Inpatient Insights
APhA Staff
Does intra-arterial tenecteplase improve outcomes for patients with acute stroke after thrombectomy?
Endovascular thrombectomy is an effective treatment for large vessel occlusion stroke, but the rate of poor outcomes remains high. A group of researchers, the ANGEL-TNK Investigators, conducted a prospective, open-label, blinded end point, randomized trial across 19 centers in China to evaluate the efficacy and safety of intra-arterial tenecteplase in patients with successful endovascular therapy.
The study, published online in JAMA on July 5, 2025, included 256 patients presenting between 4.5 and 24 hours after symptom onset who were randomized to receive intra-arterial tenecteplase at 0.125 mg/kg or standard medical treatment. The results indicated that 40.5% of patients receiving tenecteplase reached the primary endpoint of an excellent outcome at 90 days, defined as modified Rankin Scale score of 0 to 1, while 26.4% of patients who did not receive tenecteplase met this endpoint.
The authors concluded that in patients with acute large vessel occlusion stroke, treatment with intra-arterial tenecteplase after successful thrombectomy resulted in a greater likelihood of excellent neurological outcome at 90 days without increasing the risk of symptomatic intracranial hemorrhage or mortality. However, they indicated that because none of the secondary efficacy analyses showed a significant difference between the two groups, further trials are needed to confirm the results. ■
Are DOACs or LWMH most effective for intracranial hemorrhage in patients with metastatic brain cancer?
Spontaneous intracranial hemorrhage (ICH) is a common complication in patients with metastatic brain cancer. Many patients with this condition have an indication for therapeutic anticoagulation. While two small retrospective cohort studies suggested that DOACs are safe compared with LMWH in this population, the ICH profile of DOACs versus LWMH in patients with metastatic brain tumors remains uncertain. The Anticoagulation in Brain Cancer Study Group conducted a retrospective multinational cohort study to compare rates of hemorrhage among patients with metastatic brain cancer treated with DOACs or LMWH and evaluate outcomes including mortality, recurrent thrombosis, and hemorrhage.
The study, published in the June 2025 issue of Haematologica, involved 12 academic and nonacademic hospitals in Canada, Israel, Mexico, Switzerland, the Netherlands, and the United States. The study included adult patients with systemic solid cancer and brain metastases confirmed through pathology and imaging, respectively. Eligibility criteria were active cancer, defined as newly diagnosed or undergoing treatment, and therapeutic anticoagulation with either DOACs or LMWH. The primary outcome was spontaneous ICH confirmed by central adjudication of radiographic imaging. The cumulative incidence of any ICH, major ICH, overt ICH, venous thromoembolism, or stroke/systemic arterial thromboembolism over 12 months with corresponding 95% CI was calculated and compared between anticoagulation groups with anticoagulation as a fixed variable for ICH.
The 12-month cumulative incidence of spontaneous ICH was 11.1% in the DOAC group and 8.6% in the LMWH group. For major ICH, the cumulative 12-month incidence was 1.7% in the DOAC group and 2.7% in the LMWH group. The incidence of overt ICH was also similar: 8.5% in DOAC-treated patients and 7.4% in LMWH-treated patients. Mortality rates were high in both groups, at 46.5% in the DOAC group and 50.8% in the LMWH group by the end of 12 months of follow up. The authors concluded that their study indicates similar ICH profiles with LMWH and DOACs in patients with metastatic brain cancer. Validation of the identified clinical predictors of ICH, using standardized reporting and classification of ICH, is needed to support clinical decision making in this setting. ■
Researchers try to determine ceftriaxone dosage in hospitalized patients with pneumonia
Community-acquired pneumonia remains one of the leading causes of death worldwide, and effective management often involves the use of empiric antibiotic therapy to cover a range of potential pathogens, with ceftriaxone being one of the most commonly prescribed antibiotics. However, optimal dosage remains unclear.
Researchers from the University of Tokyo conducted a retrospective analysis using patients diagnosed with pneumonia between July 2010 and March 2022 from the Diagnosis Procedure Combination inpatient database in Japan to compare the effects of a 2 g/day or 1 g/day dose of ceftriaxone within the first 2 days of hospitalization. The primary outcome was 30-day in-hospital mortality, and secondary outcomes included the occurrence of adverse events (composite of biliary tract infection, Clostridioides difficile infection, and allergic reactions).
A subgroup analysis was conducted for patients requiring mechanical ventilation. The study was published online in the Journal of Antimicrobial Chemotherapy on June 10, 2025.
Almost 475,000 patients were identified for the study, with 63.3% receiving 2 g/day and 36.7% receiving 1 g/day of ceftriaxone. Propensity-score analysis showed no significant difference in 30-day in-hospital mortality between the two groups, although overall adverse events, particularly C. difficile infection, were slightly higher in the 2 g/day group. In the subgroup analysis of patients requiring mechanical ventilation, the 2 g/day regimen was associated with lower 30-day mortality (17.2% vs. 20.4%).
SGLT-2 inhibitors may reduce the risk of serious liver events for patients with cirrhosis
Cirrhosis is a significant global health burden, with serious liver-related complications leading to high morbidity and mortality. Effective therapeutic options to mitigate these complications remain limited, but SGLT-2 inhibitors are potentially beneficial in treating patients with cirrhosis who are receiving diuretic therapy and may offer liver-related benefits. Researchers from the Cleveland Clinic evaluated the association of SGLT-2 inhibitor use and the risk of serious liver events in patients with cirrhosis receiving furosemide and spironolactone. The cohort study, using data from over 120 health care organizations within the TriNetX platform, was published in the July 2025 issue of JAMA Network Open.
Adult patients with cirrhosis who were receiving furosemide and spironolactone from January 2013 to July 2021 were included in the study. Patients who were receiving SGLT-2 inhibitors plus furosemide and spironolactone were matched with a control group of patients who were receiving furosemide and spironolactone alone according to age, demographics, and comorbidities. The primary outcome was a composite of serious liver events defined as incidence of ascites, variceal development, hyponatremia, or all-cause mortality. Secondary outcomes included incidence of variceal bleeding, paracentesis, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, hepatocellular carcinoma, hypoglycemia, and all-cause hospitalizations.
Among the more than 10,000 propensity-matched patients, those receiving SGLT-2 inhibitors had a lower incidence of serious liver events compared with patients in the control group. Secondary outcomes were also associated with a reduced risk among those in the SGLT-2 inhibitors group. The researchers concluded that these findings further suggest a potential role for SGLT-2 inhibitors in cirrhosis management. ■
The authors concluded that while a ceftriaxone dose exceeding 1 g/day may not be necessary for routine pneumonia treatment, a 2 g/day regimen may be considered for patients with severe pneumonia requiring mechanical ventilation. ■