Long-term use of daily subcutaneous low molecular weight heparin in cancer patients with venous thromboembolism: why hesitate any longer?

2008 ◽  
Vol 16 (12) ◽  
pp. 1333-1341 ◽  
Author(s):  
Philippe Debourdeau ◽  
Ismail Elalamy ◽  
Axelle de Raignac ◽  
Paul Meria ◽  
Jean Marc Gornet ◽  
...  
2012 ◽  
Vol 107 (01) ◽  
pp. 37-43 ◽  
Author(s):  
Pablo Marchena ◽  
José Nieto ◽  
María Guil ◽  
Ferrán García-Bragado ◽  
Ramón Rabuñal ◽  
...  

SummaryLong-term therapy with low-molecular-weight heparin (LMWH) is the treatment of choice for cancer patients with venous thromboembolism (VTE). However, the ideal doses of LMWH have not been thoroughly studied. We used the RIETE Registry data to assess the influence of the daily LMWH dosage on outcome during the first three months after VTE. We used propensity score-matching to compare patients who received <150 vs. those receiving ≥150 UI/kg/day LMWH. Up to July 2010, 3,222 cancer patients with VTE received long-term therapy with fixed doses of LMWH. Of these, 1,472 (46%) received <150 IU/kg/day (mean, 112 ± 28), and 1,750 received ≥150 IU/kg/day (mean, 184 ± 32). Results of the propensity score matching involved 1269 matched pairs. During follow-up, the incidence of pulmonary embolism (PE) recurrences was similar (1.2% vs. 1.9%), but patients receiving <150 IU/kg/day LMWH had a lower incidence of fatal PE than those treated with ≥150 IU/kg/day (0.2% vs. 1.0%; p=0.004). Multivariate analysis confirmed that patients receiving <150 IU/kg/day LMWH had a lower risk for fatal PE (odds ratio [OR]: 0.2; 95% confidence interval [CI]: 0.06–0.8) and for major bleeding (OR: 0.6; 95% CI: 0.3–1.0) than those treated with ≥150 IU/kg/day. In real life, one in every two cancer patients with VTE received lower doses of LMWH than those used in randomised trials, with large variations from patient to patient. Unexpectedly, patients treated with <150 IU/kg/day LMWH had fewer fatal PE cases and fewer major bleeding events than those receiving ≥150 IU/kg/day LMWH. This finding, however, should be validated in prospective clinical trials.


Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 581-581 ◽  
Author(s):  
Giorgia Saccullo ◽  
Marco Marietta ◽  
Monica Carpenedo ◽  
Valerio De Stefano ◽  
Anna Falanga ◽  
...  

Abstract Introduction Cancer-related Venous Thromboembolism (VTE) requires treatment with Low Molecular Weight Heparin (LMWH), which is more effective and safer than warfarin; however, the risk of major hemorrhage still remains clinically relevant (up to 5%). This rate is even higher in case of impaired hemostasis, such as during thrombocytopenia (due to myelosuppression or chemo-therapy) where the bleeding risk is directly related to the platelet count level. At the present, the best management of adult patients with acute or non-acute cancer-related VTE during thrombocytopenia is uncertain. Objective To develop a consensus about the platelet cut-off for a safe LMWH administration in cancer patients with acute (lasting < 1 month) or non-acute VTE and thrombocytopenia, based on RAND/UCLA Appropriateness Method (RAM). Materials and methods A systematic review of the literature was performed via electronic databases (MEDLINE, EMBASE, and Cochrane Library Central Registry). Topics and research terms were: cancer, venous thromboembolism, platelets, risk of bleeding, anticoagulant drugs, low-molecular-weight heparin, and treatments. The main study outcomes were rates of VTE (first event, recurrence, and catheter-related DVT), major and minor bleeding, thrombocytopenia, and death. A panel of experts was identified; the literature review and the list of indications were sent to all members of this panel. For each indication, the panel members rated the benefit-to-harm ratio of the procedure on a scale of 1 to 9, where 1 means that the expected harms greatly outweigh the expected benefits, and 9 means that the expected benefits greatly outweigh the expected harms. A middle rating of 5 means either that the harms and benefits are about equal or that the rater cannot make the judge for the patient described in the indication. The working group comprised 9 hematologists expert in thrombosis and haemostasis (G.S., M.M., M.C., V.D.S., A.F., A.F., F.R., A.T., S.S.) including two methodologists (G.S. and M.M.) and one coordinator (S.S.). Consensus Development the RAND was construed identifying 3 platelet count cut-offs (i.e., PLT >50.000 <100.000 µL; PLT >30.000 <50.000 µL; PLT <30.000 µL) and 3 doses of LMWH (weight adjusted fixed-dose, prophylactic dose, and half of the weight adjusted fixed-dose) by administering 13 questions to the experts. Results The panel of expert reached the following consensus: 1. Cancer patients with acute VTE and a platelet count <100.000 µL - >50.000 should receive full therapeutic dose LMWH ; 2. In cases of non-acute VTE with platelet count <100.000 µL - >50.000, the dose of LMWH should be reduced to 75% of the full dose; 3. In cancer patients with acute VTE and platelet count <50.000 - >30.000 µL, the LMWH dose should be reduced to 50% of the full therapeutic dose; 4. In case of non-acute VTE and a platelet count <50.000 µL - >30.000, the expert panel considers uncertain a treatment with a reduced dose to 50% or a low dose (i.e. 4.000 IU anti-FXa/d); 5. In case of platelet count below 30.000 µL, the expert panel agreed to suspend LMWH both in acute and non-acute VTE. Conclusions This is the first expert opinion based on RAM to establish the safe platelet cut-off to administer LMWH therapy in cancer patients affected by acute and non-acute VTE. The present panel of experts suggests as appropriate the use of dose-adjusted LMWH according to platelets count. Further investigations by means of well designed prospective clinical trials are needed to establish the best management of cancer-related VTE in patients with thrombocytopenia. Disclosures: Rodeghiero: Amgen, GSK: Honoraria; Amgen, Eisai, GSK, LFB, Suppremol: Membership on an entity’s Board of Directors or advisory committees.


Author(s):  
Aurora Solier Lopez ◽  
Raquel Morillo Guerrero ◽  
Teresa Elías Hernández ◽  
Luis Jara Palomares ◽  
Remedios Otero Candelera

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