) trial with randomisation tenecteplase:alteplase 1:1.

POWER CALCULATION: NOR-TEST aims at detecting a 9 % higher percentage excellent outcome with tenecteplase vs. alteplase (r1=0.40; r2=0.49; OR 1.44; power 0.8), and will include 954 patients during 3 years.

PATIENT RECRUITMENT: All patients found eligible for thrombolytic therapy are eligible for NOR-TEST, i.e. NOR-TEST changes neither inclusion nor exclusion criteria. The number of patients treated at a participating centre will therefore essentially remain unchanged. Estimated 400 patients are thrombolysed per year in participating centres. Allowing for 20% of patients not being included in NOR-TEST, the total number of patients (n=954) will still be met.

Recruitment information / eligibility

• Status: Completed
• Enrollment: 1050
• Est. completion date: December 31, 2016
• Est. primary completion date: December 31, 2016
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Age 18 years or older

• Ischaemic stroke with measurable deficit on NIH Stroke Scale

• All stroke sub-types, severities and vascular distributions,a visible arterial occlusion is not required for inclusion

• Treatment within 4 ½ hours of stroke onset

• Patients awakening with symptoms are defined by the time last observed normal and awake

• Informed written consent signed by the patient, verbal consent from the patients as witnessed by a non-participating health care person, or consent by the signature of the patient's family must be provided

Exclusion Criteria:

• Patients with premorbid modified Rankin Scale (mRS) score =3

• Patients for whom a complete NIH Stroke Score cannot be obtained

• Hemiplegic migraine with no arterial occlusion on CTA

• Seizure at stroke onset and no visible occlusion on baseline CTA

• Intracranial haemorrhage on baseline CT

• Clinical presentation suggesting subarachnoid haemorrhage even if baseline CT is normal

• Large areas of hypodense ischaemic changes on baseline CT

• Patients with systolic blood pressure >185 mm Hg or diastolic blood pressure >110 mm Hg

• Female, pregnant or breast feeding

• Known bleeding diathesis

• Use of oral anticoagulants and International Normalized Ratio (INR) =1,4

• Use of new oral anticoagulants (NOAC) within the last 12 hours

• Heparin <48 hours and increased Activated partial thromboplastin tike (APTT)

• Low molecular weight heparin(oid) <24 hours

• Any other investigational drug <14 days

• Sepsis

• Patients with arterial puncture at a noncompressible site or lumbar puncture <7 days

• Major surgery or serious trauma <14 days

• Gastrointestinal or urinary tract hemorrhage <14 days

• Clinical stroke <2 months

• History of intracranial haemorrhage

• Brain neurosurgery <2 months

• Serious head trauma <2 months

• Pericarditis

• Any serious medical illness likely to interact with treatment

• Confounding pre-existent neurological or psychiatric disease

• Unlikely to complete follow-up

• Pregnancy

Related Conditions & MeSH terms

• Cerebral Infarction
• Ischemia
• Ischemic Stroke
• Stroke

Intervention

Drug:
• Tenecteplase
0.4 mg/kg single bolus intravenously
• Alteplase
0.9 mg/kg as 10% bolus + 90% infusion/60 minutes intravenously

Locations

Country	Name	City	State
Norway	Haukeland University Hospital	Bergen
Norway	Nordland Hospital	Bodø
Norway	Drammen Hospital	Drammen
Norway	Førde Central Hospital	Førde
Norway	Haugesund Hospital	Haugesund
Norway	Molde Hospital	Molde
Norway	Akershus University Hospital	Nordbyhagen
Norway	Ullevål University Hospital	Oslo
Norway	Baerum Hospital	Rud
Norway	Telemark Hospital	Skien
Norway	Stavanger University Hosital	Stavanger
Norway	Tønsberg Hospital	Tønsberg
Norway	St. Olav Hospital NTNU	Trondheim

Sponsors (2)

Lead Sponsor	Collaborator
Lars Thomassen	The Research Council of Norway

Country where clinical trial is conducted

Norway, 

References & Publications (1)

Logallo N, Kvistad CE, Nacu A, Naess H, Waje-Andreassen U, Asmuss J, Aamodt AH, Lund C, Kurz MW, Rønning OM, Salvesen R, Idicula TT, Thomassen L. The Norwegian tenecteplase stroke trial (NOR-TEST): randomised controlled trial of tenecteplase vs. alteplase in acute ischaemic stroke. BMC Neurol. 2014 May 15;14:106. doi: 10.1186/1471-2377-14-106. — View Citation

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Clinical: Functional handicap	Excellent outcome defined as mRS 0-1	90 days
Secondary	Symptomatic cerebral hemorrhage	Haemorrhagic transformation (haemorrhagic infarct / haematoma) as defined by CT (or MRI)	24-36 hours
Secondary	Hemorrhagic transformation	Any hemorrhagic infarct or parenchymal hematoma	24-36 hours
Secondary	Neurological improvement	NIHSS changes from baseline: NIHSS=0 or reduction of =4 NIHSS points	24 hours
Secondary	Clinical: Functional handicap	Ordinal shift analysis of mRS	90 days
Secondary	Safety	Death	90 days