DRUG DISPOSITION Clin Pharmacokinet 2002; 41 (15): 1229-1245

0312-5963/02/0015-1229/$25.00/0

© Adis International Limited. All rights reserved.

Pharmacokinetics and
Pharmacodynamics of Tenecteplase
in Fibrinolytic Therapy of Acute
Myocardial Infarction
Paul Tanswell,1 Nishit Modi,2,3 Dan Combs2 and Thierry Danays4
1 Department of Pharmacokinetics and Metabolism, Boehringer Ingelheim Pharma KG,
Biberach, Germany
2 Department of Pharmacokinetics and Metabolism, Genentech Inc, South San Francisco,
California, USA
3 ALZA Corporation, Mountain View, California, USA
4 Department of Medical and Regulatory Affairs, Boehringer Ingelheim, Reims, France

Contents
Abstract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1229
1. Biochemistry and Pharmacology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1231
1.1 Mechanism of Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1231
1.2 Protein Engineering . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1231
1.3 Preclinical Efficacy and Clot-Selectivity Measures . . . . . . . . . . . . . . . . . . . . . . . . . 1232
2. Pharmacokinetic Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1232
2.1 Plasma Assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1232
2.2 Data Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1233
3. Preclinical Pharmacokinetics and Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . . . 1234
3.1 Distribution, Biotransformation and Elimination in Animal Studies . . . . . . . . . . . . . . . . 1234
3.2 Mechanism of Hepatic Elimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1234
3.3 Pharmacokinetics and Pharmacodynamics in Animals . . . . . . . . . . . . . . . . . . . . . . 1235
4. Clinical Pharmacokinetics and Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . 1236
4.1 Pharmacokinetics in Patients, Phase I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1236
4.2 Pharmacokinetics in Patients, Phase II . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1237
4.3 Sources of Pharmacokinetic Variability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1238
4.4 In Vivo Markers of Pharmacodynamic Action . . . . . . . . . . . . . . . . . . . . . . . . . . . 1240
4.5 Pharmacokinetic-Pharmacodynamic Relationships . . . . . . . . . . . . . . . . . . . . . . . . 1242
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1243

Abstract Tenecteplase is a novel fibrinolytic protein bioengineered from human tissue

plasminogen activator (alteplase) for the therapy of acute ST-segment elevation
myocardial infarction. Specific mutations at three sites in the alteplase molecule
result in 15-fold higher fibrin specificity, 80-fold reduced binding affinity to the
physiological plasminogen activator inhibitor PAI-1 and 6-fold prolonged plasma
half-life (22 vs 3.5 minutes). Consequently, tenecteplase can be administered as
1230 Tanswell et al.

a single intravenous bolus of 30–50mg (0.53 mg/kg bodyweight) over 5–10 sec-
onds, in contrast to the 90-minute accelerated infusion regimen of alteplase.
Tenecteplase plasma concentration-time profiles have been obtained from a
total of 179 patients with acute myocardial infarction. Tenecteplase exhibited
biphasic disposition; the initial disposition phase was predominant with a mean
half-life of 17–24 minutes, and the mean terminal half-life was 65–132 min. Over
the clinically relevant dose range of 30–50mg, mean clearance (CL) was 105
ml/min. The mean initial volume of distribution V1 was 4.2–6.3L, approximating
plasma volume, and volume of distribution at steady state was 6.1–9.9L, suggest-
ing limited extravascular distribution or binding. Bodyweight and age were found
to influence significantly both CL and V1. Total bodyweight explained 19% of
the variability in CL and 11% of the variability in V1, and a 10kg increase in total
bodyweight resulted in a 9.6 ml/min increase in CL. This relationship aided the
development of a rationale for the weight-adjusted dose regimen for tenecteplase.
Age explained only a further 11% of the variability in CL.
The percentage of patients who achieved normal coronary blood flow was
clearly related to AUC. More than 75% of patients achieved normal flow at 90
minutes after administration when their partial AUC2–90 exceeded 320 μg •
min/ml, corresponding to an average plasma concentration of 3.6 μg/ml. Systemic
exposure to tenecteplase at all times after bolus administration of 30–50mg was
higher than for alteplase 100mg.
Tenecteplase has demonstrated equivalent efficacy and improved safety com-
pared with the current gold standard alteplase in a large mortality trial (ASSENT-
2). This suggests that the reduced clearance, greater fibrin specificity and higher
PAI-1 resistance of tenecteplase allow higher plasma concentrations and thus a
more rapid restoration of coronary patency to be attained, while providing a
reduction in major non-cerebral bleeding events.

The approval for clinical use of recombinant hu-
man tissue plasminogen activator (rt-PA, alte-
plase) in 1987 represented a landmark in the
pharmacological treatment of acute ST-segment
elevation myocardial infarction. Alteplase is a
fibrin-specific thrombolytic agent, derived from
natural human t-PA, that is administered by an ac-
celerated intravenous infusion regimen because of
its short half-life of 3.5 minutes.[1] Alteplase rap-
idly dissolves blood clots in occluded coronary ar-
teries and significantly reduces morbidity and mor-
tality compared both to placebo and to the previous
standard of treatment, streptokinase.[2] Streptoki-
nase, a non-fibrin-specific plasminogen activator
of bacterial origin, activates clot-bound and sys-
temic plasminogen indiscriminately, thus limiting
its efficacy and safety.[3] The superiority of alte-
plase to streptokinase was demonstrated in the
large Global Utilization of Streptokinase and Tis-
sue Plasminogen Activator for Occluded Coronary
Arteries (GUSTO I) mortality trial.[2] Neverthe-
less, it was soon recognised that further potential
existed for improvement in pharmacological throm-
bolysis, in particular ease of administration, more
rapid and complete coronary artery reperfusion,
reduction of bleeding complications and reduction
of the incidence of reocclusion and reinfarction.[4]
Tenecteplase has been specifically bioengine-
ered for improved properties compared with al-
teplase. These are: 15-fold higher fibrin specific-
ity, 80-fold reduced binding to the physiological
plasminogen activator inhibitor PAI-1[5] and 6-
fold prolonged plasma half-life, enabling single
bolus administration.[6-8] These improved proper-
ties were characterised extensively in preclinical
models and have been shown to translate into clini-
cal benefit.
In the large phase III Assessment of the Safety

© Adis International Limited. All rights reserved. Clin Pharmacokinet 2002; 41 (15)
Tenecteplase
and Efficacy of a New Thrombolytic (ASSENT-2)
trial,[9] patients with acute myocardial infarction
who were treated with a single-bolus, bodyweight-
tiered dose of tenecteplase between 30 and 50mg
(equivalent to approximately 0.53 mg/kg) showed
equivalent 30-day mortality and incidence of in-
tracranial haemorrhage compared with those
treated with a 90-minute alteplase infusion. Of a
total of 16 949 randomised patients in 1 021 hos-
pitals, covariate-adjusted 30-day mortality rates
were almost identical for the two groups: 6.18%
for tenecteplase and 6.15% for alteplase. The 95%
one-sided upper boundaries of the absolute and rel-
ative differences in 30-day mortality were 0.61%
and 10%, respectively, which met the prespecified
criteria of equivalence (1% absolute or 14% rela-
tive difference, whichever proved smaller). Rates
of intracranial haemorrhage were similar (0.93%
for tenecteplase and 0.94% for alteplase). How-
ever, there were fewer non-cerebral bleeding com-
plications (26.4% vs 29.0%, p = 0.0003) and less
need for blood transfusion (4.25% vs 5.49%, p =
0.0002) with tenecteplase. Further, the patient sub-
group with a time to treatment of greater than 4
hours (22.4% of patients) showed a lower mortal-
ity with tenecteplase compared with alteplase
(7.0% vs 9.2%, p = 0.018).
Reteplase is a further fibrinolytic agent with
prolonged half-life that has recently been mar-
keted for treatment of acute myocardial infarction,
and is administered as two bolus doses 30 minutes
apart.[10] Its structure is derived from t-PA by
deletion of amino acids 4–175 from the N-terminal
sequence; it is not glycosylated and is not fibrin-
specific.[3,11] Tenecteplase and reteplase have not
been compared directly in any clinical trial. How-
ever, reteplase was compared with alteplase in
15 059 patients in the Global Use of Strategies to
Open Occluded Coronary Arteries (GUSTO-III)
study.[12] Reteplase did not provide any additional
survival benefit compared with alteplase; mortal-
ity rates at 30 days were 7.47 and 7.24%, respec-
tively. Also, there was no difference in safety be-
tween reteplase and alteplase, as measured by the
© Adis International Limited. All rights reserved.
1231
incidence of intracranial and non-cerebral bleed-
ing complications and blood transfusions.
Tenecteplase received marketing approval as
TNKase®1 (Genentech, Inc.) in the USA in 1999
and as Metalyse® (Boehringer Ingelheim) in Eur-
ope in 2000. Clinical therapeutic trials of tenec-
teplase have recently been reviewed.[13-17] This re-
view therefore focuses on the pharmacokinetic and
pharmacodynamic characteristics of tenecteplase
and their significance for efficacy and safety in
acute myocardial infarction in comparison to al-
teplase.
1. Biochemistry and Pharmacology
1.1 Mechanism of Action
The blood fibrinolytic enzyme system is shown
schematically in figure 1. Fibrinolysis is the pro-
cess of dissolution of clots (thrombi), that were
formed by the conversion of soluble fibrinogen
into insoluble fibrin as a result of physiological or
pathological activation of the coagulation sys-
tem.[18] Plasminogen is a circulating plasma pro-
tein that also binds to the solid-phase fibrin com-
ponent of a coronary thrombus. It is activated
physiologically or pharmacologically on the clot
surface by t-PA to plasmin, a serine protease. Plas-
min digests the fibrin network of the clot, resulting
in restoration of vessel patency. Fibrinolysis is
regulated by the inhibitors α2-antiplasmin and
plasminogen activator inhibitor 1 (PAI-1).[18] The
mechanism of action of tenecteplase is identical to
that of alteplase, with the enhancements described
below.
1.2 Protein Engineering
Extensive basic research was required to iden-
tify specific molecular changes in alteplase that
might improve therapeutic performance. Initially,
investigators modified only single amino acids or
deleted entire protein domains. Such mutations
yielded a desired reduction of plasma clearance,
1 Use of tradenames is for product identification only and
does not imply endorsement.
Clin Pharmacokinet 2002; 41 (15)
1232
Plasmin PAI-1
t-PA1c t-PA2c
α2-AP
Plasminogen Plasmin
Fibrin
Thrombin
Fibrinogen Fibrin
Fig. 1. Mechanism of action of alteplase (t-PA) and ten-
ecteplase, corresponding to the physiological fibrinolytic sys-
tem. 1c and 2c indicate the one- and two-chain molecular forms
of the plasminogen activator, respectively. PAI-1 = plasminogen
activator inhibitor type 1; α2-AP = α 2-antiplasmin.
but also resulted in impaired fibrinolytic activity
or fibrin specificity.[19] To overcome these limita-
tions, a high resolution functional analysis of the
alteplase protein sequence was performed,[20] as a
result of which the tenecteplase (TNK-tPA) mole-
cule was developed.[6] Tenecteplase is a single
chain glycoprotein with 527 amino acids, 17 disul-
fide bridges and 65kD molecular mass, and is pro-
duced by recombinant DNA technology in chinese
hamster ovary cells. The enhanced properties rela-
tive to native alteplase were achieved by modifica-
tion at three molecular sites, and are summarised
in figure 2 and table I. Like alteplase, tenecteplase
also exhibits type I and type II glycoforms.[21] Type
I has three carbohydrate structures at asparagine
residues 103, 184 and 448, whereas type II lacks
the carbohydrate at asparagine 184. Tenecteplase
carbohydrates are all complex oligosaccharides
and no high mannose structure is present. Thus, the
rapid clearance mediated by the hepatic mannose
receptor observed for alteplase[22] does not occur
in tenecteplase.
1.3 Preclinical Efficacy and
Clot-Selectivity Measures
The fibrin binding affinity of tenecteplase (dis-
sociation constant, KD, 0.35 μmol/L or 23 ng/ml)
was similar to that of t-PA (KD 0.21 μmol/L).[6]
© Adis International Limited. All rights reserved.
Tanswell et al.
Tenecteplase and alteplase had the same activity
t-PA:PAI
(50% effective concentration, EC50, 3.1 μg/ml) in
an in vitro 125I-labelled human plasma clot lysis
model.[23] The second-order rate constant for bind-
Plasmin:
ing of tenecteplase to the inhibitor PAI-1 was re-
antiplasmin duced 80-fold as compared with alteplase.[6] Be-
cause PAI-1 is present in high concentrations in the
platelet-rich clots which may occur in coronary
Fibrin thrombi, it was expected that the considerably re-
degradation duced interaction of tenecteplase with PAI-1
products
would translate into greater fibrinolytic efficacy
towards platelet-rich clots compared with al-
teplase. This hypothesis was confirmed in vivo in
a rabbit arteriovenous shunt thrombolytic model.[6]
The fibrin specificity of tenecteplase, expressed as
the ratio of its catalytic activity in the presence
of fibrin as compared to fibrinogen, was 15-fold
higher than for alteplase.[8] As an in vivo correlate,
tenecteplase caused less peripheral bleeding than
alteplase at equipotent thrombolytic doses in a rab-
bit model of carotid artery thrombosis.[24]
2. Pharmacokinetic Methods
2.1 Plasma Assays
For pharmacokinetic studies, immunoreactive
tenecteplase and alteplase were analysed in human
and animal plasma using sensitive and validated
two-site enzyme-linked immunosorbent assays
(ELISA).[25,26] The lower limit of quantification
was 8 ng/ml for both analytes, and alteplase was
found to exhibit 100% immunoreactivity in the ten-
ecteplase ELISA. The alteplase ELISA had been
shown to correlate well with a functional fibrino-
lytic activity assay.[1] Blood samples for ELISA
analysis were collected in presence of EDTA anti-
coagulant and the protease inhibitors D-Phe-Pro-
Arg-chloromethyl ketone (PPACK) and aprotinin.
PPACK irreversibly inhibits the serine protease ac-
tivity of tenecteplase or alteplase and thus prevents
artifactual in vitro formation of complexes with
inhibitor proteins in plasma that are non-immuno-
reactive in the ELISA.[27,28] PPACK and aprotinin
also prevent artifactual in vitro consumption of
plasminogen and degradation of α2-antiplasmin
Clin Pharmacokinet 2002; 41 (15)
Tenecteplase 1233

and fibrinogen, [28] which are important in vivo 2.2 Data Analysis
biomarkers of tenecteplase and alteplase effects on
blood coagulation. Assays of clinical serum sam- Tenecteplase and alteplase pharmacokinetic
ples to assess potential antibody formation against parameters were derived from individual plasma
tenecteplase were performed using a validated concentration profiles using either noncompart-
radioimmuno-precipitation technique.[29] mental methods or multicompartmental intrave-

G A S C L
P Y S E S P
W
A Q K G R T N
A L R P L L V H CW S
S D S K M
S A P I
Q H N K
I L
W 117 Kringle 1 R T R A I
N L G R D G
T P K S D G R L G K
C W R D L Y T D
C P V
E P G A W
Y N R N Y
A
V C Y N HN S E
R T
G F G Y A
C Kringle 2
S K K Y S S E F C N 184 C
Y Q
E A G G D
S N N
A T F V
T 103 P H P A S H
SW P Y S S I P
N G R Y S I G Q A C K D W
C G A
D C D L Q A Q
E S E S S G L A F
Y G N A
T L
C C G A
T G G I
A P
L C
V L I K HK A F
G K C R Q F R R
A R P T Y S Q P Q R A
C E T A R 275 A A 296
F I D D A
G
V
G P S 299
E P C Q L V R E
C
V Q S L I G G C L F
F I
L S S P P H H
L R P Growth R C F D Q E R F
SW V P N S P E S C F
L
T
Q L factor F D Q C A H V
E G A A I
H R Y W W I L S L
S G C
Q S T L T G
Q Finger C E R D N D R
N S CQ Q A S I Y
Y K C S L A T T
R D S K L Q L
I V P V D N L E D Y
V S G C L D R
M R V
Q E H S D V
T Y C M L G F
K Q T P Y
G Protease E
V
E C A K H P
L G K
D W R G 478 E A L G
R C V S P F H
N G G S Y S E
C S I D E
I
S
* G R V
E
I W Q L I
V G C K Y E
Q L A K Q
G D E
Y C H A E V E F K
S G L
Q N H
1 K A V
D Q
P R
V G
P G L
G S Y
V R P
Y T S
T D S
K G
A R
527 V C
P T C
L T
R N S
M Y M Q
N L N H
DR D D L
I W
T 448 L
V T R N

Fig. 2. Secondary structure of tenecteplase showing the domains, disulfide bridges, glycosylation sites and the plasmin cleavage
site at Arg-275, which generates the two-chain molecular form. The protease domain (amino acid residues 276–527) cleaves
plasminogen to plasmin (see figure 1). The remaining domains (finger, growth factor, kringle 1 and kringle 2) mediate other ten-
ecteplase biological functions such as fibrin binding, fibrin specificity and hepatic clearance. The bioengineering modifications that
were performed relative to wild-type tissue plasminogen activator (alteplase) are summarised in table 1.

© Adis International Limited. All rights reserved. Clin Pharmacokinet 2002; 41 (15)
1234
Table I. Description of the molecular modifications in tenecteplase (TNK-tPA) compared to alteplase (t-PA), as depicted in figure 2
Designation Amino acid substitution
T Thr-103 →Asn
N Asn-117→ Gln
K Lys-His-Arg-Arg (296-299) →
Ala-Ala-Ala-Ala
K = lysine; N = asparagine; PAI = plasminogen activator inhibitor; T = threonine.
nous disposition models using the TOPFIT,
PCNonlin or WinNonlin software.[1,7,26] Pharmaco-
kinetic parameters were derived from the models
using standard methods.[30] Because the tenecte-
plase ELISA used in the clinical pharmacokinetic
studies did not distinguish between endogenous t-
PA and tenecteplase, concentrations detected prior
to tenecteplase administration and post-dose con-
centrations of less than 30 ng/ml were not included
in pharmacokinetic analyses.[26] So far, no pharma-
cokinetic analyses have been reported using the
population approach and nonlinear mixed effects
modelling,[31] but such work is currently ongoing.
3. Preclinical Pharmacokinetics and
Pharmacodynamics
3.1 Distribution, Biotransformation and
Elimination in Animal Studies
A whole body autoradiography study was con-
ducted in rats[32,33] to assess tissue distribution fol-
lowing a single intravenous bolus injection of ten-
ecteplase labelled with the novel active site reagent
125I-tyrosyl-prolyl-arginyl chloromethyl ketone[34]
compared to alteplase. The results clearly demon-
strated that the liver was the major clearance organ
for both 125I-tenecteplase and 125I-alteplase. The
liver was the only organ that had significant uptake
of radioactivity 20 minutes after administration of
125I-tenecteplase, with a tissue-to-blood ratio of 2.0
(2.7% of dose/g liver). By 90 minutes, the liver-to-
blood ratio increased to 9.1 (6.0% of dose/g liver)
and relatively little uptake of radioactivity in other
highly perfused organs was noted (spleen, intes-
tine, thyroid, bladder, kidney, adrenal, lung, bone
© Adis International Limited. All rights reserved.
Tanswell et al.
Effect
Adds a new glycosylation site on kringle-1, which decreases the rate of
clearance but decreases fibrin binding
Removes the existing glycosylation site on kringle-1, which decreases
the rate of clearance and restores fibrin binding in combination with
Thr-103 → Asn
Increases fibrin specificity and makes the molecule more resistant to the
naturally occurring inhibitor PAI-1
marrow). The tissue-to-blood ratios for these or-
gans in rank order were 3.8, 3.7, 3.6, 2.5, 2.4, 2.1,
1.3 and 1.2, respectively. No radioactivity was de-
tected in the brain. It appeared that tenecteplase
distributed to similar tissues as alteplase,[35] but
with different kinetics. Gradient gel electrophore-
sis was performed on plasma and urine samples in
order to characterise the nature of circulating and
excreted radioactivity.[33]
No low-molecular-weight polypeptides derived
from 125I-tenecteplase or 125I-alteplase were ob-
served in plasma, although there was evidence of
the formation of higher molecular weight com-
plexes with other plasma proteins. It is likely that
these correspond to an association between the
tenecteplase serine protease domain and several
plasma protein inhibitors, which have been well
characterised for alteplase.[36] Radioactivity ex-
creted in urine was primarily trichloroacetic acid
soluble, and no intact (62–65kD) test material was
observed. A radiolabelled degradation fragment of
28–30kD, believed to be the protease domain, was
detected at very low levels in urine (<2% of the
radioactive dose) following administration of ei-
ther 125I-tenecteplase or 125I-alteplase.
Overall, the results were consistent with hepatic
uptake of tenecteplase followed by catabolism to
small peptides, as described for alteplase.[37]
3.2 Mechanism of Hepatic Elimination
Strong evidence for the hepatic elimination of
tenecteplase in humans is provided by the afore-
mentioned rat studies, the observation that al-
teplase is cleared in human liver,[37,38] and the
structural similarity of tenecteplase and alteplase.
Clin Pharmacokinet 2002; 41 (15)
Tenecteplase
However, it is not precisely known which hepatic
receptor systems are responsible for tenecteplase
elimination. Tenecteplase, like alteplase, is a gly-
coprotein but with differing oligosaccharide struc-
tures. The hepatic mannose receptor, which is im-
portant for alteplase elimination,[22] cannot be
involved in tenecteplase clearance because tenec-
teplase does not contain high-mannose oligosac-
charide. This glycosylation site was eliminated by
mutation of amino acid residue Asn-117 to Gln.
The hepatic low-density lipoprotein receptor re-
lated protein (LRP)[39] could be involved in clear-
ance of both alteplase and tenecteplase via a non-
carbohydrate-mediated mechanism. In addition,
the hepatic asialoglycoprotein receptor, which
binds terminal galactose,[40] may also mediate
clearance of alteplase and tenecteplase.
3.3 Pharmacokinetics and
Pharmacodynamics in Animals
The animal species mouse, rat, rabbit, dog and
monkey were used in safety pharmacology, indi-
cation-specific pharmacology and toxicity studies
of tenecteplase. Extensive pharmacokinetic stud-
ies were performed in these species to define ten-
ecteplase systemic exposure for comparison with
clinical therapy.[33]
Tenecteplase, like alteplase,[41] demonstrated
multiexponential, three-compartment pharmaco-
kinetics in animals, which did not allow the assign-
ment of a principal plasma half-life. However,
mean residence time was always markedly longer
Table II. Comparison of plasma clearance of tenecteplase and alteplase in various animal species and humans
Speciesa Tenecteplase
dose (mg/kg)
Mouse 0.3
Rat 0.3
Rabbit 0.3
Dog 0.3
Rhesus monkey 0.3
Humanb 0.5
a Single dose animal pharmacokinetic data.[33]
b Clinical phase II, TIMI 10B study, 40mg dose group.[7]
CL = total body clearance; TIMI = Thrombolysis in Myocardial Infarction.
© Adis International Limited. All rights reserved.
1235
for tenecteplase than for alteplase. Plasma clear-
ance of tenecteplase was reduced significantly in
all species by a factor of 4–7.5 compared with al-
teplase, as summarised in table II. Clearance data
in patients from the Thrombolysis in Myocardial
Infarction (TIMI) 10B phase II clinical trial are
also included in table II and demonstrate a similar
4-fold decrease in clearance of tenecteplase com-
pared with alteplase. The initial volume of distri-
bution (V1) of tenecteplase in the animal species
generally approximated plasma volume, and steady-
state volume of distribution (Vss) was approxi-
mately 1.5- to 2-fold greater than V1 (data not
shown). Similar pharmacokinetic characteristics
were found in humans, and are described in section
4. Thus overall, the pharmacokinetics of ten-
ecteplase can be regarded as highly consistent
across animal species and humans.
The principal experimental pharmacological
model used for investigating the fibrinolytic po-
tency of tenecteplase in vivo consisted of rabbits
that were fitted with an extracorporal arteriove-
nous shunt containing clots made from whole
blood or platelet-enriched plasma.[6] It was found
that bolus tenecteplase induced 50% lysis in one-
third of the time required by the same dose of al-
teplase by infusion, and that in rabbits tenecteplase
was 8- and 13-fold more potent on a mg/kg basis
than alteplase to whole blood and platelet-enriched
clots, respectively. This superior potency was at-
tributable to pharmacokinetics (reduced clear-
ance) of tenecteplase in the whole blood clot
Alteplase Clearance ratio
(alteplase/tenecteplase)
CL (ml/min/kg) dose (mg/kg) CL (ml/min/kg)
4.9 0.3 29 5.9
4.7 0.3 27 5.7
1.9 0.3 16.1 7.5
4.1 0.3 23 5.6
2.4 0.3 9.5 4.0
1.4 1.22 5.5 4.0
Clin Pharmacokinet 2002; 41 (15)
1236
model, and to a combination of pharmacokinetics
and pharmacodynamics (enhanced PAI-1 resis-
tance) in the platelet-enriched clot model. In phase
II clinical studies, tenecteplase 40mg was found to
achieve approximately equivalent efficacy and
safety to alteplase 100mg.[42,43] This indicated a
relative potency of about 2.5. While not exhibiting
the same potency increase compared with alteplase
as in the rabbit model, the effective total clinical
dose of bolus tenecteplase was nevertheless con-
siderably lower than that of infused al-
teplase.[9,42,43]
4. Clinical Pharmacokinetics and
Pharmacodynamics
Adequate blood sampling for pharmacokinetic
studies of tenecteplase or alteplase in patients with
an acute myocardial infarction is subject to consid-
erable practical constraints because these agents
are given in an intensive care setting as a single
dose only. This greatly restricts the time frame in
which sampling may be performed. During myo-
cardial infarction, patients may exhibit fluctua-
tions in cardiac output and hepatic blood flow
which increase intra-individual pharmacokinetic
variability. The required blood sampling schedule,
including the necessary addition of protease inhib-
itors, often coincides with coronary angiography
or other invasive procedures, which may also af-
fect the pharmacokinetic results.
Table III. Summary of tenecteplase clinical trials for regulatory approval and patient subgroups used for pharmacokinetic analysis
Study (objective) Clinical Dose range
phase
TIMI 10A I 5–50mg
(dose ranging)
TIMI 10B II 30, 40, 50mg
(efficacy)
ASSENT-1 II 30, 40, 50mg
(safety)
ASSENT-2 III Bodyweight
(safety and adjusted: 0.53
efficacy) mg/kg
ASSENT = Assessment of the Safety and Efficacy of a New Thrombolytic; PK = pharmacokinetic; TIMI = Thrombolysis in Myocardial Infarction.
© Adis International Limited. All rights reserved.
Tanswell et al.
In contrast to alteplase,[44] no pharmacokinetic
studies were performed with tenecteplase in healthy
volunteers because of ethical concerns arising
from its increased fibrinolytic potency and longer
half-life. The pharmacokinetics of tenecteplase
were studied in 179 patients with acute myocardial
infarction during clinical development up to regu-
latory approval. Comparative data with alteplase
were obtained concurrently in an additional 53 pa-
tients. Table III indicates the clinical studies for
which pharmacokinetic data for tenecteplase or al-
teplase were obtained. Two large pharmacokinetic
substudies were integrated into the TIMI 10A
phase I dose-ranging clinical trial[26,45] and the
TIMI 10B phase II angiographic clinical trial.[7,42]
No pharmacokinetic data were obtained in the
phase II safety trial (ASSENT-1)[43] and in the
large phase III trial (ASSENT-2),[9] in order not to
compromise the clinical objectives of these trials.
Post-approval clinical trials have been aimed prin-
cipally at studying combinations of tenecteplase
with antithrombotic agents, for example en-
oxaparin or abciximab in ASSENT-3,[46] and no
further tenecteplase pharmacokinetic data were
obtained in those studies.
4.1 Pharmacokinetics in Patients, Phase I
In the phase I (TIMI 10A) study, pharmacoki-
netic parameters were obtained over a wide ten-
ecteplase dose range of 5–50mg, administered as
a single intravenous bolus over 5–10 seconds in
No. of patients entered PK data No. of patients in PK analysis References
(tenecteplase/alteplase) obtained?
tenecteplase alteplase
113/– Yes 80 26,45
555/325 Yes 99 53 7,42
3235/– No 43
8461/8488 No 9
Clin Pharmacokinet 2002; 41 (15)
Tenecteplase 1237

Table IV. Principal pharmacokinetic parameters of tenecteplase in comparison with alteplase in patients with acute myocardial infarction
Dose (mg) and regimen n CL (ml/min) Cmax (μg/ml) V1 (L) Vss (L) Initial t1⁄2 Terminal t1⁄2 Initial AUC
(min) (min) (%)

Tenecteplase bolus, phase I (TIMI 10A)[26]

5 5 216 ± 98 0.70 ± 0.39 8.4 ± 6.3 10 ± 5.3 11 ± 5.2 41 ± 16 31 ± 22
7.5 5 168 ± 66 1.0 ± 0.07 5.8 ± 1.8 8.4 ± 2.8 16 ± 8.5 96 ± 73 58 ± 16
10 5 185 ± 35 1.5 ± 0.30 6.4 ± 1.1 11 ± 5.5 15 ± 8.1 121 ± 100 57 ± 14
15 6 182 ± 76 2.7 ± 1.2 6.7 ± 3.3 9.6 ± 3.7 11 ± 7.9 54 ± 13 42 ± 30
20 7 169 ± 63 2.8 ± 6.5 7.6 ± 2.7 15 ± 7.3 18 ± 6.8 138 ± 84 56 ± 25
30 26 143 ± 45 5.9 ± 3.0 6.3 ± 4.0 9.9 ± 6.0 18 ± 7.7 132 ± 140 64 ± 20
40 18 130 ± 41 9.5 ± 3.4 4.3 ± 1.9 6.3 ± 1.8 17 ± 5.6 88 ± 45 69 ± 15
50 7 125 ± 25 8.8 ± 1.4 5.7 ± 1.4 6.7 ± 1.3 20 ± 5.5 65 ± 25 55 ± 29

Tenecteplase bolus, phase II (TIMI 10B)[7]

30 48 98.5 ± 42 7.5 ± 5.2 4.2 ± 2.6 6.3 ± 3.3 22 ± 8.2 116 ± 63 72 ± 22
40 31 119 ± 49 9.5 ± 8.1 5.4 ± 2.7 8.0 ± 5.9 24 ± 5.5 129 ± 87 75 ± 16
50 20 99.9 ± 32 11.6 ± 4.4 4.7 ± 2.6 6.1 ± 2.4 20 ± 10 90.4 ± 35 66 ± 29

Alteplase infusion over 90 minutes

100 (phase II, TIMI 10B[7])a 53 453 ± 170 4.3 ± 3.4 7.2 ± 4.1 28.9 ± 22 144 ± 100
100 (earlier data, TAPS[1]) 10 572 ± 130 4.0 ± 1.0 3.4 ± 1.5 8.4 ± 5.0 3.5 ± 1.4 72 ± 68 85 ± 15
a Initial t1⁄2 of alteplase not sampled, pharmacokinetic data are from noncompartmental analysis.
AUC = area under the concentration-time curve; CL = total body clearance; Cmax = peak plasma concentration; n = number of patients;
TAPS = rt-PA-APSAC Patency Study; TIMI = Thrombolysis in Myocardial Infarction; t1⁄2 = half-life; Vss = volume of distribution at steady
state; V1 = initial volume of distribution.

patients with acute myocardial infarction.[26,45]
The number of patients for whom pharmacokinetic
data was obtained in each group varied between 5
and 26. Tenecteplase exhibited biphasic (two-
compartment) kinetics in 60 patients, and mono-
phasic kinetics in 20 patients. It is likely that ten-
ecteplase disposition is generally biphasic, but in
some patients only a single compartment was de-
tected. The principal pharmacokinetic parameters
are listed in table IV. Clearance of tenecteplase
decreased from 216 ml/min at the 5mg dose to 125
ml/min at 50mg (table IV, figure 3), indicating a
moderate pharmacokinetic nonlinearity.[26] How-
ever, in the dose range 30–50mg, which was
judged to be clinically relevant based on an-
giographic efficacy, there was no significant dif-
ference in clearance (125–143 ml/min). This clear-
ance was 4-fold slower, and the initial half-life of
17–20 min, which corresponded to 55–69% of area
under the concentration-time curve (AUC), was 5-
fold longer, than reported for alteplase.[1] This
study, therefore, provided a clear pharmacokinetic
rationale, based on the considerably reduced
plasma clearance and prolonged half-life com-
pared with alteplase, to support further clinical de-
velopment of tenecteplase using a single intrave-
nous bolus rather than an infusion regimen.
4.2 Pharmacokinetics in Patients, Phase II
In the phase II (TIMI 10B) pharmacokinetic
study, tenecteplase bolus doses of 30, 40 and 50mg
were administered and compared with alteplase
100mg given as a 90-minute accelerated infusion
regimen.[7] The plasma concentration-time pro-
files are shown in figure 4, and pharmacokinetic
parameters are summarised in table IV.
Tenecteplase exhibited two-compartment ki-
netics in 90 out of 99 patients, and alteplase phar-
macokinetics were evaluated by noncompartmen-
tal analysis. In contrast to the phase I (TIMI 10A)
study there was no dose dependence of clearance,
probably because of the more restricted dose
range. The mean initial half-life was 22 minutes
and the mean terminal half-life was 115 minutes.

© Adis International Limited. All rights reserved. Clin Pharmacokinet 2002; 41 (15)
1238
400
350
300
CL (ml/min)
250
200
150
100
50
0 10 20 30 40
Dose (mg)
Fig. 3. Dependence of tenecteplase plasma clearance (CL) on
dose in the Thrombolysis in Myocardial Infarction (TIMI) 10A
phase I clinical trial in patients with acute myocardial infarction
(reproduced from Modi et al.,[26] with permission).
The mean clearance of tenecteplase (105 ml/min)
was 4.3-fold slower than that measured for al-
teplase in TIMI 10B, and the initial (dominant)
half-life was 6.3 times longer than that reported
for alteplase in the rt-PA-APSAC Patency Study
(TAPS),[1] confirming the phase I results. Other
pharmacokinetic parameters of alteplase measured
in TIMI 10B were similar to those reported in the
TAPS study.[1]
Tenecteplase pharmacokinetics were very simi-
lar in both the TIMI 10A and TIMI 10B studies
(table IV). The initial plasma half-life was slightly
longer in TIMI 10B (20–24 min) than in TIMI 10A
(17–20 min), but this may be attributable to the
more sparse blood sampling in TIMI 10B (reduced
from 15 to 8 samples per patient), and the differ-
ence is not clinically important. Although ten-
ecteplase clearance was similar at the 40 and 50mg
doses, clearance at the 30mg dose was 31% lower
in TIMI 10B than in TIMI 10A. This may have
been attributable to known minor increases in sia-
lic acid content resulting from manufacturing scale
changes and process optimisation of tenecteplase
that occurred after TIMI 10A.[7,33] Increases in sia-
lic acid content will block exposed galactose in
© Adis International Limited. All rights reserved.
Tanswell et al.
oligosaccharide moieties of the tenecteplase mol-
ecule and may therefore reduce its clearance by the
hepatic asialoglycoprotein receptor.[33,40]
The initial half-life of tenecteplase was domi-
nant in both studies, accounting for 55–72% of
AUC. Overall, V1 (4.2–6.3L) approximated plas-
ma volume, and Vss was 6.1–9.9L, suggesting
mainly intravascular distribution. These parame-
ters are consistent with the large molecular mass of
tenecteplase (65kD). In contrast to alteplase,[36] lit-
tle information is available on binding of ten-
ecteplase to plasma proteins in humans. Recently,
50 60 slow complex formation between tenecteplase and
C1 inhibitor was demonstrated in vitro in human
plasma.[47]
4.3 Sources of Pharmacokinetic Variability
Interindividual variability of tenecteplase phar-
macokinetic parameters was relatively high (table
IV). For example, overall coefficients of variation
were 41% for clearance and 58% for V1 in the TIMI
10B study. The intra-individual (residual) variabil-
ity was not quantitatively assessed, and a combined
analysis of the TIMI 10A and TIMI 10 B studies
was not performed; both aspects would require fur-
ther analysis by population mixed effect model-
100 000 30mg tenecteplase (n = 48)
40mg tenecteplase (n = 31)
Plasma concentration (μg/L)
50mg tenecteplase (n = 20)
10 000 100mg alteplase (n = 53)
1 000
100
10
0 60 120 180 240 300 360 420
Time (min)
Fig. 4. Pharmacokinetics in the Thrombolysis in Myocardial In-
farction (TIMI) 10B phase II clinical trial. Mean immunoreactive
plasma concentration-time profiles for tenecteplase following an
intravenous bolus dose and for alteplase following the acceler-
ated infusion regimen (100mg in 90 minutes) [reproduced from
Modi et al.,[7] with permission].
Clin Pharmacokinet 2002; 41 (15)
Tenecteplase
ling.[31] In the TIMI 10A and TIMI 10B studies,
two-stage data analysis approaches were used to
identify patient covariates that contributed to inter-
individual pharmacokinetic variability. These in-
volved stepwise linear regression of pharmacoki-
netic parameters on covariates after the former had
been computed by model fitting of individual
plasma concentration profiles. Demographic data
for patients of the TIMI 10 B pharmacokinetic
study are given for reference in table V.
In the TIMI 10A study, dose followed by total
or lean bodyweight, age and gender were signifi-
cantly correlated with clearance, whereas none in-
fluenced V1.[26] Dose was the most important cov-
ariate but only explained 17% of the variability in
clearance. On including all covariates in the re-
gression model, still only 30% of the total variabil-
ity could be accounted for. In TIMI 10B, total or
lean bodyweight and age were found significantly
to influence both clearance and V1.[7] However, the
predictive value of these covariates was again
small. Total bodyweight explained 19% of the
variability in clearance and 11% of the variability
in V1. Age explained a further 11% of the variabil-
ity in clearance. A 10kg increase in total body-
weight resulted in a 9.6 ml/min increase in plasma
clearance. Conversely, a 10-year increase in pa-
tient age resulted in a 16.1 ml/min decrease in
plasma clearance. These effects are summarised
graphically in figure 5.
In both studies, clearance increased with body-
weight and decreased with age. This is not unex-
pected on consideration of the hepatic elimination
route for tenecteplase, because heavier patients
might have higher liver weights and therefore in-
creased capacity for tenecteplase clearance. The
Table V. Patient demographic data for the pharmacokinetic part of the TIMI 10B study (reproduced from Modi et al.,[7] with permission)
Characteristic Tenecteplase
30mg 40mg
Male/female 29/18 23/6
Age (years) 56.8 ± 11 55.2 ± 11
Weight (kg) 84.7 ± 17 85.4 ± 25
Lean bodyweight (kg) 58.3 ± 11 58.9 ± 9.4
TIMI = Thrombolysis in Myocardial Infarction.
© Adis International Limited. All rights reserved.
1239
decrease of clearance with age may reflect reduced
expression and/or function of hepatic receptor sys-
tems for tenecteplase catabolism. With initial dis-
tribution corresponding to plasma volume, the in-
crease of V1 with bodyweight observed in TIMI
10B can also be rationalised, because heavier pa-
tients will have higher blood volume. Men had
higher mean clearance than women, but the effect
was not statistically significant and may have been
attributable to the greater bodyweight of male pa-
tients. Also, only 28% of the patients with com-
plete demographic data in the pharmacokinetic
subset of TIMI 10B were women, which reflected
the low female/male ratio in the full trial popula-
tion[42] and acute myocardial infarction studies in
general[9] (table V).
No separate clinical trials were performed to
investigate specifically the pharmacokinetics of
tenecteplase in special populations such as individ-
uals with hepatic and renal insufficiency. Rat stud-
ies showed that tenecteplase is not excreted intact
into the urine.[33] Also, the molecular mass of ten-
ecteplase, which is close to that of serum albumin,
precludes glomerular filtration in any species.
Therefore, it is not expected that renal dysfunction
will affect pharmacokinetics. The effect of hepatic
dysfunction on the pharmacokinetics of ten-
ecteplase in humans was not studied.
No separate clinical studies were performed to
evaluate specifically the potential for pharmacoki-
netic interaction between tenecteplase and other
drugs commonly administered in the treatment of
subjects with acute myocardial infarction. All
study patients included in the pharmacokinetic
analyses received aspirin and heparin as concom-
itant medication.[42,45] A study in dogs revealed no
Alteplase
50mg 100mg
17/3 38/15
59.0 ± 11 57.8 ± 12
78.8 ± 15 81.8 ± 16
58.5 ± 9.7 57.8 ± 10
Clin Pharmacokinet 2002; 41 (15)
1240 Tanswell et al.

V1 could only partially be explained by the patient

y = 25.331 + 0.961 • x; r2 = 0.185
covariates bodyweight and age and therefore
300
largely reflect random variability in distribution
250 and clearance of tenecteplase in patients with acute
myocardial infarction.
200
Antibodies to tenecteplase were not detected in
CL (ml/min)

150 any patient at 30 days in the TIMI 10A trial, al-

though one patient had a positive titre before treat-
100 ment.[45] In the TIMI 10B trial, antibodies were
50
detected in only 1 out of 364 patients at 30 days
after administration, and no antibodies were de-
0 tected in this patient at 90 days.[42] Thus, ten-
40 60 80 100 120 140 160 180 200 ecteplase is essentially non-antigenic after single
Weight (kg)
administration, and antibody formation can be ex-
cluded as a source of pharmacokinetic or pharma-
300 y = 197.054 − 1.608 • x; r2 = 0.169
codynamic variability.

250
4.4 In Vivo Markers of Pharmacodynamic
200 Action
CL (ml/min)

150
100
50
0 two main features.
30 40 50 60 70 80
Age (years)
Fig. 5. Dependence of tenecteplase plasma clearance (CL) on
bodyweight and age in the Thrombolysis in Myocardial Infarc-
tion (TIMI) 10B phase II trial (reproduced from Modi et al.,[7] with
permission).
effect of either aspirin or heparin on the pharma-
cokinetics of tenecteplase.[33] Tenecteplase clear-
ance in the TIMI 10A study was not affected by
concomitant administration of nitrates or β-block-
ers. [26] Alteplase clearance has been shown to
exhibit liver blood flow dependence,[48] but the
substantially reduced hepatic clearance of ten-
ecteplase will decrease the likelihood that it would
be influenced by drugs that alter hepatic blood
flow.
In summary, the relatively high observed inter-
individual variability of tenecteplase clearance and
The fibrinolytic enzyme reaction scheme de-
picted in figure 1, in which alteplase/tenecteplase
activates plasminogen to plasmin preferentially on
the solid-phase fibrin surface, has the following
90
• Fibrinolysis or clot dissolution is the desired
pharmacological effect, where the fibrin com-
ponent of the blood clot is dissolved by plasmin
to form measurable soluble fibrin degradation
products.
• In systemic lysis, a certain amount of plasmin-
ogen is additionally activated to plasmin in the
fluid phase, resulting in measurable degradation
of coagulation proteins such as fibrinogen and
consumption of plasminogen and α2-anti-
plasmin. This is undesirable because it reduces
the coagulability of blood and may be responsi-
ble for adverse bleeding effects.
The extent to which systemic lysis occurs for a
given amount of fibrinolysis decreases with in-
creasing fibrin specificity of the fibrinolytic agent
used.[3] Thus, tenecteplase at therapeutically equiva-
lent doses to alteplase results in less consumption
of fibrinogen, plasminogen and α2-antiplasmin as
measured in plasma samples by coagulation labo-

© Adis International Limited. All rights reserved. Clin Pharmacokinet 2002; 41 (15)
Tenecteplase 1241

ratory methods in clinical trials,[42] as shown in
figure 6.
Mathematical models for alteplase pharmaco-
dynamic action in fibrinolysis based on the en-
zymatic reactions of figure 1 have been devel-
oped.[49,50] They can be regarded as a type of
indirect pharmacodynamic response model,[51] be-
cause the therapeutic agent (plasminogen activa-
tor) stimulates the production of an endogenous
enzyme (plasmin) that mediates both the pharma-
cological effect (clot lysis) and adverse effects
(consumption of coagulation/fibrinolytic proteins)
as a function of plasma concentration of the agent.
However, although mechanistic pharmacody-
namic models for alteplase and tenecteplase based
on enyzmatic reactions in plasma have been exten-
sively used for in vitro studies,[8,52] they have
found essentially no application in clinical therapy.
With respect to efficacy, this is because fibrin
degradation products in plasma are not specific
biomarkers for the lysis of coronary thrombi.[53]
Fibrin occurs elsewhere in the vascular system,[54]
and fibrin degradation products are heterogeneous
in nature, posing problems for specific laboratory
analysis.[55] Examples of more specific serum
biomarkers that originate from myocardium, and
have been recently explored as indicators of coro-
nary recanalisation or survival, are creatine kinase
MM subforms[56] and troponin T or I.[57,58] The
preferred clinical/pharmacological and therapeu-
tic efficacy measures of tenecteplase and alteplase
include:
• extent of recanalisation of the culprit coronary
artery determined angiographically according
to TIMI flow grade;[42,59]
• corrected TIMI frame count;[60]
• all-cause mortality at 30 days;[9]
• composite endpoints such as 30-day mortality,
in-hospital re-infarction or in-hospital refrac-
tory ischaemia.[46]
The composite endpoints probably reflect the
combined effects of fibrinolysis and conjunctive
anticoagulation.[3]

30 mg
40 mg
50 mg
Alteplase

α2-Antiplasmin Fibrinogen Plasminogen

0
0
−10 −10

−20 −20
−20
Change (%)

−30
−40
−30
−40
−60
−40 −50

−80 −60

0 1 3 6 0 1 3 6 0 1 3 6
Time post-dose (h)
Fig. 6. Tenecteplase pharmacodynamics showing improved fibrin specificity. Markedly reduced systemic effects occurred during
fibrinolytic therapy with tenecteplase (bolus doses in mg, indicated by the symbols) compared with alteplase infusions of 100mg
over 90 minutes in the Thrombolysis in Myocardial Infarction (TIMI) 10B study, as measured by the time course of median concen-
trations of the proteins of the fibrinolytic system α 2-antiplasmin and plasminogen, and the coagulation protein fibrinogen (reproduced
from Cannon et al.,[42] with permission).

© Adis International Limited. All rights reserved. Clin Pharmacokinet 2002; 41 (15)
1242
With respect to safety measures, the time
courses of concentrations of fibrinogen, plasmino-
gen, α2-antiplasmin and other coagulation/fibri-
nolysis proteins in plasma are useful indicators of
the relative fibrin specificity of tenecteplase com-
pared with alteplase and other plasminogen activa-
tors (figure 6).[42,49] However, the preferred clini-
cal variables that are used to assess safety in
therapeutic trials are the incidence of intracranial
bleeding, non-cerebral major or minor bleeding ep-
isodes and blood transfusion requirements.[9,14,43]
Intracranial haemorrhage is the most serious bleed-
ing complication, which is estimated to occur at a
low frequency of 0.5–1% in large-scale studies of
patients with acute myocardial infarction.[61]
4.5 Pharmacokinetic-Pharmacodynamic
Relationships
Pharmacokinetic-pharmacodynamic modelling
attempts to establish quantitative relationships be-
tween drug dose, plasma concentrations, patient-
specific factors such as age, body size, gender, or-
gan dysfunction or concomitant medication, and
therapeutic effects and adverse events. The objec-
tives of such modelling are to compute the mean
and variability of key model parameters (such as
clearance or clinical response) and to aid simula-
tion of new dosage regimens.
As a significant step in this direction, Modi et
al.[7] showed that the percentage of patients achiev-
ing TIMI 3 grade coronary artery blood flow
yielded a clear AUC-response relationship. It was
found that >75% of patients achieved TIMI 3 flow
at 90 minutes after administration when the corre-
sponding partial AUC2–90 was >320 μg • min/ml
(figure 7). This corresponds to an average plasma
concentration of 3.6 μg/ml during the 90-minute
time interval. Systemic exposure to tenecteplase at
all times after bolus administration of 30–50mg
was higher than for alteplase 100mg (figure 4)
without compromising clinical safety. For exam-
ple, AUC for tenecteplase 40mg, which is close to
the finally adopted clinical dose of 0.53 mg/kg,
was 1.8 times higher than for alteplase 100mg, and
peak concentration (Cmax) was 2.2 times higher.[7]
© Adis International Limited. All rights reserved.
Tanswell et al.
100
TIMI-3 flow at 90 minutes (%)
80
Patients who achieved
60
40
20
0
n = 17 n = 17 n = 19 n = 16 n = 16
<220 220-260 260-320 320-430 >430
AUC2-90 (mg • min/L)
Fig. 7. Tenecteplase pharmacodynamics showing the relation-
ship between the partial area under the concentration-time
curve from 2 to 90 minutes (AUC2–90) and the percentage of
patients who achieved Thrombolysis in Myocardial Infarction
(TIMI) grade 3 coronary artery flow at 90 minutes (reproduced
from Modi et al.,[7] with permission).
This suggests that the reduced clearance, greater
fibrin specificity and higher PAI-1 resistance de-
signed for tenecteplase allow higher plasma con-
centrations and thus a more rapid restoration of
coronary patency to be attained, while providing a
reduction in serious bleeding events.
Although the amount of pharmacokinetic data
collected during the clinical development of ten-
ecteplase was considerably greater than has been
reported for other fibrinolytic agents,[1,10,62] it was
restricted for the practical reasons explained above
to subsets of phase I and early phase II clinical
trials. These comprised 70 and 18% of the TIMI
10A and TIMI 10B patients, respectively. The
available pharmacokinetic-pharmacodynamic data
were therefore dwarfed by the amount of dose-
response data on clinical variables, such as mortal-
ity and bleeding events, that were obtained without
plasma concentrations in the remainder of the
TIMI 10A and 10B trials, the ASSENT-1 phase II
safety trial and the ASSENT-2 phase III ‘megatr-
ial’ (see table III for citations and comparisons of
patient numbers). Therefore, although dose-plasma
concentration-effect data sets are in general con-
Clin Pharmacokinet 2002; 41 (15)
Tenecteplase
siderably more informative than dose-effect data
sets without pharmacokinetics, even with intrave-
nous administration, the former were available for
‘only’ 179 tenecteplase patients, whereas the latter
were available for approximately 12 100 patients.
This situation was illustrated quite clearly dur-
ing the development of the rationale for body-
weight-tiered administration of tenecteplase in the
ASSENT-2 phase III study and post-approval use.
The rationale was initially derived from data ob-
tained from fixed doses per patient in phase II, and
could be confirmed in the ASSENT-2 study.[15-17,63]
The bodyweight dependence of tenecteplase clear-
ance shown in figure 5 provided valuable support-
ing data, but the final bolus dosage regimen of
30–50mg (approximately equivalent to 0.53 mg/kg)
was determined by means of bodyweight-based
analysis of clinical variables (corrected TIMI
frame count, TIMI flow grade, intracranial haem-
orrhage, stroke and severe bleeding) using multi-
variate Cox and logistic regression.[15] It is essen-
tial to note that these clinical variables reflect both
pharmacokinetic and pharmacodynamic variabil-
ity. The former has been defined by the pharmaco-
kinetic studies reviewed above. The latter is criti-
cally important but much more difficult to quantify
because it is the variability, resulting from a given
systemic exposure to tenecteplase in different in-
dividuals, both of the susceptibility of coronary
thrombi to fibrinolysis and of the susceptibility of
the vascular system to adverse bleeding events.
For example, pharmacodynamic rather than
pharmacokinetic variability is much more likely to
be responsible for the increased mortality and
bleeding events in the important patient group
aged >75 years that is observed both for ten-
ecteplase and for other thrombolytic agents.[9,14,16]
The increase in systemic exposure to tenecteplase
with age that results from reduced clearance is rel-
atively modest (figure 5), whereas it is known that
hypertension and pathological alterations in blood
vessels that may predispose to bleeding events are
more prevalent in elderly patients.[64]
© Adis International Limited. All rights reserved.
1243
5. Conclusions
The fibrinolytic agent tenecteplase exemplifies
the power of rational drug development applied to
therapeutic proteins. By means of a high resolution
structural analysis of the physiological t-PA mol-
ecule and combined specific mutagenesis at three
sites, tenecteplase was developed to exhibit en-
hanced biological properties compared with re-
combinant t-PA (alteplase). These properties were
first extensively characterised in preclinical stud-
ies and appeared to be confirmed in clinical trials.
Pharmacodynamically, fibrin specificity was
increased more than 10-fold and reactivity with
PAI-1, which is present in platelet-rich blood clots,
was decreased 80-fold relative to alteplase. Phar-
macokinetically, plasma clearance was reduced 4-
fold to 105 ml/min and the dominant half life
prolonged 6-fold to 22 minutes compared with al-
teplase in patients with acute myocardial infarc-
tion, with essentially unchanged distribution char-
acteristics. This enabled tenecteplase to be
administered as a 5–10 second intravenous bolus
dose rather than the 90-minute accelerated infu-
sion regimen of alteplase, while providing equiv-
alent efficacy in angiographic studies and less sys-
temic fibrinogenolysis. Tenecteplase, given as a
single bodyweight-tiered bolus dose of approxi-
mately 0.53 mg/kg, is the only fibrinolytic agent
that has demonstrated equivalent efficacy and im-
proved safety (reduced frequency of major bleed-
ing) compared with alteplase in a large mortality
trial (ASSENT-2).
More pharmacokinetic data were obtained for
tenecteplase than for any other fibrinolytic agent
hitherto (complete concentration-time profiles for
179 patients), which provided excellent estimates
of mean and variability of pharmacokinetic param-
eters (two-compartment model). The relatively
high interindividual variability of tenecteplase
clearance and initial volume of distribution could,
via regression analysis, be partially explained by
the patient covariates bodyweight and age. The in-
crease of clearance with bodyweight aided the de-
velopment of a rationale for the weight-tiered dose
regimen for tenecteplase in clinical practice.
Clin Pharmacokinet 2002; 41 (15)
1244
A pharmacokinetic-pharmacodynamic relation-
ship could be established between partial AUC of
tenecteplase and coronary artery recanalisation as
measured by angiography. Because of its utility in
aiding rational dose regimen design, there is poten-
tial for more extensive use of pharmacokinetic-
pharmacodynamic modelling in future clinical tri-
als of fibrinolytic agents and their combinations
with antiplatelet drugs.
Acknowledgements
We wish to thank Drs K. Schleenhain and G. Heusel for
expert help in the preparation of the manuscript. The authors
are or were employed by Boehringer Ingelheim or Genetech,
Inc. These companies sponsored the clinical trials described
in the review and also manufacture and market tenecteplase.
References
1. Tanswell P, Tebbe U, Neuhaus KL, et al. Pharmacokinetics and
fibrin specificity of alteplase during accelerated infusions in
acute myocardial infarction. J Am Coll Cardiol 1992; 19:
1071-5
2. Topol E. An international, randomized trial comparing four
thrombolytic strategies for acute myocardial infarction. N
Engl J Med 1993; 329: 673-82
3. Sobel BE. Fibrin specificity of plasminogen activators, rebound
generation of thrombin, and their therapeutic implications.
Coron Artery Dis 2001; 12: 232-332
4. Collen D, De Bono DP, Lijnen HR, et al. Development of novel
thrombolytic agents: mini-symposium on the role of the fibri-
nolytic system in the pathophysiology and treatment of throm-
bosis; 1993 Oct; Leuven. J Intern Med 1994; 236: 433-7
5. Huber K. Plasminogen activator inhibitor type-I (part two): role
for failure of thrombolytic therapy. PAI-1 resistance as a po-
tential benefit for new fibrinolytic agents. J Thrombosis
Thrombolysis 2001; 11: 195-202
6. Keyt B, Paoni N, Refino C, et al. A faster-acting and more
potent form of tissue plasminogen activator. Proc Natl Acad
Sci U S A 1994; 91 (1): 3670-4
7. Modi NB, Fox NL, Fong WC, et al. Pharmacokinetics and phar-
macodynamics of tenecteplase: results from a phase II study
in patients with acute myocardial infarction. J Clin Pharmacol
2000; 40: 508-15
8. Stewart RJ, Fredenburgh JC, Leslie BA, et al. Identification of
the mechanism responsible for the increased fibrin specificity
of TNK-tissue plasminogen activator relative to tissue plas-
minogen activator. J Biol Chem 2000; 275: 10112-20
9. Van de Werf F, Adgey J, Ardissino D, et al. Single bolus ten-
ecteplase compared with front-loaded alteplase in acute myo-
cardial infarction: the ASSENT 2 double-blind randomised
trial. Lancet 1999; 354 (9180): 716-22
10. Martin U, Kaufmann B, Neugebauer G. Current clinical use of
reteplase for thrombolysis: a pharmacokinetic-pharmacody-
namic perspective. Clin Pharmacokinet 1999; 36: 265-76
11. Kohnert U, Rudolph R, Verheijen JH, et al. Biochemical prop-
erties of the kringle-2 and protease domains are maintained in
the refolded t-PA deletion variant BM 06.022. Protein Eng
1992; 5: 95-100
© Adis International Limited. All rights reserved.
Tanswell et al.
12. GUSTO III Investigators. A comparison of reteplase with al-
teplase for acute myocardial infarction. N Engl J Med 1997;
337: 1118-23
13. Dunn CJ, Goa KL. Tenecteplase: a review of its pharmacology
and therapeutic efficacy in patients with acute myocardial
infarction. Am J Cardiovasc Drugs 2001; 1: 51-66
14. Van de Werf F, Barron HV, Armstrong PW, et al. Incidence and
predictors of bleeding events after fibrinolytic therapy with
fibrin-specific agents. Eur Heart J 2001; 22: 2253-61
15. Wang-Clow F, Fox NL, Cannon CP, et al. Determination of a
weight adjusted dose of TNK-tissue plasminogen activator.
Am Heart J 2001; 141: 33-50
16. Gibson CM, Marble SJ. Issues in the assessment of the safety
and efficacy of tenecteplase (TNK-tPA). Clin Cardiol 2001;
24: 577-84
17. Angeja BG, Alexander JH, Chin R, et al. Safety of the weight-
adjusted dosing regimen of tenecteplase in the ASSENT trial.
Am J Cardiol 2001; 88: 1240-5
18. Collen D, Lijnen HR. Molecular basis of fibrinolysis, as rele-
vant for thrombolytic therapy. Thromb Haemost 1995; 74:
167-71
19. Lijnen H, Collen D. Strategies for the improvement of throm-
bolytic agents. Thromb Haemost 1991; 66: 88-110
20. Bennett WF, Paoni NF, Keyt BA, et al. High resolution analysis
of functional determinants on human tissue-type plasminogen
activator. J Biol Chem 1991; 266: 5191-201
21. Parekh RB, Dwek RA, Thomas JR, et al. Cell-type-specific and
site-specific N-glycosylation of type I and type II human tis-
sue plasminogen activator. Biochemistry 1989; 28: 7644-62
22. Noorman F, Rijken DC. Regulation of tissue-type plasminogen
activator concentrations by clearance via the mannose recep-
tor and other receptors. Fibrinolysis Proteolysis 1997; 11:
173-86
23. McCluskey ER, Keyt BA, Refino CJ, et al. Biochemistry, phar-
macology and initial clinical experience with TNK-tPA. In:
Sasahara AA, Loscalzo J, editors. New therapeutic agents in
thrombosis and thrombolysis. New York: Marcel Dekker,
Inc., 1997: 475-93
24. Benedict CR, Refino CJ, Keyt BA, et al. New variant of human
tissue plasminogen activator (TPA) with enhanced efficacy
and lower incidence of bleeding compared with recombinant
human TPA. Circulation 1995; 92: 3032-40
25. Eppler S, Senn T, Gilkerson E, et al. Pharmacokinetics and
pharmacodynamics of recombinant tissue-type plasminogen
activator following intravenous administration in rabbits;
comparison of three dosing regimens. Biopharm Drug Dispos
1998; 19: 31-8
26. Modi NB, Eppler S, Breed J, et al. Pharmacokinetics of a slower
clearing tissue plasminogen activator variant, TNK-tPA, in
patients with acute myocardial infarction. Thromb Haemost
1998; 79: 134-9
27. Mohler MA, Refino CJ, Chen SA, et al. D-Phe-Pro-Arg-chloro-
methyl ketone: its potential use in inhibiting the formation of
in vitro artifacts in blood collected during tissue-type plasmin-
ogen activator thrombolytic therapy. Thromb Haemost 1986;
56: 160-4
28. Seifried E, Tanswell P. Comparison of specific antibody, D-
Phe-Pro-Arg-CH2Cl and aprotinin for prevention of in vitro
effects of recombinant tissue-type plasminogen activator on
haemostasis parameters. Thromb Haemost 1987; 58: 921-6
29. Reed BR, Chen AB, Tanswell P, et al. Low incidence of anti-
bodies to recombinant human tissue-type plasminogen acti-
vator in treated patients. Thromb Haemost 1990; 64: 276-80
Clin Pharmacokinet 2002; 41 (15)
Tenecteplase
30. Gibaldi M, Perrier D, editors. Pharmacokinetics. 2nd ed. New
York: Marcel Dekker, 1982
31. Ette EL, Ludden TM. Population pharmacokinetic modeling:
the importance of informative graphics. Pharm Res 1995; 12:
1845-55
32. DeGuzman G, Richarson L, Berleau L, et al. Hepatic uptake and
processing of TNK-tPA [abstract]. Pharm Res 1995; 123: 332
33. Tanswell P, Stassen JM, Platz S. Regulatory submission to
EMEA. Metalyse® (tenecteplase): expert report on the tox-
ico-pharmacological documentation. Biberach: Boehringer
Ingelheim, 1999. (Data on file)
34. Keyt BA, Berleau LT, Nguyen HV, et al. Radioiodination of
the active site of tissue plasminogen activator: a method for
radiolabeling serine proteases with tyrosylprolyarginyl
chloromethyl ketone. Anal Biochem 1992; 206: 73-83
35. Bakhit C, Lewis D, Busch U, et al. Biodisposition and catabo-
lism of tissue-type plasminogen activator in rats and rabbits.
Fibrinolysis 1988; 2: 31-6
36. Lucore CL, Sobel BE. Interactions of tissue-type plasminogen
activator with plasma inhibitors and their pharmacologic im-
plications. Circulation 1988; 77: 660-9
37. Tanswell P, Seifried E, Stang E, et al. Pharmacokinetics and
hepatic catabolism of tissue-type plasminogen activator.
Arzneimittel Forschung 1991; 41: 1310-9
38. Krause J. Hepatic catabolism of tissue-type plasminogen acti-
vator (t-PA), its variants, mutants and hybrids. Fibrinolysis
1988; 2: 133-42
39. Bu G, Williams S, Strickland DK, et al. Low density lipoprotein
receptor-related protein/alpha(2)-macroglobulin receptor is
an hepatic receptor for tissue-type plasminogen activator.
Proc Natl Acad Sci U S A 1992; 89: 7427-31
40. Smedsrod B, Einarsson M. Clearance of tissue plasminogen
activator by mannose and galactose receptors in the liver.
Thromb Haemost 1990; 63: 60-6
41. Tanswell P, Heinzel G, Greischel A, et al. Nonlinear pharma-
cokinetics of tissue-type plasminogen activator in three ani-
mal species and isolated perfused rat liver. J Pharmacol Exp
Ther 1990; 255: 318-24
42. Cannon CP, Gibson CM, McCabe CH, et al. TIMI 10B Inves-
tigators. TNK tissue plasminogen activator compared with
front-loaded alteplase in acute myocardial infarction: results
of the TIMI 10B trial. Circulation 1998; 98: 2805-14
43. Van de Werf F, Cannon CP, Luyten A, et al. Safety assessment
of single-bolus administration of TNK tissue-plasminogen
activator in acute myocardial infarction: the ASSENT-1 trial.
The ASSENT-1 Investigators. Am Heart J 1999; 137: 786-91
44. Tanswell P, Seifried E, Su CAPF, et al. Pharmacokinetics and
systemic effects of tissue-type plasminogen activator in nor-
mal subjects. Clin Pharmacol Ther 1989; 46: 155-62
45. Cannon CP, McCabe CH, Gibson CM, et al. TNK-tissue plas-
minogen activator in acute myocardial infarction: results of
the Thrombolysis In Myocardial Infarction (TIMI) 10A dose-
ranging trial. Circulation 1997; 95: 351-6
46. Van de Werf F, ASSENT-3 investigators. Efficacy and safety
of tenecteplase in combination with enoxaparin, abciximab,
or unfractionated heparin: the ASSENT–3 randomised trial
in acute myocardial infarction. Lancet 2001; 358: 605-13
47. Sulikowski T, Patson PA. The inhibition of TNK-tPA by C1-
inhibitor. Blood Coagul Fibrinolysis 2001; 12: 75-7
48. Van Griensven JMT, Koster RW, Burggraaf J, et al. Effects of
liver blood flow on the pharmacokinetics of tissue-type plas-
minogen activator (alteplase) during thrombolysis in patients
with acute myocardial infarction. Clin Pharmacol Ther 1998;
63: 39-47
© Adis International Limited. All rights reserved.
1245
49. Sobel BE, Gross RW, Robison AK. Thrombolysis, clot selec-
tivity, and kinetics. Circulation 1984; 70: 160-4
50. Thomaseth K, Boniollo B. Simulation of plasmatic enzymatic
reactions during thrombolytic therapy with recombinant tis-
sue-type plasminogen activator: from in vitro knowledge to
new assumptions in vivo. Simulation 1996; 66: 219-28
51. Sharma A, Jusko WJ. Characteristics of indirect pharmacody-
namic models and application to clinical drug responses. Br
J Clin Pharmacol 1998; 48: 229-39
52. Hoylaerts M, Rijken DC, Lijnen HR, et al. Kinetics of the acti-
vation of plasminogen by human plasminogen activator: role
of fibrin. J Biol Chem 1982; 257: 2912-9
53. Lee LV, Ewald GA, McKenzie CR, et al. The relationship of
soluble fibrin and cross-linked fibrin degradation products to
the clinical course of myocardial infarction. Arterioscler
Thromb Vasc Biol 1997; 17: 628-33
54. Seifried E, Tanswell P, Rijken DC, et al. Fibrin degradation
products are not specific markers for thrombolysis in myo-
cardial infarction. Lancet 1987; II: 333-4
55. Walker JB, Nesheim ME. The molecular weights, mass distri-
bution, chain composition, and structure of soluble fibrin deg-
radation products released from a fibrin clot perfused with
plasmin. J Biol Chem 1999; 274: 5201-12
56. Binbrek A, Rao N, Absher M, et al. The relative rapidity of
recanalization induced by recombinant tissue-type plasmino-
gen activator (r-tPA) and TNK-tPA, assessed with enzymatic
methods. Coron Artery Dis 2000; 11 (5): 429-35
57. Ohman EM, Armstrong PW, White HD, et al. GUSTO-III In-
vestigators. Risk stratification with a point-of-care cardiac
troponin T test in acute myocardial infarction. Am J Cardiol
1999; 84: 1281-6
58. Antman EM, Tanasijevic MJ, Thompson B, et al. Cardiac spe-
cific troponin I levels to predict the risk of mortality in pa-
tients with acute coronary syndromes. N Engl J Med 1996;
335: 1342-9
59. The TIMI study group. The thrombolysis in myocardial infarc-
tion (TIMI) trial. N Engl J Med 1985; 312: 932-6
60. Gibson CM, Cannon CP, Daley WL, et al. TIMI Frame Count:
a quantitative method of assessing coronary artery flow. Cir-
culation 1996; 93: 879-88
61. Mehta SR, Eikeboom JW, Yusuf S. Risk of intracranial haem-
orrhage with bolus vs infusion thrombolytic therapy: a meta-
analysis. Lancet 2000; 356: 449-54
62. Liao WC, Beierle FA, Stouffer BC, et al. Single bolus regimen
of lanoteplase (nPA) in acute myocardial infarction: pharma-
cokinetic evaluation from the InTIME-1 study. Circulation
1997; 96 Suppl. I: 1260-1
63. Gibson CM, Cannon CP, Murphy SA, et al. Weight-adjusted
dosing of TNK-tissue plasminogen activator and its relation
to angiographic outcomes in the thrombolysis in myocardial
infarction 10 B trial. Am J Cardiol 1999; 84: 976-80
64. Hammann GF, Okada Y, del Zoppo GJ. Hemorrhagic transfor-
mation and microvascular integrity during focal cerebral isch-
emia/reperfusion. J Cereb Blood Flow Metab 1996; 16:
1373-8
Correspondence and offprints: Dr Paul Tanswell, Depart-
ment of Pharmacokinetics and Metabolism, Boehringer
Ingelheim Pharma KG, Birkendorfer Strasse 65, 88397
Biberach, Germany.
E-mail: paul.tanswell@bc.boehringer-ingelheim.com
Clin Pharmacokinet 2002; 41 (15)