Studies and
Registries
March 2012
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Studies and
Registries
Studies and Registries
ECASS 3
Imaging studies (MRI-based patient selection)
Meta- and pooled analyses
SITS register
SITS-MOST
SITS-ISTR
SITS-NEW
VISTA
ECASS 3
ECASS 3: Background
 Thrombolysis with rt-PA initiated within 3 h of symptom onset
is the only approved treatment for acute ischaemic stroke
 Efficacy is highest if initiated within 90 min
 Many stroke victims do not reach a centre equipped to
administer rt-PA in time
 Worldwide, <5% of acute ischaemic stroke patients are
treated with rt-PA within 3 hours of stroke symptom onset
NINDS Trialists N Engl J Med 1995;333:1581-1587.
Hacke et al. Lancet 2004;363:768-774.
Ingall. Stroke 2009;40:2264-2265.
ECASS 3: Rationale
 rt-PA was approved by the EU regulatory authority EMEA in
2002 for use within 3 h of ischaemic stroke with two postapproval requirements:
 All patients should be registered in the SITS internet database
and entered into an observational safety study, SITS-MOST
 A randomised trial of rt-PA versus placebo, with an extended
therapeutic window greater than 3 hours
 The pooled analysis of individual patient data (N=2,775) from
6 trials of i.v. rt-PA vs. placebo showed that the effective
treatment window may extend to 4.5 hours
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
Hacke et al. Lancet 2004;363:768-774.
ECASS 3: Overview
Objective

To assess efficacy and safety of rt-PA between 3 and 4.5 hours
after stroke onset in the European setting
Primary Endpoint: Disability at day 90

Favourable (mRS ≤1) vs. unfavourable outcome (mRS 2-6)
Secondary Endpoint

Global outcome analysis at day 90, combining mRS (0-1), Barthel
Index ≥95, NIHSS (0-1), Glasgow Outcome Scale (1)
Safety Endpoints

Included mortality at 90 days, any ICH, SICH
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
ECASS 3: Primary Endpoint (ITT)
Disability at Day 90, mRS ≤1
Analysis
rt-PA
n/N (%)
Placebo
n/N (%)
OR
(95% CI)
p
Unadjusted
219/418 (52.4%)
182/403
(45.2%)
1.34
(1.02−1.76)
0.04‡
−
−
1.42
(1.02−1.98)
0.04§
Adjusted*
0.5
1
1.5
Favours placebo Favours rt-PA
ITT, intent-to-treat
*Adjusted for NIHSS score at presentation and the time to start of treatment
‡ p value was obtained by the Pearson chi-square test of proportions
§p value was obtained by stepwise logistic regression
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
ECASS 3: Secondary Endpoint (ITT)
Day 90: NINDS global endpoint statistic
(mRS 0-1; BI ≥95; NIHSS ≤1 or >8 point improvement; GOS 1)
rt-PA
(N=418)
Placebo
(N=403)
OR
(95% CI)
p
n/a
n/a
1.28
(1.00–1.65)
0.05
mRS score ≤1
219 (52.4%)
182 (45.2%)
1.34
(1.02–1.76)
0.04‡
BI score ≥95
265 (63.4%)
236 (58.6%)
1.23
(0.93–1.62)
0.16‡
NIHSS score ≤1
210 (50.2%)
174 (43.2%)
1.33
(1.01–1.75)
0.04‡
GOS score 1
213 ( 51.0%)
183 (45.4%)
1.25
(0.95–1.64)
0.11‡
Global outcome
0.5
1
1.5
Favours placebo Favours rt-PA
ITT, intent–to-treat; ‡ p value was obtained by the Pearson chi-square test of proportions
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
ECASS 3: Functional Efficacy Endpoints at 90 Days
(PP Population)
730 patients (out of 821 randomised)
Endpoint day
90
rt-PA
(N=375)
Placebo
(N=355)
OR
(95% CI)
p
mRS score 0-1
206 (54.9%)
161 (45.4%)
1.47
(1.10−1.97)
0.01‡
Global outcome
statistic
(unadjusted)
n/a
n/a
1.39
(1.07−1.80)
0.02
0.5
1
1.5
Favours placebo Favours rt-PA
mRS, modified Rankin Scale
PP, per protocol
‡ p value was obtained by the Pearson chi-square test of proportions
Bluhmki et al. Lancet Neurol 2009;8:1095-1102.
ECASS 3: Distribution of Scores on the mRS at 90
Days for the Per-Protocol Populations
Per-protocol population
Patients
p=0.016
‡stratified
on Cochran–Mantel–Haenszel test, adjusted for baseline NIHSS scores and time-to-treatment onset
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
ECASS 3 - Efficacy: Summary
 rt-PA administered 3-4.5 hours after stroke symptom onset is
effective
 Significantly more patients benefitted vs. placebo in terms of:
• Disability at day 90, mRS 0-1
• Overall greater functionality/independence (global outcome statistic) at
day 90
• Improved neurological functioning (NIHSS 0-1 or >8 point improvement)
at day 30
• Independence (mRS 1-2) at day 30 in the PP population
mRS, modified Rankin Scale
PP, per protocol
NIHSS, National Institute of Health Stroke Scale
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
ECASS 3 – Safety Endpoints: Mortality (ITT)
Mortality by time interval
10%
0.7%
8%
Death (%)
After day 90 (7 deaths)
Days 8–90 (34 deaths)
Days 1–7 (25 deaths)
1.0%
6%
4.5%
3.8%
4%
2%
0%
Overall mortality
3.2%
2.9%
rt-PA
Placebo
rt-PA
(N=418)
Placebo
(N=403)
OR
(95% CI)
p
32 (7.7%)
34 (8.4%)
0.90
0.68
(0.54–1.49)
0.5
ITT, intent-to-treat
1
1.5
Favours rt-PA Favours placebo
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
ECASS 3 – Safety Endpoints: Summary
 sICH (symptomatic intracranial haemorrhage)
 Significant difference in sICH rates (2.14% absolute difference),
although the incidence of sICH among rt-PA-treated patients was
low (2.4%)
 Mortality
 Low overall mortality rate (approximately 8%), not different between
treatment arms
 Probably due to the mild to moderate initial stroke severity
 Consistent with results from other randomised controlled trials of
thrombolysis in acute ischaemic stroke
 No safety concerns in the longer time window
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
ECASS 3:
Further Analyses
ECASS 3: Further Analyses
 Additional outcome analyses included functional endpoints at
day 90 or day 30
 mRS 0-1 [day 30], mRS 0-2, Barthel Index ≥85, and global outcome
statistic [day 30] and treatment response (8-point improvement from
baseline or 0-1 score on NIHSS)
 A stratified responder analysis by baseline NIHSS
 The subgroup analyses were based on the mRS 0-1 at day 90,
sICH, and death
mRS, modified Rankin Scale
sICH, symptomatic intracranial haemorrhage
NIHSS, National Institutes of Health Stroke Scale
Bluhmki et al. Lancet Neurol 2009;8:1095-1102.
ECASS 3 – Subgroup Analysis of Favourable Outcome
(mRS 0-1): Demographics (ITT)
rt-PA
% (n/N)
Placebo
% (n/N)
OR
(95% CI)
p
0-9
10-19
≥20
73% (156/215)
34% (57/166)
16% (6/37)
67% (128/190)
31% (50/161)
8% (4/52)
1.28 (0.84-1.96)
1.16 (0.73-1.84)
2.32 (0.61-8.9)
0.631
<65
≥65
57% (105/184)
49% (144/234)
45% (70/155)
45% (112/247)
1.61 (1.05-2.48)
1.15 (0.80-1.64)
0.230
53% (139/264)
52% (80/154)
42% (97/231)
50% (85/171)
1.54 (1.08-2.19)
1.09 (0.71-1.69)
0.237
58% (23/40)
49% (93/191)
56% (98/174)
40% (17/42)
47% (91/193)
43% (64/148)
1.99 (0.83-4.79)
1.06 (0.71-1.59)
1.69 (1.09-2.63)
0.212
NIHSS at baseline
Age
Gender
Male
Female
Time to treatment
181-210 min
211-240 min
241-270 min
1
Favours placebo Favours rt-PA
mRS, modified Rankin scale
ITT, intent-to-treat
Bluhmki et al. Lancet Neurol 2009;8:1095-1102.
ECASS 3 – Subgroup Analysis of Favourable Outcome
(mRS 0-1): Risk factors (ITT)
rt-PA
% (n/N)
Placebo
% (n/N)
OR
(95% CI)
p
Diabetes
No
Yes
54% (191/356)
45% (28/62)
44% (149/335)
49% (33/67)
1.45 (1.07-1.95)
0.85 (0.42-1.70)
0.167
Prior stroke
No
Yes
52% (199/387)
63% (20/32)
47% (163/345)
33% (19/57)
1.19 (0.89-1.59)
3.33 (1.35-8.22)
0.033
Hypertension
No
Yes
57% (90/157)
49% (129/261)
44% (66/149)
46% (116/253)
1.69 (1.07-2.66)
1.15 (0.82-1.63)
0.190
Atrial flutter/
fibrillation
No
Yes
56% (205/365)
26% (14/53)
47% (163/347)
35% (19/55)
1.45 (1.08-1.94)
1.69 (0.30-1.55)
0.092
1
mRs, modified Rankin scale
ITT, intent-to-treat
Favours placebo Favours rt-PA
Bluhmki et al. Lancet Neurol 2009;8:1095-1102.
ECASS 3 – Further Analyses: Summary
 Subgroup results
For mRS 0-1 all subgroups were in favour of rt-PA; most
notably no interaction by age and stroke severity was
established
 Additional endpoints
mRS 0-1, 0-2, Barthel index ≥85 and global outcome statistic
and treatment response (8 point improvement from baseline
or 0-1 on the NIHSS) stratified responder analysis
mRS, modified Rankin scale
NIHSS, National Institutes of Health Stroke Scale
Bluhmki et al. Lancet Neurol 2009;8:1095-1102.
ECASS 3:
Conclusions
ECASS 3: Conclusions
 Intravenous rt-PA initiated 3-4.5 h after onset of stroke
symptoms is:
 An effective treatment for patients with AIS, who cannot be
thrombolysed within 3 h, with no relevant increase in intracranial
bleeding compared with treatment within 3 h
 A viable therapeutic option for the many patients previously
excluded from thrombolysis by missing the narrow treatment timeframe
 Favourable across a broad range of subgroups of patients
 This finding opens a window of opportunity for later-arriving
stroke patients
 However …
AIS, acute ischaemic stroke
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
Bluhmki et al. Lancet Neurol 2009;8:1095-1102.
ECASS 3: Conclusions (cont)
 … having more time does not mean we should take
more time
 Patients need to be treated as early as possible with
rt-PA, to maximise the benefit therefore networks
have to work fast!
There may be more time for the patients,
but not for the treating physicians
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
Bluhmki et al. Lancet Neurol 2009;8:1095-1102.
Clinical Implications of ECASS 3
 Provides a better understanding of stroke systems of care for
patients with acute ischaemic stroke
 A multidisciplinary team is required to implement changes,
including healthcare professionals and professional
organisations
 Extension of the treatment window to 4.5 hours will impact all
stages of stroke networks from dispatchers and emergency
medicine services to acute stroke units and imaging facilities
 The balance of costs and benefits (in terms of gain in QALYs)
favours treatment with rt-PA in the 3-4.5 hour time window after
stroke onset vs. non-thrombolytic therapy
Tung et al. Stroke 2011;42:2257-2262.
Ingall. Stroke 2009;40:2264-2265.
Impact of ECASS 3 on Time to Thrombolysis
Following confirmation by ECASS 3 of the extended time window to 4.5 hours for the
administration of rt-PA to patients with an acute ischaemic stroke, delays in administration
were not confirmed and the proportion of patients with a DTN <60 min increased
ECASS 3
publication
Guideline
publication
Minnerup et al. Stroke 2011;42:2838-2843.
Imaging studies
(MRI-based Patient
Selection)
MRI-Based Patient Selection
 Mismatch concept
 Mismatch decreases over time, but may be found in individual
patients as late as 24 hours or more, depending on individual
symptoms
 This may help to increase the time window and also allow
treatment in patients without known onset of stroke
 Practical issues
 15-20 minutes scan time
 Some patients do not tolerate MR study
 Overall feasibility in experienced centres >90%
Warach et al. Ann. Neurol 2000;48:713-722.
Kidwell et al. Stroke 2002;33:95-98.
Jansen et al. Der Nervenarzt 1998;69:465-471.
Schellinger, Fiebach. In Fiebach, Schellinger 2003;6:31-34.
What is Mismatch?
 Historically defined on MRI as the difference in volume of DWI
lesion and PWI lesion
 PWI > DWI by at least 20%
 Uncorrected / unthresholded time-based perfusion parameter map
(TTP, MTT)
 Isotropic DWI
 Limitations
 DWI lesion reversibility in a minority of patients
 Therefore, DWI lesion is an approximation of infarct
 PWI without any thresholding identifies all brain tissue with
hypoperfusion
MRI, magnetic resonance imaging; DWI, diffusion weighted imaging; PWI, perfusion weighted imaging
TTP, time to peak; MTT, mean transit time
Other Mismatch Definitions
 Clinical DWI mismatch
 Higher NIHSS score than DWI lesion size would
suggest
 MRA DWI mismatch
 MRA vessel occlusion more proximal and involving
more brain tissue than infarcted on DWI
 FLAIR DWI mismatch
 Positive lesion on DWI but not seen on FLAIR images
Paradigm: MRI-Based Studies and
Individual Therapeutic Approach
Baseline
Acute
ischaemic
stroke
4-8h after rt-PA
30 days
Reperfusion
Higher
chance for
better
outcome
Higher
chance for
poorer
outcome
Acute
tissue at risk
Healthy brain
Interim
lesion
Tissue at risk
(penumbra)
Final
lesion
Dead brain
(ischaemic core)
Example: Imaging on Presentation of Acute
Ischaemic Stroke
Example: Imaging After rt-PA
Rationale for (MRI-)Mismatch Based Thrombolysis
 Time from symptom onset and (more or less) normal CT is an
excellent tool to screen for patients likely responsive to rt-PA



The earlier the time, the smaller the core
The earlier the time, the likelier no demarcation as also seen on normal CT
The earlier the time, the larger the tissue at risk
 Note: After 3-4.5h patients still have a reduced benefit
 Unselected treatment (CT, NIHSS, time 4.5-9h) leads to low or
no benefit with higher risk of bleeding and mortality (pooled
analyses)
 Therefore, selection of suitable patients beyond established
time windows is a worthwhile target
 This includes patients with unknown time window
DEFUSE
Objective
 To determine whether MRI profiles can help to predict clinical
response in patients with ischaemic stroke treated with iv
thrombolysis at 3-6 hours after onset
Key Results
 Target Mismatch pattern was associated with substantial benefit
from early reperfusion in 67%
 Malignant MRI pattern was associated with high risk of fatal
SICH following reperfusion
 Small DWI and PWI lesions are associated with favourable
outcomes
Albers et al; the DEFUSE Investigators. Ann Neurol 2006;60:508-517.
DEFUSE: MRI Profile and Clinical Outcome
MRI profile
N
Mean age (y)
Median
baseline
NIHSS score
Favourable
clinical
response*
Target mismatch with
early reperfusion
15
78.3
14
67%**
(42-84)
Target mismatch
without early
reperfusion
16
68.0
13
19%
(7-43)
Malignant profile
6
68.3
18.5
17%
(3-56)
* Improvement of 8 points or more in the NIHSS score between baseline and 30 days or a score of 0-1 at 30 days
** p≤0.01, compared with target mismatch without early reperfusion
Target mismatch excludes patients with malignant mismatch
Albers et al. Ann Neurol 2006;60:508-517.
Take 5: Multicentre Study (N=1,210 Patients)
 Large dataset
 More than 500 MRI-based rt-PA treated patients
 Comparison
 Standard CT based rt-PA <3 hours
 MR-based rt-PA <3 hours
 MR-based rt-PA >3 hours (-17 hours)
Schellinger et al. Stroke 2007;38:2640-2645.
Take 5: Safety and Efficacy Multivariate
Symptomatic ICH
Age
NIHSS
Use of MRI
OR=1.033, 95% CI 1.006-1.060, p=0.016
OR=1.057, 95% CI 1.010-1.106, p=0.016
OR=0.520, 95% CI 0.270-0.999, p=0.05
Good outcome
Age and NIHSS
Use of MRI >3h
Use of MRI <3h
OR=0.973 and 0.862, for both, p<0.001
OR=1.467, 95% CI 1.017-2.117, p=0.040
OR=1.36, 95% CI 0.841-1.534, p=NS
Conclusion
 MRI-based thrombolysis within and beyond the 3-h time window
is at least as safe and possibly more effective than CT-based
thrombolysis
Schellinger et al. Stroke 2007;38:2640-2645.
EPITHET
Hypotheses

PI/DWI mismatch represents potentially salvageable tissue in the
ischaemic penumbra

rt-PA will attenuate infarct growth by increased perfusion of the
penumbra
Objective

To determine whether rt-PA administered 3-6 hours after stroke onset
decreases infarct growth in patients with a known PI/DWI mismatch
Design

Randomised, double-blind, placebo-controlled trial
Davis et al. Lancet Neurol 2008;7:299-309.
EPITHET Outcomes: Infarct Growth
Primary measure
Ratio of geometric means (rt-PA/placebo)
p
0.24
Secondary growth measures
Median relative growth
0.05
Growth >0%
0.03
Geometric mean growth (baseline lesion >5 ml)
0.01
Davis et al. Lancet Neurol 2008;7:299-309.
EPITHET Clinical Outcomes:
Rankin Day 90 in Mismatch Patients
Functional outcome in mismatch patients
Patients
mRS, modified Rankin Scale
Davis et al. Lancet Neurol 2008;7:299-309.
EPITHET Clinical Outcomes:
Rankin Day 90 in Mismatch Patients
rt-PA
(N=42)
Placebo
(N=43)
p
mRS 0-2
45%
(19/42)
40%
(17/43)
0.60
mRS 0-1
36%
(15/42)
21%
(9/43)
0.13
NIHSS improvement ≥8 or NIHSS ≤1
50%
(21/42)
37%
(16/43)
0.23
Results suggest, in mismatch patients a Phase III
trial of rt-PA vs placebo 3-6 hours could be powered
with <200 patients per arm
mRS, modified Rankin Scale
Davis et al. Lancet Neurol 2008;7:299-309.
Reperfusion and Mismatch
 EPITHET study confirms the results of DEFUSE
 Reperfusion is associated with a better outcome and a reduced
infarct growth
Reperfusion
No reperfusion
N=30
N=47
Median relative growth
0.86
(0.34 to 1.75)
2.07
(1.19 to 3.65)
<0.0001
Median absolute growth
-1.0
(-9.0 to 11.2)
43.6
(4.0 to 92.3)
<0.0001
N=30
N=47
Good neurological outcome
22
(73%)
13
(27%)
<0.0001
Good functional outcome
19
(63%)
15
(32%)
0.007
Infarct growth
Clinical outcomes
p
Davis et al. Lancet Neurol 2008;7:299-309.
Imaging Studies: Conclusions
 CT is sufficient for exclusion of intracranial haemorrhage and
therefore decision making for or against thrombolysis
 Infarct detection <3h is achieved in only a third of ischaemic
strokes
 MRI is more sensitive than CT
 Perfusion/diffusion MRI can add more information about the
penumbra and potentially salvageable tissue after acute
ischaemic stroke
 Specific patient profiles on MRI can help to identify subgroups of
patients that may benefit from early reperfusion with thrombolytic
therapy outside of approved time windows
Albers et al; the DEFUSE Investigators. Ann Neurol 2006;60:508-517.
Davis et al. Lancet Neurol 2008;7:299-309.
Schellinger et al. Neurology 2010;75:177-185.
Meta- and Pooled
Analyses
Cochrane Meta-Analysis of IV rt-PA Versus Control
(including ECASS 3)
Mori 1992
13/19
10/12
0.4%
0.43 [0.07, 2.62]
ECASS 1995
201/313
217/307
11.3%
0.74 [0.53, 0.68]
NINDS 1995
179/312
229/312
11.3%
0.49 [0.35, 0.68]
ECASS II 1998
244/409
248/391
15.8%
0.85 [0.64, 1.13]
ATLANTIS B 1999
161/307
162/306
12.8%
0.98 [0.71, 1.35]
ATLANTIS A 2000
64/71
56/71
1.4%
2.45 [0.93, 6.44]
Wang 2003
29/67
26/33
1.4%
0.21 [0.08, 0.54]
EPITHET 2008
34/52
37/49
1.7%
0.61 [0.26, 1.46]
ECASS 3 2008
140/418
155/403
15.7%
0.81 [0.61, 1.07]
1968
1884
71.7%
0.76 [0.66, 0.87]
Subtotal (95% Cl)
Total events: 1065 (Thrombolysis), 1140 (Control)
Heterogeneity: Chi2=23.25, df=8 (p=0.003); I2=66%
Test for overall effect: Z=4.03 (p=0.000055)
0.1
1.0
Favours thrombolysis
10
Favours control
Wardlaw et al. Cochrane Database of Systematic Reviews 2009;4: CD000213. DOI:
10.1002/14651858.CD000213.pub2.
Updated Pooled Analysis
(Including ECASS 3 and EPITHET)
 Data from ECASS 3 and EPITHET were added to the pool of
common data elements from the 6 previous trials of rt-PA for
acute ischaemic stroke
 N=3,670 patients (old analysis N=2,779)
 1,850 patients treated with rt-PA;1,820 patients given placebo
 Men: 60%
 Median age: 68 years (IQR 59-74)
 Median NIHSS: 11 (IQR 7-16)
 Median time-window: 240 min (IQR 180-284)
 Separate analyses at four OTT intervals (0-90 min, 91-180 min,
181-270 min, 271-360 min) were undertaken
Hacke et al. Lancet 2004;363:768-774.
Lees et al. Lancet 2010;375:1695-1703.
Comparison of Pooled Analysis Data with ECASS 3
The earlier you treat, the greater the benefit
Time
Window
Adjusted OR
(95% CI)
0-90
2.81
(1.75-4.50)
91-180
1.55
1.12-2.15)
Pooled
1.40
(1.05-1.85)
ECASS 3
1.42
(1.02-1.98)
1.15
(0.90-1.47)
181-270
271-360
0.1
1.0
Odds Ratio (95% CI)
10.0
Pooled data analysis of NINDS, ATLANTIS and ECASS I and II trials (green) showing odds ratios and
95% confidence intervals for favourable outcome in different time windows from onset, adjusted for
prognostic confounders, with ECASS 3 outcome superimposed (blue)
Hacke et al; the ECASS 3 Investigators. N Engl J Med 2008;359:1317-1329.
Hacke et al. Lancet 2004;363:768-774.
Updated Pooled Analysis:
Favourable Outcome (mRS 0-1) vs. Time
5
Odds ratio and 95% CI
Odds ratio (OR)
4
OR
2.55
OR
1.64
3
OR
1.34
OR
1.22
2
1
0
60
90
120
150
NNT
4-5
180
NNT
9
210
240
OTT (min)
270
300
NNT
14
330
360
NNT
21
NNT, Number needed to treat
OTT, Time from stroke onset to start of treatment
mRS, modified Rankin Scale
Lees et al. Lancet 2010;375:1695-1703.
Updated Pooled Analysis:
Mortality
Placebo
n/N (%)
rt-PA
n/N (%)
OR*
(95%CI)
p
0-90 min
31/151
(20.5%)
3/161
(18.6%)
0.78
(0.41-1.48)
0.440
91-180 min
49/315
(15.6%)
51/303
(16.8%)
1.13
(0.70-1.82)
0.608
181-270 min
82/811
(10.0%)
89/809
(10.6%)
1.22
(0.87-1.71)
0.252
271-360 min
55/542
(10.2%)
86/757
(15.0%)
1.49
(1.00-2.21)
0.050
217/1820
(11.9%)
257/1849
(13.9%)
1.19
(0.96-1.47)
0.108
0-360 min
*OR adjusted for NIHSS, age, diastolic blood pressure
Lees et al. Lancet 2010;375:1695-1703.
Updated Pooled Analysis:
Interpretation
 Patients with ischaemic stroke selected by clinical
symptoms and CT benefit from intravenous rt-PA when
treated up to 4.5 h
 No increase in mortality with rt-PA use up to 4.5 h
 The earlier treatment with rt-PA is administered, the
greater the benefit
 To maximise benefit, every effort should be taken to
shorten delay in initiation of treatment
 Beyond 4.5 h, risk might outweigh benefit
Lees et al. Lancet 2010;375:1695-1703.
SITS Register
SITS Register
 SITS (Safe Implementation of Treatments in Stroke) is an
internet-based interactive thrombolysis register
 The SITS register is an instrument for clinical centres to
follow their own treatment results and compare them with
other centres in their own or in collaborating countries
 The SITS register is the technical basis for the
International Stroke Treatment Register (SITS-ISTR) and
SITS Stroke Monitoring Study (SITS-MOST)
www.sitsinternational.org
SITS Register
 www.sitsinternational.org
 >60,167 patients added into the
SITS register by December 2011
 Recruitment is ongoing
 Now 1,273 registered centres
 55 participating countries in four continents
www.sitsinternational.org
SITS-MOST
SITS-MOST: Rationale
 Randomised controlled trials show thrombolysis to be beneficial
when given within 3 hours of ischaemic stroke
 rt-PA was approved by the EU regulatory authority EMEA in
2002 for use within 3 hours of ischaemic stroke on two
conditions:
 That patients be registered in the SITS internet database and
entered into an observational safety study, SITS-MOST
AND
 A new, randomised trial of rt-PA versus placebo, ECASS 3, be
launched, with an extended therapeutic window greater than 3
hours
Wahlgren et al; the SITS-MOST Investigators. Lancet 2007;369:275-282.
SITS-MOST: Overview
 An observational safety monitoring study within the EU, plus
Norway, Iceland, and Switzerland
 A cohort of the existing online stroke register SITS-International
Stroke Thrombolysis Register (SITS-ISTR)
Objective
 To assess whether intravenous rt-PA, when given as
thrombolytic therapy within 3 hours of the onset of ischaemic
stroke is as safe and effective in routine clinical practice as
reported in randomised controlled clinical trials
Wahlgren et al; the SITS-MOST Investigators. Lancet 2007;369:275-282.
SITS-MOST: Outcomes
Primary outcome

Symptomatic intracerebral haemorrhage*

Death within 3 months
Secondary outcome

Functional independence (mRS ≤2 at 3 months)

SICH according to NINDS and Cochrane reviews§

SICH according to ECASS (I + II)#

Complete recovery (mRS ≤1 at 3 months)
*Defined as local or remote parenchymal haemorrhage type 2 on the 22–36 hour post-treatment imaging scan; plus deterioration of
NIHSS by ≥4 points; or leading to death
§ Any haemorrhage + deterioration of NIHSS ≥1
# Any haemorrhage + deterioration of NIHSS ≥4
Wahlgren et al; the SITS-MOST Investigators. Lancet 2007;369:275-282.
Modified Rankin Scores at 3 Months
Modified Rankin scores (mRS) at 3 months in SITS-MOST and
RCTs for placebo and rt-PA patients
mRS
Pooled placebo
0–3 h (N=465)
Pooled rt-PA
0–3 h (N=463)
SITS-MOST
(N=6,136)
RCT, randomised controlled trial
Wahlgren et al; the SITS-MOST Investigators. Lancet 2007;369:275-282.
SITS-MOST: Summary

Mortality rates within the first 3 months were lower in SITS-MOST
(11.3%) than in RCTs (17.3%)

Functional independence at 3 months was higher in SITS-MOST
(54.8%) than in RCTs (50.1%)

The results of SITS-MOST confirm that routine use of rt-PA within 3
hours of ischaemic stroke has a safety profile at least as good as that
seen in RCTs

SITS-MOST showed that safety could be maintained across centres,
regardless of experience in acute stroke thrombolysis

SITS-MOST demonstrates the advantage of establishing stroke centres
for treating stroke patients and the need for a multidisciplinary approach
to ensure recognition of symptoms, rapid transportation, accurate
diagnosis, & effective treatment
RCT, randomised controlled trial
Wahlgren et al; the SITS-MOST Investigators. Lancet 2007;369:275-282.
Wahlgren et al. Lancet 2007;369:826.
SITS-MOST: Conclusion
 SITS-MOST, the largest monitored stroke register to
date, with over 6,000 patients, demonstrated that
broad implementation of thrombolysis with rt-PA in
acute stroke treatment is as safe and effective as in
randomised controlled clinical trials
 SITS-MOST confirmed the existing European
labelling of rt-PA for thrombolysis of acute ischaemic
stroke
Wahlgren et al; the SITS-MOST Investigators. Lancet 2007;369:275-282.
SITS-ISTR
Updated Analysis of SITS-ISTR
 Centres participating in the SITS database are required to
enter all patients into SITS-ISTR (International stroke treatment
register), regardless of whether they fulfil the SITS-MOST
criteria or not
 Between December 2002 and February 2010, SITS-ISTR
looked at a cohort of patients (N=2,376) treated with rt-PA
within 3-4.5 hours after the onset of ischaemic stroke and
compared the outcome with that of patients treated within the
3-hour time window (N=21,566)
 Outcome measures were:
 sICH within 24 hours
 Mortality
 Independence (mRS 0-2) at 3 months
Ahmed et al; for the SITS Investigators. Lancet Neurol 2010;9:866-874.
SITS-ISTR: Results
No significant difference for any outcome measure between patients
treated within 0-3 hours or at 3-4.5 hours after stroke onset
0-3h
3 - 4.5 h
Unadjusted results
Adjusted results
n/N (%)
n/N (%)
Odds ratio
(95% CI)
p
value
Odds ratio
(95% CI)
p
value
sICH (SITS-MOST
definition)
352/21204
(1.7%)
52/2317
(2.2%)
1.36
(1.01-1.83)
0.04
1.44
(1.05-1.97)
0.02
sICH (ECASS II definition)
1020/21206
(4.8%)
121/2304
(5.3%)
1.10
(0.90-1.33)
0.35
1.27
(1.03-1.55)
0.02
sICH (NINDS definition)
1515/21245
(7.1%)
171/2317
(7.4%)
1.04
(0.88-1.22)
0.66
1.18
(0.99-1.41)
0.06
Mortality at 3 months
2287/18583
(12.3%)
218/1817
(12.0%)
0.97
(0.84-1.13)
0.70
1.26
(1.07-1.49)
0.005
Mortality at 7 days
1307/20956
(6.2%)
132/2259
(5.8%)
0.93
(0.78-1.12)
0.46
1.22
(1.00-1.48)
0.052
Functionally independent
at 3 months (mRS 0-2)
10531/18317
(57.5%)
1075/1784
(60.3%)
1.12
(1.02-1.24)
0.02
0.84
(0.75-0.95)
0.005
Minimal or no disability at 3
months (mRS 0-1)
7467/18317
(40.8%)
793/1784
(44.5%)
1.16
(1.05-1.28)
0.003
0.92
(0.83-1.03)
0.17
mRS, modified Rankin Scale
Ahmed et al; for the SITS Investigators. Lancet Neurol 2010;9:866-874.
SITS-ISTR: mRS at 3 Months
Proportion of patients in the 3-4.5 h and within 3 h cohorts according to
the modified Rankin scale (mRS) score at 3 months
0
mRS
3−4.5 h
(n=1,784)
20%
Within 3 h
(n=18,317)
2
4
13%
16%
22%
20%
3
17%
20%
22%
0%

1
40%
60%
Patients (%)
12%
5
6
12%
5%
12%
11%
5%
12%
80%
100%
Functional independence at 3 months was almost identical in the 2
treatment groups
Ahmed et al; for the SITS Investigators. Lancet Neurol 2010;9:866-874.
SITS-ISTR: Conclusions
 Early treatment with thrombolysis has been confirmed and leads
to better outcomes
 SITS-ISTR confirms the safety and efficacy of rt-PA for the
thrombolysis of ischaemic stroke within the approved 3-hour
time window as well as in the 3-4.5 hour time window
 SITS-ISTR confirms the results of SITS-MOST and reinforces
the results of ECASS 3
 These results should provide more patients with access to
thrombolysis which should be administered as early as possible
 However, “time is brain” and patients should be treated as
early as possible after stroke
Ahmed et al; for the SITS Investigators. Lancet Neurol 2010;9:866-874.
Wahlgren et al. SITS Investigators. Lancet 2008;372:1303-1309.
SITS-NEW
SITS NEW: Background
 Patients >80 years are underrepresented in approval
relevant studies
 SITS NEW focused on Asian patients (48 stroke centres
from Korea, China, India and Singapore participated)
 Objective was to evaluate if the results for the use of
intravenous rt-PA within 3 hours of symptom onset are
consistent compared to rest of the world
The Virtual
International
Stroke Trials
Archive
(VISTA)
VISTA: Rationale and Objective
Rationale

The datasets from many studies investigating risk factors, aetiology,
prevalence, ethnic disparity and potential benefits of stroke treatment
regimens reside in industry and academic archives long after the
studies have been published

The importance of this stored information is often underestimated

By collating these datasets, a large and rich pool of information can
be utilised for novel analyses of the natural history of homogeneous
subgroups of stroke patients
Objective

To establish a comprehensive resource comprising patient data from
acute stroke clinical trials, on which novel analyses to inform clinical
trial design could be performed
Ali et al. Stroke 2007;38:1905-1910.
VISTA: Overview
 VISTA contains 29 anonymised acute stroke clinical trials and
one acute stroke registry
 Over 27,500 patients with either ischaemic or haemorrhagic
stroke
 Patients aged 18-103 years
 Medical history and onset-to-treatment time are readily
available, and computed tomography lesion data are available
for selected trials
 Outcome measures include Barthel Index, Scandinavian
Stroke Scale, National Institutes of Health Stroke Scale,
Orgogozo Scale, and modified Rankin Scale
Ali et al. Stroke 2007;38:1905-1910.
VISTA: Baseline Stroke Severity Predicts Outcome
with Thrombolysis
In a non-randomised comparison of 5,817 patients from the VISTA
database, outcomes with thrombolysis were significantly better across
baseline NIHSS levels 5 to 24
NIHSS at
baseline
Forest plot
OR (95%Cl)
CMH
p
Sample size
Alteplase/Control
rt-PA/Control
1-4
1.14 (0.30, 4.35)
0.82
8/161
5-8
1.25 (0.98, 1.59)
0.04
278/934
9-12
1.32 (1.07, 1.62)
0.01
404/942
13-16
1.63 (1.30, 2.05)
< 0.05
342/814
17-20
1.67 (1.32, 2.12)
< 0.05
311/736
21-24
1.56 (1.14, 2.14)
< 0.05
178/466
≥ 25
1.12 (0.66, 1.90)
0.08
64/179
0.2
0.5
Favours control
1
2
5
Favours alteplase
Mishra et al; VISTA Collaborators. Stroke 2010;41:2612-2617.
VISTA: Outcomes by Age Group
Odds ratios (OR) with 95% confidence intervals for better outcome are
estimated from ordinal logistic regression, adjusted for age and NIHSS
Age
decile
Forest plot
OR (95%Cl)
CMH
p
Sample size
rt-PA/Control
21-30
1.14 (0.30, 4.35)
0.82
8/161
31-40
1.25 (0.98, 1.59)
0.04
278/934
41-50
1.32 (1.07, 1.62)
0.01
404/942
51-60
1.63 (1.30, 2.05)
< 0.05
342/814
61-70
1.67 (1.32, 2.12)
< 0.05
311/736
71-80
1.56 (1.14, 2.14)
< 0.05
178/466
81-90
1.12 (0.66, 1.90)
0.08
64/179
91-100
0.01
0.1
Favours control
0.2
0.5
1
2
5
Favours rt-PA
Mishra NK, et al. Stroke 2010;41:2840-2848.
VISTA: Diabetes and Prior Stroke
mRS
Diabetes
NIHSS
SITS recorded only Rankin
mRS
Previous stroke
NIHSS
SITS recorded only Rankin
mRS
Diabetes & prior stroke
No diabetes/stroke interaction: p=0.5
No diabetes/stroke interaction: p=0.9
NIHSS
0.5
SITS recorded only Rankin
1
Favours Control
2
Favours Thrombolysis
5
0.5
1
Favours Control
2
5
Favours Thrombolysis
Mishra et al, for VISTA & SITS Collaborators. Cerebrovascular Diseases 2010 [abstract from ESC];
Mishra et al, for VISTA Collaborators. Diabetes Care 2010 PMID 20843977.
VISTA: Summary
 rt-PA is an approved* and recommended treatment
 Age restriction


Age >80 years does not appear to influence response to rt-PA
No loss of benefit or enhanced ICH with age <90 years
 Severity restriction

Efficacy extends across NIHSS up to 24
 Diabetes and prior stroke restriction

No interaction between diabetes and prior stroke
* Marketing approval does not extend to >25 NIHSS; diabetes with prior stroke; or in some countries, >80
years (e.g. EU, although relaxed to a warning in others, e.g. Australia)
Prescribing
information
Actilyse®
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
1.
NAME OF THE MEDICINAL PRODUCT
Actilyse®
Powder and solvent for solution for injection and infusion
2.
QUALITATIVE AND QUANTITATIVE COMPOSITION
1 vial with powder contains:
10 mg alteplase (corresponding to 5,800,000 IU) or
20 mg alteplase (corresponding to 11,600,000 IU) or
50 mg alteplase (corresponding to 29,000,000 IU), respectively.
Alteplase is produced by recombinant DNA technique using a Chinese hamster ovary cell-line. The specific activity of alteplase in-house reference
material is 580,000 IU/mg. This has been confirmed by comparison with the second international WHO standard for t-PA. The specification for the
specific activity of alteplase is 522,000 to 696,000 IU/mg.
For a full list of excipients, see section 6.1.
3.
PHARMACEUTICAL FORM
Powder and solvent for solution for injection and infusion.
The powder is presented as a colourless to pale yellow lyophilizate cake.
4.
CLINICAL PARTICULARS
4.1
Therapeutic indications:
Thrombolytic treatment in acute myocardial infarction
-90 minutes (accelerated) dose regimen (see section 4.2): for patients in whom treatment can be started within 6 h after symptom onset
-3 h dose regimen (see section 4.2): for patients in whom treatment can be started between 6 - 12 h after symptom onset provided that the diagnosis
has been clearly confirmed.
Actilyse 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.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
4.2
Posology and method of administration
Actilyse should be given as soon as possible after symptom onset. The following dose guidelines apply.
Under aseptic conditions the content of an injection vial of Actilyse (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:
Actilyse vial
10 mg
20 mg
50 mg
Volume of water for injections to be added to dry powder:
Final concentration
(a) 1 mg alteplase/ml (ml)
10
20
50
(b) 2 mg alteplase/ml (ml)
5
10
25
The reconstituted solution should then be administered intravenously. It 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 dilution of the reconstituted solution with sterilised water for injections or in general, the use
of carbohydrate infusion solutions, e.g. dextrose is not recommended. Actilyse should not be mixed with other medicinal products neither in the same
infusion-vial nor the same catheter (not even with heparin). For further practical instructions for preparation and handling see sections 6.2 and 6.6.
The experience in children and adolescents is limited. Actilyse is contraindicated for the treatment of acute stroke in children and adolescents (see
section 4.3).
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
Myocardial infarction
a)
90 minutes (accelerated) dose regimen for patients with myocardial infarction, in whom treatment can be started within 6 hours
after symptom
onset:
Concentration of alteplase
1 mg/ml
2 mg/ml
15 mg as an intravenous bolus
15
7.5
50 mg as an infusion over 30 minutes
50
25
followed by an infusion of 35 mg over 60 minutes until the maximal dose of 100 mg
35
17.5
In patients with a body weight below 65 kg the dose should be weight adjusted according to the following table:
Concentration of alteplase
1 mg/ml
2 mg/ml
15
7.5
ml/kg bw
ml/kg bw
and 0.75 mg/kg body weight (bw) over 30 minutes (maximum 50 mg)
0.75
0.375
followed by an infusion of 0.5 mg/kg body weight (bw) over 60 minutes
(maximum 35 mg)
0.5
0.25
15 mg as an intravenous bolus
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
b)
3 h dose regimen for patients, in whom treatment can be started between 6 and 12 hours after symptom onset:
Concentration of alteplase
1 mg/ml
2 mg/ml
10 mg as an intravenous bolus
10
5
50 mg as an infusion over the first hour
50
25
ml/30 min
ml/30 min
10
5
followed by infusions of 10 mg over 30 minutes until the maximal dose of 100 mg
over 3 hours
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 STelevation myocardial infarction; acetylsalicylic acid should be initiated as soon as possible after symptom onset and continued with lifelong
treatment unless it is contraindicated.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
Pulmonary embolism
A total dose of 100 mg of alteplase should be administered in 2 hours. Most experience is available with the following dose regimen:
Concentration of alteplase
1 mg/ml
2 mg/ml
10 mg as an intravenous bolus over 1 - 2 minutes
10
5
followed by an intravenous infusion of 90 mg over 2 hours
90
45
The total dose should not exceed 1.5 mg/kg in patients with a body weight below 65 kg.
Adjunctive therapy:
After treatment with Actilyse 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).
Acute ischaemic stroke
Treatment must only be performed under the responsibility and follow-up of a physician trained and experienced in neurovascular care, see
sections 4.3 and 4.4.
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.
Treatment with Actilyse must be started as early as possible within 4.5 hours of the onset of symptoms. Beyond 4.5 hours after onset of stroke
symptoms there is a negative benefit risk ratio associated with Actilyse administration and so it should not be administered (see section 5.1). 5
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 Actilyse. 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.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
4.3
Contraindications
Hypersensitivity to the active substance or to any of the excipients.
Additional contraindications in acute myocardial infarction, acute pulmonary embolism and acute ischaemic stroke:
Actilyse 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 oral anticoagulants, 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 3
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 3
hours.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
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 (see section 5.1)
•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
Actilyse is not indicated for the treatment of acute stroke in paediatric patients under 18 years.
Use in elderly patients
Actilyse is not indicated for the treatment of acute stroke in adults over 80 years of age.
4.4
Special warnings and precautions for use
Special warnings and precautions in acute myocardial infarction, acute pulmonary embolism and acute ischaemic stroke:
Thrombolytic/fibrinolytic treatment requires adequate monitoring. Actilyse should only be used by physicians trained and
experienced in the use of thrombolytic treatments and with the facilities to monitor that use. It is recommended that when
Actilyse is administered standard resuscitation equipment and pharmacotherapy be available in all circumstances.
The risk of intracranial haemorrhage is increased in elderly patients, therefore in these patients the risk/benefit evaluation
should be carried out carefully.
As yet, there is only limited experience with the use of Actilyse in children and adolescents.
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
•conditions with an increased risk of haemorrhage which are not mentioned in section 4.3.
The use of rigid catheters should be avoided.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
Additional special warnings and precautions in acute myocardial infarction:
A dose exceeding 100 mg of alteplase must not be given because it has been associated with an additional increase in
intracranial bleeding.
Therefore special care must be taken to ensure that the dose of alteplase infused is as described in section 4.2.
There is limited experience with readministration of Actilyse. Actilyse is not suspected to cause anaphylactic reactions. If an
anaphylactoid reaction occurs, the infusion should be discontinued and appropriate treatment initiated.
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 pulmonary embolism:
same as for acute myocardial infarction (see above)
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.
Special warnings / conditions with a decreased benefit/risk ratio:
Compared to other indications patients with acute ischaemic stroke treated with Actilyse 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:
•all situations listed in section 4.3. 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 Actilyse should not be delayed.
•patients pre-treated with acetyl salicylic acid (ASA) may have a greater risk of intracerebral haemorrhage, particularly if Actilyse
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 (see section 4.3).
Patients with very severe stroke are at higher risk for intracerebral haemorrhage and death and should not be treated (see section
4.3).
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.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
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 Actilyse (see
section 4.3).
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 Actilyse 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 oedama 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.
4.5
Interaction with other medicinal products and other forms of interaction
No formal interaction studies with Actilyse and medicinal products commonly administered in patients with acute myocardial
infarction have been performed.
The risk of haemorrhage is increased if coumarine derivatives, oral anticoagulants, platelet aggregation inhibitors, unfractionated
heparin or LMWH or active substances which interfere with coagulation are administered (before, during or within the first 24
hours after treatment with Actilyse) (see section 4.3).
Concomitant treatment with ACE inhibitors may enhance the risk of suffering an anaphylactoid reaction, as in the cases describing
such reactions a relatively larger proportion of patients were receiving ACE inhibitors concomitantly.
Concomitant use of GPIIb/IIIa antagonists increases the risk of bleeding.
4.6
Pregnancy and lactation
There is very limited experience with the use of alteplase during pregnancy and lactation. Studies in animals have shown
reproductive toxicity (see section 5.3). In cases of an acute life-threatening disease the benefit has to be evaluated against the
potential risk. It is not known if alteplase is excreted into breast milk.
4.7
Effects on ability to drive and use machines
Not relevant.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
4.8
Undesirable effects
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 intracranial haemorrhage as adverse reaction in the indication stroke and reperfusion arrhythmias in the indication
myocardial infarction, there is no medical reason to assume that the qualitative and quantitative adverse reaction profile of Actilyse
in the indications pulmonary embolism and acute ischaemic stroke is different from the profile in the indication myocardial
infarction.
Haemorrhage
The most frequent adverse reaction associated with Actilyse is bleeding resulting in a fall in haematocrit and/or haemoglobin
values:
very common: bleeding from damaged blood vessels (such as haematoma), injection site haemorrhage (puncture site
haemorrhage, catheter site haematoma, catheter site haemorrhage)
common: intracranial haemorrhage (such as cerebral haemorrhage, cerebral haematoma, haemorrhagic stroke, haemorrhagic
transformation of stroke, intracranial haematoma, subarachnoid haemorrhage) in the treatment of acute ischaemic stroke.
Symptomatic intracerebral haemorrhage represents the major adverse reaction in the treatment of acute ischaemic stroke (up to
10 % of patients without any increase of overall mortality and without any relevant increase in overall mortality and severe disability
combined, i.e. mRS of 5 and 6), respiratory tract haemorrhage (such as pharyngeal haemorrhage, epistaxis, haemoptysis),
gastrointestinal haemorrhage (such as gastric haemorrhage, gastric ulcer haemorrhage, haemorrhage, rectum, haematemesis,
melaena, mouth haemorrhage, gingival bleeding), ecchymosis, urogenital haemorrhage (such as haematuria, haemorrhage
urinary tract), blood transfusion (necessary)
uncommon: intracranial haemorrhage (such as cerebral haemorrhage, cerebral haematoma, haemorrhagic stroke, haemorrhagic
transformation of stroke, intracranial haematoma, subarachnoid haemorrhage) in the treatment of acute myocardial infarction and
acute pulmonary embolism, ear haemorrhage, haemopericardium, retroperitoneal haemorrhage (such as retroperitoneal
haematoma)
rare: bleeding in parenchymatous organs (such as hepatic haemorrhage, pulmonary haemorrhage)
very rare: eye haemorrhage
Death and permanent disability are reported in patients who have experienced stroke (including intracranial bleeding) and other
serious bleeding episodes.
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.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
Immune system disorders
uncommon: hypersensitivity reactions / anaphylactoid reactions (e.g. allergic reactions including rash, urticaria, bronchospasm,
angio-oedema, hypotension, shock or any other symptom associated with allergic reactions)
very rare: serious anaphylaxis
Transient antibody formation to Actilyse has been observed in rare cases and with low titres, but a clinical relevance of this finding
could not be established.
Nervous system disorders
very rare: events related to the nervous system (e.g. epileptic seizure, convulsion, aphasia, speech disorder, delirium, acute brain
syndrome, agitation, confusion, depression, psychosis) often in association with concurrent ischaemic or haemorrhagic
cerebrovascular events.
Cardiac disorders
As with other thrombolytic agents, the following events have been reported as sequelae of myocardial infarction and / or
thrombolytic administration.
very common: recurrent ischaemia / angina, hypotension and heart failure / pulmonary oedema, reperfusion arrhythmias (such as
arrhythmia, extrasystoles, AV block I° to complete, atrial fibrillation / flutter, bradycardia, tachycardia, ventricular arrhythmia,
ventricular tachycardia / fibrillation, electromechanical dissociation [EMD])
common: cardiac arrest, cardiogenic shock and reinfarction
uncommon: mitral regurgitation, pulmonary embolism, other systemic embolism / cerebral embolism, ventricular septal defect
These cardiac events can be life-threatening and may lead to death.
Vascular disorders
uncommon: embolism (thrombotic embolisation), which may lead to corresponding consequences in the organs concerned
Gastrointestinal disorders
common: nausea, vomiting
Investigations
very common: blood pressure decreased
common: body temperature increased
Injury and poisoning and procedural complications
rare: fat embolism (cholesterol crystal embolisation), which may lead to corresponding consequences in the organs concerned
4.9
Overdose
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 Actilyse
therapy has been terminated. If, however, severe bleeding results, the infusion of fresh frozen plasma or fresh blood is
recommended and if necessary, synthetic antifibrinolytics may be administered.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
5.PHARMACOLOGICAL PROPERTIES
5.1
Pharmacodynamic properties
Pharmacotherapeutic group: antithrombotic agent, ATC code: B 01 A D 02
The active ingredient of Actilyse 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 %).
Actilyse-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 Actilyse leads to a
fast reduction of the thrombus size and a reduction of pulmonary artery pressure. Mortality data are not available.
Acute stroke
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.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
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 Actilyse 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 symptomatic
intracranial haemorrhage was higher with alteplase vs. placebo (27.0% vs 17.6%, p=0.0012; 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 ACTILYSE 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 ACTILYSE 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.
5.2
Pharmacokinetic properties
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 t1/2 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.
5.3
Preclinical safety data
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.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg,
Netherlands, Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
6.PHARMACEUTICAL PARTICULARS
6.1
List of excipients
Powder for solution: Arginine
Phosphoric acid, dilute
Polysorbate 80
Solvent:
Water for injections
The pH of the reconstituted solution is 7.3 ± 0.5
6.2
Incompatibilities
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.
Actilyse should not be mixed with other medicinal products neither in the same infusion vial nor the same catheter (not even with
heparin).
6.3
Shelf life
10 mg, 20 mg and 50 mg pack sizes: 3 years
After reconstitution, an immediate use is recommended. However, the in-use stability has been demonstrated for 24 hours at 2 °C
– 8 °C and for 8 hours at 25 °C
6.4
Special precautions for storage
Store in the original package in order to protect from light.
For 10 mg, 20 mg and 50 mg pack sizes: Do not store above 25 °C.
For storage conditions of the reconstituted medicinal product, see section 6.3.
SUMMARY OF PRODUCT
CHARACTERISTICS
This is the SPC as approved for Austria, Belgium, Denmark, Finland, France, Germany, Ireland, Luxembourg, Netherlands,
Portugal, Spain, Sweden, UK. For product use, please check the local SPC of the country you live in.
6.5
Nature and contents of container
Powder for solution:
10 ml, 20 ml or 50 ml sterilised glass vials, sealed with sterile siliconised grey butyl-type stoppers with aluminium/plastic flip-off caps.
Solvent:
For the 10 mg, 20 mg and 50 mg pack sizes, the water for injections is filled into either 10 ml, 20 ml or 50 ml vials, depending on the size of the powder
vials. The water for injections vials are sealed with rubber stoppers and aluminium/plastic flip-off caps.
Transfer cannulas (included with pack sizes of 20 mg and 50 mg only)
Pack sizes:
10 mg:
1 vial with 467 mg powder for solution for injection and infusion
1 vial with 10 ml of water for injections
20 mg:
1 vial with 933 mg powder for solution for injection and infusion
1 vial with 20 ml of water for injections
1 transfer cannula
50 mg:
1 vial with 2333 mg powder for solution for injection and infusion
1 vial with 50 ml of water for injections
1 transfer cannula
Not all pack sizes may be marketed.
6.6
Special precautions for disposal and other handling
For reconstitution to a final concentration of 1 mg altpelase per ml the full volume of solvent provided should be transferred to the vial containing the
Actilyse powder. To this purpose a transfer cannula is included with the 20 mg and 50 mg pack sizes, which is to be used. For the 10 mg pack sizes 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. In these cases always a syringe should
be used to transfer the required amount of solvent to the vial containing the Actilyse powder.
A table giving the volumes of solvent required for reconstitution to the final concentrations for each pack size is provided in section 4.2.
When reconstituting the product from the respective amount of powder and solvent, the mixture should only be agitated gently until complete dissolution.
Any vigorous agitation should be avoided to prevent foam formation.
The reconstituted preparation is a clear and colourless to pale yellow solution. Prior to administration it should be inspected visually for particles and colour.
The reconstituted solution is for single use only. Any unused solution should be discarded.
7. MARKETING AUTHORISATION HOLDER
Boehringer Ingelheim International GmbH, Binger Str. 173, D-55216 Ingelheim am Rhein, Germany
Impressum
Published by
Boehringer Ingelheim GmbH
www.actilyse.com
Realisation
infill healthcare communication
www.infill.com
Supported by
Professors Peter Schellinger & Patrick Goldstein