NAPLEX Question of the Week: Act FAST!

This week's question is a common one everyday in the United States. Should we give the thrombolytic?
NAPLEX Question of the Week: Act FAST!
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DW, a 58-year-old male, presented to the ED with complaints of right-sided weakness, right facial droop, and slurred speech. His wife reported that his symptoms started about 1 hour ago.

PMH: Hypertension, Diabetes, Atrial Fibrillation

Weight 105 kg, Height 69 in

Vitals: BP 175/100 mmHg, HR 113 bpm

Notable labs from today (fingerstick obtained 30 minutes ago):

Fasting blood sugar: 80 mg/dL

INR 2.6

Labs from most recent PCP visit:

A1c 8.3%

Hgb 15.6 g/dL, Hct 46.8%, Plt 257,000/μL

Current medications:

Norvasc 10 mg PO QD

Rybelsus 7 mg PO QD

Coumadin 4 mg PO QD

Non-contrast CT scan revealed no intracranial hemorrhage. The ED physician diagnosed DW with an acute ischemic stroke and wants to administer TNKase as part of initial management. She wants to confirm if DW would be eligible for thrombolysis.

What are the absolute contraindications to using TNKase in DW? 

A. DW’s current INR

B. DW’s current blood pressure

C. DW’s current blood glucose

D. DW has no contraindications and should receive TNKase as soon as possible

Answer with Rationale

Stroke is a leading cause of death in the US, affecting more than 795,000 individuals each year. Every 40 seconds, someone in the US has a stroke. Every 3 minutes and 14 seconds, someone dies of stroke. About 87% of all strokes are ischemic strokes. Acute ischemic stroke, a medical emergency, is often brought on by decreased blood flow to the brain, resulting in damaged brain tissues. Signs and symptoms include sudden-onset one-sided numbness or weakness and facial droop, speech impairments, confusion, loss of balance and vision, etc. Patients are at an increased risk of developing an acute ischemic stroke if they have high blood pressure, high cholesterol, diabetes, obesity, atrial fibrillation, history of transient ischemic attack (TIA), and tobacco use. Prompt treatment of acute ischemic stroke is warranted as it is associated with improved patient outcomes. If diagnosed within 4.5 hours of symptoms onset, patients may be eligible to receive IV thrombolytic therapy, such as alteplase or tenecteplase. Thrombolytics, also known as fibrinolytics, dissolve clots by binding to fibrin in a clot and converting entrapped plasminogen to plasmin.

Answer A is correct. The risk of all types of hemorrhage may be increased with IV thrombolytics if a patient is systemically anticoagulated. Since DW's INR is therapeutic, providing therapy with TNKase would be inappropriate.

Answer B is incorrect. Severe uncontrolled hypertension has been associated with increased risk of poor outcomes and intracranial hemorrhage post-thrombolytics. Blood pressure must be kept at < 185/110 mmHg BEFORE thrombolytic administration. AFTER thrombolytic administration, blood pressure must remain at < 180/105 mmHg for the first 24 hours. DW's blood pressure is currently in range to receive thrombolytic therapy. 

Answer C is incorrect. Not only can severe hypoglycemia produce symptoms that mimic ischemic stroke, but it can also aggravate ongoing neuronal ischemia. However DW's glucose is within range to receive TNKase. The cutoff for not receiving thrombolysis is a blood glucose less than 50 mg/dL. This would be easily correctable to give therapy if needed. 

Answer D is incorrect. DW’s INR makes TNKase currently contraindicated.

Generic/Brand: Amlodipine (Norvasc), Semaglutide (Rybelsus), Warfarin (Coumadin), Tenecteplase (TNKase), Alteplase (Activase)

NAPLEX Core Competencies Covered:

  • 1.1 – From instruments, screening tools, laboratory, genomic or genetic information, or diagnostic findings
  • 1.2 – From patients: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background
  • 1.5 – Signs or symptoms of medical conditions, healthy physiology, etiology of diseases, or pathophysiology
  • 2.1 – Pharmacology, mechanism of action, or therapeutic class
  • 2.2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied
  • 3.6 – Drug contraindications, allergies, or precautions

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