scholarly journals The Prevention and treatment of cancer-associated thrombosis

2020 ◽  
Vol 27 (5) ◽  
Author(s):  
S. Ng ◽  
M. Carrier
Keyword(s):  
Low Molecular Weight Heparin ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Standard Of Care ◽  
Low Molecular Weight ◽  
Safe Alternative ◽  
Patients With Cancer ◽  
Increased Risk ◽  
Cancer Associated Thrombosis

Cancer is a hypercoagulable state with an associated increased risk of venous thromboembolism (vte) that is further amplified in individuals who undergo chemotherapy. Compared with patients having cancer alone or vte alone, patients who develop cancer-associated vte have a significantly poorer prognosis. The risks of recurrent vte despite appropriate anticoagulation therapy and of bleeding are also higher in patients with cancer than in those without. For those reasons, the prevention and appropriate management of cancer-associated thrombosis is of paramount importance. Although low-molecular-weight heparin has been the standard of care for the prevention and treat­ment of cancer-associated thrombosis, direct oral anticoagulants are increasingly being adopted as an effective and safe alternative.

scholarly journals Direct oral anticoagulants and cancer-associated VTE: good for all, or just some?

Blood ◽  
2020 ◽  
Vol 136 (6) ◽  
pp. 669-673 ◽  
Author(s):  
Marc Carrier ◽  
Tzu-Fei Wang
Keyword(s):  
Low Molecular Weight Heparin ◽  
Clinical Characteristics ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Mortality And Morbidity ◽  
Patients With Cancer ◽  
Risk Of Bleeding ◽  
Cancer Associated Thrombosis ◽  
Significant Mortality

Abstract Venous thromboembolism (VTE) is associated with significant mortality and morbidity in patients with cancer. Therefore, tailoring anticoagulation is of utmost importance to decrease the risk of recurrent VTE while minimizing the risk of bleeding. Direct oral anticoagulants have been recently compared with low-molecular-weight heparin for the management of acute cancer-associated thrombosis. Although direct oral anticoagulants are a welcome addition, clinicians need to incorporate clinical characteristics, drug–drug interactions, and patient preference in decision making.

A single center retrospective cohort study comparing low-molecular-weight heparins to direct oral anticoagulants for the treatment of venous thromboembolism in patients with cancer – A real world experience

2018 ◽  
Vol 25 (4) ◽  
pp. 793-800 ◽  
Author(s):  
Megan K Phelps ◽  
Tracy E Wiczer ◽  
H Paige Erdeljac ◽  
Kelsey R Van Deusen ◽  
Kyle Porter ◽  
...  
Keyword(s):  
Molecular Weight ◽  
Major Bleeding ◽  
Oral Anticoagulant ◽  
Low Molecular Weight Heparin ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Direct Oral Anticoagulant ◽  
Recurrent Cancer ◽  
Cancer Associated Thrombosis

Introduction Low-molecular-weight heparins are the standard treatment for cancer-associated thrombosis. Recently, direct oral anticoagulants are a new option for thrombosis treatment; however, data supporting the use of direct oral anticoagulants for cancer-associated thrombosis are limited. Objectives The primary objective of this study was to determine the rate of recurrent cancer-associated thrombosis and major bleeding within 6 months of starting either low-molecular-weight heparin or direct oral anticoagulant for treatment of cancer-associated thrombosis. Secondary objectives were to determine the rates of clinically relevant-non-major bleeding and all-cause mortality. Patients/methods This is a retrospective cohort study including adults with cancer-associated thrombosis treated with low-molecular-weight heparin or direct oral anticoagulant between 2010 and 2016 at the Ohio State University. Medical records were reviewed for 6 months after initiation of anticoagulation or until the occurrence of recurrent cancer-associated thrombosis, major bleeding, cessation of anticoagulation of interest, or death, whichever occurred first. Results Four hundred and eighty patients were included (290 low-molecular-weight heparin and 190 direct oral anticoagulant). Patients treated with direct oral anticoagulant were found to carry “lower risk” features including cancer with lower VTE risk and lower rate of metastatic disease. After adjustment for baseline differences, there was no significant difference in the rate of recurrent cancer-associated thrombosis (7.2% low-molecular-weight heparin vs 6.3% direct oral anticoagulant, p = 0.71) or major bleeding (7.6% low-molecular-weight heparin vs 2.6% direct oral anticoagulant, p = 0.08). Conclusions Our study demonstrates that in a select population of cancer patients with VTE, direct oral anticoagulant use can be as effective and safe compared to the standard therapy with low-molecular-weight heparin.

Low-Molecular-Weight Heparin in Cancer Patients: Overview and Indications

2019 ◽  
Vol 39 (01) ◽  
pp. 067-075 ◽  
Author(s):  
Minna Voigtlaender ◽  
Florian Langer
Keyword(s):  
Molecular Weight ◽  
Cancer Patients ◽  
Anticancer Agents ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Vte Prophylaxis ◽  
Patients With Cancer ◽  
Increased Risk

AbstractAlthough venous thromboembolism (VTE) is a well-known cause of death in patients with cancer, both its treatment and prevention remain a challenge in daily practice. Direct oral anticoagulants have emerged as safe and efficacious alternatives to vitamin K antagonists in the general population, and recent clinical trials also support their use in select patients with cancer-associated VTE. Despite this, low-molecular-weight heparins (LMWHs), a comparatively ancient class of antithrombotic drugs, remain the anticoagulants of choice in many indications relevant to modern haematology and oncology. In addition to the treatment of established VTE, these indications include VTE prophylaxis in surgical or acutely ill, hospitalized medical cancer patients as well as the prevention of VTE in high-risk patients undergoing ambulatory chemotherapy. In a constantly changing landscape of approved anticancer agents, this review article summarizes pivotal clinical trial data and guideline recommendations regarding the use of LMWH in haematological and oncological patients, who constitute a highly vulnerable patient population due to their increased risk for both bleeding and VTE recurrence.

A retrospective single-center evaluation of the safety and efficacy of direct oral anticoagulants versus low molecular weight heparin in patients with cancer-associated thrombosis.

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. e24102-e24102
Author(s):  
Melissa McShane ◽  
Jordan Senchak ◽  
Anthony Stack ◽  
Justina Frimpong ◽  
Van T Hellerslia ◽  
...  
Keyword(s):  
Molecular Weight ◽  
Major Bleeding ◽  
Low Molecular Weight Heparin ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Safety And Efficacy ◽  
The Past ◽  
Cancer Associated Thrombosis

e24102 Background: Over the past decade, there has been an increase in the use of direct oral anticoagulants (DOACs) in the cancer population despite limited data comparing its use against low molecular weight heparin (LMWH), the standard of care in cancer patients. Increasing data supporting DOACs in cancer-associated thrombosis has emerged over the past few years. Nonetheless, this study will evaluate the relative safety and efficacy of DOACs versus LMWH in cancer-associated thrombosis within an urban setting associated with low socioeconomic status. Methods: This is a retrospective chart review of medical records from patients treated at an urban academic medical center from October 2010 through October 2018. Patients met study inclusion if they had a diagnosis of venous thromboembolism occurring after the date of diagnosis of active cancer and were prescribed a direct oral anticoagulant (rivaroxaban, apixaban, dabigatran, edoxaban) or a low molecular weight heparin (dalteparin, enoxaparin, or fondaparinux) as monotherapy for the treatment of venous thromboembolic disease. Patients were excluded if they had less than 6 months of follow up data for reasons other than death. The primary outcomes were recurrent venous thromboembolism, major bleeding and death. Results: Of the 914 patients who met inclusion criteria, 286 were excluded due to lack of follow up data. The remaining patients included 472 in the LMWH arm and 156 in the DOAC arm. At 6 months, recurrent thromboembolism occurred in 5 of the 472 patients (1.1%) in the LMWH group as compared with 4 of the 156 patients (2.6%) in the DOAC group (p = 0.170). Major bleeding occurred in 36 patients (7.6%) in the LMWH group and 11 patients (7.0%) in the DOAC group (p = 0.813). Death within 6 months of starting anticoagulation occurred in 76 patients (16.1%) in the LMWH group and 16 patients (9.6%) in the DOAC group (p = 0.046). Discontinuation before 6 months of treatment occurred in 241 patients (51.2%) in the LMWH group and 46 patients (29.5%) in the DOAC group. Conclusions: The LMWH and DOAC groups had similar rates of recurrent thromboembolism and major bleeding. The mortality rate within 6 months of starting anticoagulation was significantly higher in the LMWH group and this difference requires further evaluation. These results help support the continued use of DOACs for the treatment of cancer-associated thrombosis and demonstrate that DOACs are as safe and effective as LMWH in this patient population.

scholarly journals Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 2: treatment

2015 ◽  
Vol 22 (2) ◽  
pp. 144 ◽  
Author(s):  
J.C. Easaw ◽  
M.A. Shea-Budgell ◽  
C.M.J. Wu ◽  
P.M. Czaykowski ◽  
J. Kassis ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Renal Insufficiency ◽  
Cancer Patients ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Factor Xa ◽  
Patients With Cancer ◽  
Clinical Scenarios ◽  
Increased Risk

Patients with cancer are at increased risk of venous thromboembolism (vte). Anticoagulation therapy is used to treat vte; however, patients with cancer have unique clinical circumstances that can often make decisions surrounding the administration of therapeutic anticoagulation complicated. No national Canadian guidelines on the management of established cancer-associated thrombosis have been published. We therefore aimed to develop a consensus-based, evidence-informed guideline on the topic.PubMed was searched for clinical trials and meta-analyses published between 2002 and 2013. Reference lists of key articles were hand-searched for additional publications. Content experts from across Canada were assembled to review the evidence and make recommendations.Low molecular weight heparin is the treatment of choice for cancer patients with established vte. Direct oral anticoagulants are not recommended for the treatment of vte at this time. Specific clinical scenarios, including the presence of an indwelling venous catheter, renal insufficiency, and thrombocytopenia, warrant modifications in the therapeutic administration of anticoagulation therapy. Patients with recurrent vte should receive extended (>3 months) anticoagulant therapy. Incidental vte should generally be treated in the same manner as symptomatic vte. There is no evidence to support the monitoring of anti–factor Xa levels in clinically stable cancer patients receiving prophylactic anticoagulation; however, levels of anti–factor Xa could be checked at baseline and periodically thereafter in patients with renal insufficiency. Follow-up and education about the signs and symptoms of vte are important components of ongoing patient care.

Efficacy and safety of direct oral anticoagulants vs. low molecular weight heparin for cancer-related venous thromboembolism: a meta-analysis of randomized trials

2020 ◽  
Author(s):  
Ayman Elbadawi ◽  
Mina Shnoda ◽  
Karim Mahmoud ◽  
Islam Y Elgendy
Keyword(s):  
Molecular Weight ◽  
Major Bleeding ◽  
Lower Incidence ◽  
Low Molecular Weight Heparin ◽  
Randomized Trials ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Efficacy And Safety ◽  
Patients With Cancer

Abstract Aims To examine the efficacy and safety of direct oral anticoagulants (DOACs) vs. low molecular weight heparin (LMWH) in patients with cancer-related venous thromboembolism (VTE). Methods and results An electronic search of the MEDLINE, SCOPUS, and Cochrane databases without language restrictions was performed through April 2020 for randomized controlled trials that compared the outcomes with DOACs vs. LMWH among patients with cancer-related VTE. Summary estimates were reported using random effects model. The main efficacy outcome was VTE recurrence, while the main safety outcome was major bleeding . The final analysis included four randomized trials with a total of 2907 patients. The weighted mean follow-up was 6.1 months. Compared with LMWH, DOACs were associated with lower incidence of VTE recurrence [5.7% vs. 9.1%, risk ratio (RR) 0.62; 95% confidence interval (CI) 0.44–0.87; P = 0.01], driven by lower incidence of deep venous thrombosis (RR 0.60, 95% CI 0.39–0.93; P = 0.02). There was no difference in the incidence of major bleeding between DOACs and LMWH (4.8% vs. 3.6%, RR 1.33; 95% CI 0.84–2.11; P = 0.23). The incidence of all-cause mortality was similar (RR 0.99; 95% CI 0.84–1.16; P = 0.91). Subgroup analysis suggested no differences according to the type of DOAC regarding recurrent VTE or major bleeding (Pinteraction = 0.53 and Pinteraction = 0.11, respectively). Conclusion Among patients with cancer-related VTE, DOACs were associated with lower incidence of VTE recurrence and no difference in the incidence of major bleeding compared with LMWH. Future studies examining the subset of cancer patients who drive the most benefit are encouraged.

scholarly journals An Untoward Effect: Anticoagulation Therapy in Cancer Patients Leads to Gastrointestinal Bleeding and Increased Mortality

2018 ◽  
Vol 3 (12) ◽  
Author(s):  
Dr. Arine Mathew
Keyword(s):  
Causes Of Death ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Morbidity And Mortality ◽  
Major Surgery ◽  
Low Molecular Weight ◽  
High Morbidity ◽  
Public Concern ◽  
Patients With Cancer

Cancer, a condition involving uncontrolled division of cells, ranks second among leading causes of death worldwide.[1] According to an estimate, cancer will contribute 609,640 deaths in the year 2018 in United States.[2] Therefore, cancer is a major public concern as it has high morbidity and mortality rates. The patients with cancer are at high risk of developing venous thromboembolism (VTE) as it is a hypercoagulable state.[3] Therefore, thrombotic events are a major cause of morbidity and mortality among the patients with cancer.[4,5] Recommendations of anticoagulation in acute VTE are same in the patients with or without cancer.[3] Anticoagulation prophylaxis and therapy is recommended in the patients with cancer who are hospitalized with acute illness or undergoing major surgery and those who have developed VTE, respectively.[6] Usually, low molecular weight heparin (LMWH), vitamin K antagonist (VKA) and direct oral anticoagulants are used for the treatment of VTE in the patients with cancer. The purpose of this anticoagulation is to prevent extension, recurrence and embolism of thrombus. However, higher recurrence of VTE and risk of bleeding complicates the treatment.

scholarly journals Direct Oral Anticoagulants Compared to Low Molecular Weight Heparin in the Treatment of Cancer-Associated Thromboembolism: An Updated Meta-Analysis of Randomized Controlled Trails

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4962-4962
Author(s):  
Sariya Wongsaengsak ◽  
Somedeb Ball ◽  
Nuvneet Khandelwal ◽  
Alay Tikue ◽  
Arunee Motes ◽  
...  
Keyword(s):  
Major Bleeding ◽  
Low Molecular Weight Heparin ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Patients With Cancer ◽  
Randomized Controlled ◽  
Significant Difference ◽  
Recurrent Vte

Introduction: Cancer patients have approximately 4 times higher risk of developing venous thromboembolism (VTE) compared to the general population. High tendency of bleeding from anticoagulant use in this population makes the treatment of cancer-associated thromboembolism (CAT) very challenging. Low molecular weight heparin (LMWH) is still considered as standard treatment for CAT. Direct oral anticoagulants (DOAC) have emerged as a potential alternative for LMWH due to the ease of administration and predictable pharmacokinetics, but data on DOACs in CAT is limited. Few randomized controlled trials (RCT) published recently have compared the efficacy and safety of DOACs with LMWH in the treatment of CAT. Hence, we conducted an updated meta-analysis of RCTs to determine the relative risk of recurrent VTE and bleeding complications associated with DOACs compared to LMWH in the treatment of thromboembolism in patients with cancer, and to evaluate if the risk estimates have changed since prior report (Li et al.). Methods: We performed a systemic search using Embase, Medline, and the meeting abstracts with appropriate keywords through 06/30/19, to find all RCTs comparing a DOAC with LMWH in treatment of patients with CAT. The search strategy, study selection, data extraction and analysis were performed in accordance with the Preferred Reporting Items for Meta-Analyses (PRISMA) guidelines. We pooled the point estimates in form of risk ratios (RR) with respective 95% confidence intervals (CI), using the random effects model (Mantel-Haenszel method) of Der Simonian and Laird. Heterogeneity of effect size across studies was quantified using I2 statistic and Cochran's Q. Publication bias was assessed by the Egger's regression test. All the statistical analyses were performed with the RevMan 5.3 software. Copenhagen: The Nordic Cochrane Centre, the Cochrane Collaboration, 2014. Results: Overall a total of 1,739 patients with CAT (870 in the DOAC arms and 869 in LMWH arms) from three RCTs were included in the final analysis. Characteristics of studies included in the analysis are summarized in table 1. Different DOACs (Select-D: rivaroxaban, Hokusai VTE cancer: edoxaban and ADAM VTE: apixaban) were used to compare with dalteparin in included trials. Duration of anticoagulation was 6 to 12 months in these studies. Use of DOAC was associated with a significantly lower risk of recurrent VTE in comparison with LMWH [pooled RR 0.48, 95%CI: 0.26-0.87, p = 0.02, I2 = 56%, figure 1]. In addition, there was no statistically significant increase in the risk of major bleeding in patients on the DOAC arms, as compared to those on LMWH arms [ pooled RR 1.55 ,95%CI: 0.79-3.04, p = 0.20, I2 = 29%, figure 2]. Criteria for major bleeding in the studies were defined by the International Society on Thrombosis and Hemostasis. The pooled RR for clinically relevant non major bleeding (CRNMB) was 1.80 [95%CI: 0.96-3.38, p = 0.07, I2 = 60%, figure 3], thus suggesting no significant difference in risk of CRNMB between DOAC and LMWH groups. Moderate heterogeneity was noted across trials. We found no publication bias among studies included in the analysis. Conclusion: In our meta-analysis, use of DOACs for the treatment of CAT was associated with a significantly decreased risk of recurrent VTE compared to LMWH. There was no significant difference in the incidence of major or non-major bleeding events between DOAC and LMWH groups. These study results provide additional evidence for potential use of DOAC as a safe and effective alternative to LMWH for the treatment of thromboembolism in patients with cancer. Disclosures No relevant conflicts of interest to declare.

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