Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus

Patients with cancer-associated thrombosis (CAT) are at high risk of recurrent venous thromboembolism (VTE) and major bleeding complications. Risks vary significantly between individuals based on cancer status, treatment, and other characteristics. To facilitate the evidence-based management of anticoagulant therapy in this patient population, a committee of 11 Canadian clinical experts updated a consensus-based algorithm for the acute and extended treatment of symptomatic and incidental CAT that was developed in 2018. Following a systematic review of the literature, updates to the algorithm were discussed during an online teleconference, and the algorithm was subsequently refined based on feedback from committee members. Clinicians using this treatment algorithm should consider bleeding risk, type of cancer, and drug–drug interactions, as well as patient and clinician preferences, in tailoring anticoagulation for patients with CAT. Anticoagulant therapy should be adapted as the patient’s cancer status and management change over time.

Comparison Of Drugs in Patients Using New Generation Anticoagulants

Aim: New generation anticoagulants rapidly find a wider area of use in the clinic due to the use problems of other oral anticoagulants. Anticoagulants such as Dabigatran, Rivaroxaban, and Apixaban with safer treatment intervals have been accepted in clinical practice guidelines and have taken their place as preferred drugs. In this study, we aimed to retrospectively examine the effects of three new-generation anticoagulant drugs on a group of patients. Material and Methods: In this retrospectively planned study, patients diagnosed with atrial fibrillation (n = 522) were divided into three groups according to the drugs used for treatment (Dabigatran, Rivaroxaban, and Apixaban). Routine blood values of the patients in each group were retrospectively scanned according to age, gender, time of drug initiation and presence of chronic disease. Results: According to the results obtained, it was found that the mean HCT, BUN, AST, ALT, MPV, Iron, and Ferritin were higher in patients using Apixaban than those using Dabigatran and Rivaroxaban drugs, but the age, average values of Hgb1 Hgb2, Hgb1, PLT, CrCl, Gfr and INR of the patients using Apixaban lower than those using Dabigatran and Rivaroxaban. The highest rate (22.5%) was found in the group of patients taking apixaban (n=93) when people taking the drugs were examined in terms of mortality. Conclusion: It has been observed that Rivaroxaban can be used more safely in patients with a history of acute cancer and thrombosis, patients with recurrent venous thromboembolism, and patients with high frailty, three drugs should be preferred instead of oral anticoagulants.

The comparative effectiveness of direct oral anti-coagulants and low molecular weight heparins for prevention of recurrent venous thromboembolism in cancer: The CANVAS pragmatic randomized trial.

12020 Background: Previous randomized trials in cancer patients suggest that DOACs are non-inferior to LMWH for preventing recurrent VTE but have higher risk of bleeding. However, the balance of benefits and burdens remains uncertain. Objective: The CANVAS pragmatic trial compared recurrent VTE, bleeding and death in cancer patients following an initial VTE treated with either DOAC or LMWH therapy. Methods: CANVAS was an unblinded hybrid comparative effectiveness non-inferiority trial, with randomized and preference cohorts. Between 12/16 and 4/20, 671 participants were randomized and followed for 6-months. Between 12/16 and 12/17, 140 participants declined randomization, chose their preferred anticoagulant and were followed for 6-months. The preference cohort was closed when predetermined stopping criteria were met. Final follow-up was 11/30/20. Randomized patients were assigned 1:1 to receive either a DOAC or a LMWH. If assigned to LMWH, transitions to warfarin were allowed. Physicians and patients could choose among any DOAC or LMWH. Doses were suggested based on FDA-approved labeling but not mandated. Patients from 67 practices in the US with any invasive solid tumor, lymphoma, multiple myeloma or CLL and a diagnosis of symptomatic or radiographically detected VTE within 30 days of enrollment were eligible. The 1° analysis was conducted in the randomized modified-into to treat popululation, (all subjects who received study drug). The 1° outcome was recurrent VTE. The aim was to establish noninferiority of anticoagulation with a DOAC as defined by the upper limit of the 2-sided 90% CI for the difference in the event rate at 6 months of < 3%. Secondary outcomes included death and bleeding. Hypothesis testing included only the randomized cohort but propensity score adjusted results for the preference and combined cohorts are also shown. Results: The non-inferiority criteria for recurrent VTE was met. Conclusions: Among adult cancer patients with VTE, the use of a DOAC compared with a LMWH resulted in a noninferior risk of recurrent VTE with no differences in rates of bleeding or death in randomized patients. Clinical trial information: NCT02744092. [Table: see text]