| Drug | Recommended IV regimen* | Advantages and limitations |
| Alteplase (accelerated regimen) | 15 mg bolus over 1 to 2 minutes | Better outcomes than streptokinase in GUSTO-1 (30-day mortality; 6.3 versus 7.3%). Costlier than streptokinase. More difficult to administer because of short half-life. |
| then 0.75 mg/kg (maximum 50 mg) over 30 minutes | ||
| then 0.5 mg/kg (maximum 35 mg) over the next 60 minutes | ||
| Tenecteplase | Single bolus over 5 to 10 seconds based upon body weight: | As effective as alteplase in ASSENT-2 with less noncerebral bleeding and need for transfusion. Easier to administer (single bolus due to longer half-life) both in and out of hospital. These advantages make tenecteplase the drug of choice in many United States hospitals. |
| <60 kg: 30 mg | ||
| 60 to 69 kg: 35 mg | ||
| 70 to 79 kg: 40 mg | ||
| 80 to 89 kg: 45 mg | ||
| ≥90 kg: 50 mg | ||
| Reteplase | 10 units over 2 minutes then repeat 10 unit bolus at 30 minutes | Similar outcomes as alteplase but easier to administer. |
| Streptokinase | 1.5 million units over 30 to 60 minutes | Generally a much less costly option than other fibrinolytics but outcomes are inferior. Neutralizing antibodies develop, which can diminish efficacy of subsequent use. Elevated risk of hypersensitivity reaction with repeated doses. Used extensively outside North America due to lower cost. (Not available in United States or Canada). |
GUSTO-1: Global Utilization of t-PA and Streptokinase for Occluded Coronary Arteries; ASSENT-2: Assessment of the Safety of a New Thrombolytic.
* All patients are also given nonenteric-coated aspirin 162 to 325 mg and, with alteplase, reteplase, and tenecteplase, unfractionated heparin as 60 units/kg bolus (maximum 4000 units) followed by an intravenous infusion of 12 units/kg per hour (maximum 1000 units per hour) adjusted to target aPTT of 50 to 70 seconds. Heparin has not been definitively shown to improve outcomes with non-fibrin-specific agents such as streptokinase. However, heparin is recommended with streptokinase in patients who are at high risk for systemic thromboembolism (eg, large or anterior myocardial infarction, atrial fibrillation, previous embolus, or known left ventricular thrombus).