Tracking the National Transition to Tenecteplase - Daksh Mehta
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This article is part of a series: Bennett Prize in OpenPrescribing Winner Blogs
- Improving Respiratory Prescribing - Dr Huw Miles
- Dosulepin Prescribing Across Suffolk Primary Care Practices - Dr Paul Driscoll
- Improving Methotrexate Safety Nationwide - Ruth Dales
- Tracking the National Transition to Tenecteplase - Daksh Mehta
This post below was written by Daksh Mehta, Student winner of the Bennett Prize in OpenPrescribing.
Tracking the National Transition to Tenecteplase
By Daksh Mehta
The transition of clinical evidence into routine practice is rarely uniform. When the National Institute for Health and Care Excellence (NICE) updated its guidance in July 2024 to recommend tenecteplase as an equivalent alternative to alteplase for acute ischaemic stroke, it presented a unique opportunity to evaluate the agility of the NHS in adopting a more cost-effective, operationally efficient and clinically equivalent treatment.
Tenecteplase offers unique advantages in the acute setting over alteplase, which has been the standard thrombolytic agent for over two decades. Administered as a single bolus rather than an infusion, it simplifies the “drip and ship” model of stroke care, where patients are transferred from district general hospitals where they present to hyperacute stroke units (HASUs) for specialist care and rehabilitation. The ease of use also results in lower operational costs, reductions in nursing time and greater accessibility without the need for specialist nurses to set up infusions.
Our analysis sought to determine how effectively these clinical and fiscal benefits were realised across the 42 Integrated Care Boards (ICBs) in England and whether there was any regional variation in the incorporation of tenecteplase in secondary care. To examine this, I conducted an interrupted time series analysis (ITSA) using the secondary care medicines dataset (SCMD). I analysed prescribing volumes (calculated as Defined Daily Doses, or DDDs) from July 2023 to June 2025, providing a clear window into practice patterns twelve months before and after the NICE guidance change. To ensure a robust comparison, we benchmarked these trends against the Sentinel Stroke National Audit Programme (SSNAP) data to account for patient volume and clinical performance metrics.
While there was a significant national shift toward tenecteplase adoption post July 2024, the speed of transition was markedly inconsistent. ICBs such as Mid and South Essex demonstrated near-complete formulary switches within months. In contrast, other regions exhibited a “flat” prescribing trajectory for tenecteplase, indicating no reaction to the new NICE guidance.
A striking finding was the lack of adoption across all five London-based ICBs. Despite these regions hosting major academic centres and pivotal clinical trials that provided the clinical evidence base for tenecteplase, their adoption rates were significantly lower than the national average. This suggests that academic involvement did not inherently correlate with rapid implementation of new guidance in this case.
The analysis also revealed no correlation between an ICB’s baseline stroke care quality (as measured by SSNAP) and its speed of tenecteplase adoption. Stroke centres that thrombolyse a greater proportion of patients or have patients spending more time in stroke specialist wards did not adopt faster. This suggested to us that barriers to adoption are likely not clinical but rather related to organisational governance and complex multi trust decision making.
The variability in adoption represents a measurable economic inefficiency. We estimate that had all NHS ICBs transitioned to tenecteplase immediately following the NICE update, the NHS could have saved approximately £3 million in drug costs alone during the first year. These savings are equivalent to funding nearly 4,000 additional thrombolysis treatments.
These findings underscore the need for a deeper understanding of guideline implementation within the NHS and the potential for datasets and OpenPrescribing tools to be used for real-time monitoring. By utilising the secondary care medicines dataset, NHS commissioners and regional stroke networks can transition towards active benchmarking to identify implementation bottlenecks.