1
|
Nepal G, Kharel S, Kumar Yadav J, Kumar Yadav S, Bhagat R, Ka Shing Y, Coghlan M, Lal Bhattarai S, Sigdel K, Chandra Mahat B. Low-dose alteplase for the management of acute ischemic stroke in South Asians: A systematic review on cost, efficacy and safety. J Clin Neurosci 2022; 103:92-99. [PMID: 35853390 DOI: 10.1016/j.jocn.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/27/2022] [Accepted: 07/09/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION South Asia is responsible for more than 40% of the stroke burden and stroke mortality in the developing world. South Asia, which is home to one-fourth of the world's population, is the most densely populated and one of the poorest regions. The majority of patients in this region are unable to afford intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). If low-dose alteplase proves effective and safe in South Asians, it may be a more cost-effective treatment option. METHODS The study was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and meta-Analyses) guideline. Researchers searched PubMed, EMBASE, and Google Scholar for English literature from 2005 to 2021. END, ENI, good functional outcome, SICH, and all-cause mortality were used to assess efficacy and safety. RESULTS In the low-dose alteplase treated patients, different studies reported 32 to 57% ENI 24 h after IVT, and 7% to 9.7% END. At 3 months follow-up, good functional outcome was achieved by 48%-76.92% of low-dose alteplase treated patients. SICH rates ranged from 0% to 16.6% across studies. Asymptomatic ICH occurred in 5-14% of patients. The mortality rate in all included studies varied from none to 25%. CONCLUSION Our systematic review demonstrates that the use of low-dose alteplase for AIS in the South Asians offer comparable efficacy and reduced risk of SICH at a significantly lower cost than standard alteplase dose. Future well-randomized clinical trials are necessary to validate the findings of our study.
Collapse
Affiliation(s)
- Gaurav Nepal
- Rani Primary Health Care Centre, Biratnagar, Nepal.
| | - Sanjeev Kharel
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Jayant Kumar Yadav
- Department of Neurology, Annapurna Neurological Institute and Allied Sciences, Maitighar, Kathmandu, Nepal.
| | - Sushil Kumar Yadav
- Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu, Nepal.
| | - Riwaj Bhagat
- Department of Neurology, Boston University Medical Center, Boston, MA, USA
| | - Yow Ka Shing
- Department of Internal Medicine, National University Hospital, Singapore, Singapore.
| | - Megan Coghlan
- University of Louisville School of Medicine, Louisville, KY, USA
| | | | - Kaushal Sigdel
- Nobel Medical College and Teaching Hospital, Biratnagar, Nepal
| | - Bishow Chandra Mahat
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| |
Collapse
|
2
|
Tan G, Wang H, Chen S, Chen D, Zhu L, Xu D, Zhang Y, Liu L. Efficacy and safety of low dose alteplase for intravenous thrombolysis in Asian stroke patients: a meta-analysis. Sci Rep 2017; 7:16076. [PMID: 29167555 PMCID: PMC5700077 DOI: 10.1038/s41598-017-16355-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 11/10/2017] [Indexed: 02/05/2023] Open
Abstract
Whether low dose alteplase is comparable to standard dose in efficacy and safety for intravenous thrombolysis (IVT) in Asian stroke patients remains unverified. PubMed, EMBASE, and Cochrane Library Database from the beginning to June 30, 2017 were searched. IVT efficacy was measured by favorable outcome (modified Rankin Scale scores of 0–1) at 3 months, and safety measured by mortality within 3 months and symptomatic intracerebral hemorrhage (SICH). Pooled estimates were conducted using fixed- or random-effects model depending on heterogeneity. For SICH, studies were pooled separately according to different definitions. Twelve studies involving 7,905 participants were included. No association was found between alteplase dose and favorable outcome (OR = 0.94, 95% CI 0.78–1.14, P = 0.5; heterogeneity: Phetero = 0.01, I2 = 57.3%) and mortality (OR = 0.87, 95% CI 0.74–1.02, P = 0.08; Phetero = 0.83, I2 = 0) using random- and fixed-effects models, respectively. Low dose alteplase was associated with lower SICH as defined by the National Institute of Neurological Disorders and Stroke study (OR = 0.79, 95% CI 0.64–0.99, P = 0.04; Phetero = 0.57, I2 = 0) using fixed-effects model. Subgroup and sensitivity analysis could change the results significantly. Current limited evidence was insufficient to support the speculation that low dose alteplase was comparable to standard dose in thrombolytic efficacy and safety in Asian stroke patients.
Collapse
Affiliation(s)
- Ge Tan
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Haijiao Wang
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Sihan Chen
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Deng Chen
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Lina Zhu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Da Xu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Yu Zhang
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan Province, China.
| |
Collapse
|