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Linder M, Ekbom A, Brobert G, Vogtländer K, Balabanova Y, Becattini C, Carrier M, Cohen AT, Coleman CI, Khorana AA, Lee AYY, Psaroudakis G, Abdelgawwad K, Rivera M, Schaefer B, Giunta DH. Comparison of rivaroxaban and low molecular weight heparin in the treatment of cancer-associated venous thromboembolism: a Swedish national population-based register study. J Thromb Thrombolysis 2024:10.1007/s11239-024-02992-1. [PMID: 38735015 DOI: 10.1007/s11239-024-02992-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Treating cancer-associated venous thromboembolism (CAT) with anticoagulation prevents recurrent venous thromboembolism (rVTE), but increases bleeding risk. OBJECTIVES To compare incidence of rVTE, major bleeding, and all-cause mortality for rivaroxaban versus low molecular weight heparin (LMWH) in patients with CAT. METHODS We developed a cohort study using Swedish national registers 2013-2019. Patients with CAT (venous thromboembolism within 6 months of cancer diagnosis) were included. Those with other indications or with high bleeding risk cancers were excluded (according to guidelines). Follow-up was from index-CAT until outcome, death, emigration, or end of study. Incidence rates (IR) per 1000 person-years with 95% confidence interval (CI) and propensity score overlap-weighted hazard ratios (HRs) for rivaroxaban versus LMWH were estimated. RESULTS We included 283 patients on rivaroxaban and 5181 on LMWH. The IR for rVTE was 68.7 (95% CI 40.0-109.9) for rivaroxaban, compared with 91.6 (95% CI 81.9-102.0) for LMWH, with adjusted HR 0.77 (95% CI 0.43-1.35). The IR for major bleeding was 23.5 (95% CI 8.6-51.1) for rivaroxaban versus 49.2 (95% CI 42.3-56.9) for LMWH, with adjusted HR 0.62 (95% CI 0.26-1.49). The IR for all-cause mortality was 146.8 (95% CI 103.9-201.5) for rivaroxaban and 565.6 (95% CI 541.8-590.2) for LMWH with adjusted HR 0.48 (95% CI 0.34-0.67). CONCLUSIONS Rivaroxaban performed similarly to LMWH for patients with CAT for rVTE and major bleeding. An all-cause mortality benefit was observed for rivaroxaban which potentially may be attributed to residual confounding. TRIAL REGISTRATION NUMBER NCT05150938 (Registered 9 December 2021).
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Affiliation(s)
- Marie Linder
- Department of Medicine Solna, Clinical Epidemiology/ Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Anders Ekbom
- Department of Medicine Solna, Clinical Epidemiology/ Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Cecilia Becattini
- Department of Internal and Emergency Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Craig I Coleman
- School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Agnes Y Y Lee
- University of British Columbia and BC Cancer, Vancouver, Canada
| | | | | | - Marcela Rivera
- Consultant for Bayer AG, Berlin, Germany
- Janssen Research and Development, Barcelona, Spain
| | | | - Diego Hernan Giunta
- Department of Medicine Solna, Clinical Epidemiology/ Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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2
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Kürzinger ML, El-Haddad C, Gouin-Soboleva T, Fazekas Z, Granados D, Benito-Garcia E, Djoudi Y. Structured benefit-risk assessment for enoxaparin, in the context of its label extension, for the extended treatment of deep vein thrombosis and pulmonary embolism, and prevention of its recurrence in patients with active cancer. Pharmacoepidemiol Drug Saf 2024; 33:e5795. [PMID: 38680090 DOI: 10.1002/pds.5795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/15/2024] [Accepted: 04/01/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Guidelines recommend low-molecular-weight heparins (LMWHs) for patients with cancer-associated thrombosis. However, until recently, only dalteparin and tinzaparin were approved in the European Economic Area (EEA) for these patients. This study compares the benefit-risk profile of enoxaparin with dalteparin and tinzaparin for the extended treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrence in adult patients with active cancer. METHODS A semi-quantitative structured benefit-risk assessment was conducted for the label-extension application of enoxaparin based on the benefit-risk action team descriptive framework: define decision context; determine key benefit and risk outcomes; identify data sources; extract data; interpret results. RESULTS The key benefits were defined as reduced all-cause mortality and venous thromboembolism (VTE) recurrence (including symptomatic DVT, fatal PE or non-fatal PE); the key risks were major and non-major bleeding of clinical significance, and heparin-induced thrombocytopenia (HIT). Enoxaparin demonstrated comparable effects for the reduction of VTE recurrence and all-cause mortality versus other EEA-approved LMWHs (dalteparin, tinzaparin). There was no evidence of a significant difference between enoxaparin and the comparator groups with regard to incidence of major and non-major bleeding. The data on HIT were too limited to assess the difference between the two groups. CONCLUSIONS The assessment demonstrated a favourable benefit-risk profile for enoxaparin similar to that of other EEA-approved LMWHs for the treatment of DVT and PE and the prevention of recurrence in patients with active cancer and thus supported the label-extension approval.
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Affiliation(s)
| | - Chantal El-Haddad
- Sanofi, Global Epidemiology and Benefit-Risk, PSPV, Gentilly, France
| | | | - Zita Fazekas
- Sanofi, Global Regulatory Affairs-EU-GenMed, Vienna, Austria
| | - Denis Granados
- Sanofi, Global Epidemiology and Benefit-Risk, PSPV, Gentilly, France
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3
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Patrzalek P, Wysokinski WE, Kurmann RD, Houghton D, Hodge D, Kuczmik W, Klarich KW, Wysokinska EM. Cancer-associated non-bacterial thrombotic endocarditis-Clinical series from a single institution. Am J Hematol 2024; 99:596-605. [PMID: 38348537 DOI: 10.1002/ajh.27239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 03/19/2024]
Abstract
Premortem clinical presentation of cancer-associated non-bacterial thrombotic endocarditis (Ca-NBTE), therapy, and the clinal course is limited to case reports and small clinical series. An electronic search of Mayo Clinic records (03/31/2002-06/30/2022) with a subsequent manual review was performed to identify adult patients with echocardiographically detected NBTE and active malignancy, excluding those with infectious endocarditis or lupus anticoagulant/antiphospholipid antibodies. In this retrospective cohort study, we analyzed 115 Ca-NBTE patients (mean age 63.2 ± 9.7 years, 66.1% female) involving 71 (61.7%) mitral, 58 (50.4%) aortic, 8 (6.9%) tricuspid, and 1 (0.9%) pulmonary valve. The most common cancer was lung (n = 45 cases (39.1%), followed by pancreatic (n = 19, 16.5%), gynecological (17, 14.8%), gastrointestinal (n = 10, 8.7%), and 10 (8.7%) with hematologic malignancy; 6 patients had two active cancers. Embolic complications at presentation were frequent: 94 (81.7%) brain, 11 splenic, 10 renal, 6 coronary, and 4 to the extremities. Of 104 anticoagulated patients, 60 received low molecular weight heparin, 17 unfractionated heparin, 16 apixaban, 8 warfarin, and 3 rivaroxaban. There were 18 arterial thromboembolisms; the Kaplan-Meier estimates of the incidence at 2 years were consistent with a rate of 15.9% [95% Confidence Interval (CI) 9.9-23.3], including 14 strokes (12.4%, 95%CI, 7.1-19.2), and 8 other arterial emboli (10.5%, 95%CI, 4.7-18.9); there were 10 venous thromboembolisms (8.9%, 95%CI, 4.5-15.0). Fourteen major bleedings occurred (12.8%, 95%CI, 7.3-19.9) and 94 patients died during follow-up (77.9%, 95%CI, 71.1-85.8). Ca-NBTE predominantly affected women with lung adenocarcinoma or digestive tract cancers and manifested by stroke with high mortality and frequent embolic and bleeding complications during anticoagulation therapy.
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Affiliation(s)
- Patryk Patrzalek
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Waldemar E Wysokinski
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Reto D Kurmann
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Damon Houghton
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - David Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Wiktoria Kuczmik
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Kyle W Klarich
- Cardiovascular Disease, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
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4
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Fredman D, McNeil R, Eldar O, Leader A, Gafter-Gvili A, Avni T. Efficacy and safety of rivaroxaban versus apixaban for venous thromboembolism: A systematic review and meta-analysis of observational studies. J Thromb Thrombolysis 2024; 57:453-465. [PMID: 38127261 DOI: 10.1007/s11239-023-02926-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Direct-acting oral anticoagulants (DOACs) including rivaroxaban and apixaban are preferred over vitamin K antagonists for the treatment of venous thromboembolism (VTE). We conducted a systematic review and a meta-analysis to compare the efficacy and safety of rivaroxaban versus apixaban in the treatment of VTE. METHODS We conducted an electronic search for studies that directly compared treatment with rivaroxaban and apixaban in adult patients with VTE. The relative risks (RRs) and 95% confidence intervals (CIs) were estimated and pooled using a fixed-effect model unless significant heterogeneity was present (I2 > 40%), then random-effects model was used. The primary efficacy and safety outcomes were recurrent VTE (rVTE) and major bleeding events, respectively. RESULTS Nine observational studies were included in our meta-analysis, assessing 24,156 patients for apixaban and 38,847 for rivaroxaban. Pooling of data for our primary efficacy outcome showed a trend towards lower risk of rVTE with apixaban compared to rivaroxaban (RR 0.77, 95% CI 0.57-1.04, I2 = 53%). Analysis of our primary safety outcome showed a significantly lower risk of major bleeding with apixaban compared to rivaroxaban (RR 0.68, 95% CI 0.61-0.76, I2 = 0%). Apixaban was associated with significantly decreased risk of net clinical harm, clinically relevant non major bleeding (CRNMB) and any bleeding, compared to rivaroxaban (RR 0.75, 95% CI 0.61-0.92, I2 = 50%; RR 0.58, 95% CI 0.50-0.67, I2 = 7%; RR 0.64, 95% CI 0.59-0.70, I2 = 0%, respectively). CONCLUSIONS Apixaban is associated with a significantly lower risk of major bleeding compared to rivaroxaban for treatment of VTE. Given the limitations of the existing evidence, further interventional studies comparing the two drugs are needed.
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Affiliation(s)
- Danielle Fredman
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
| | - Rotem McNeil
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Ofir Eldar
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Avi Leader
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Institute of Haematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Anat Gafter-Gvili
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
- Institute of Haematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Tomer Avni
- Internal Medicine Department A, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
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5
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Baloch MF, Adepoju AV, Falki V, Hajjaj M, Habet T, Habet K, Mahrosh A, Kundu S, Kataria J, Mathew M, Saka T, Al-Tawil M. Comparative Efficacy of Oral Apixaban and Subcutaneous Low Molecular Weight Heparins in the Treatment of Cancer-Associated Thromboembolism: A Meta-Analysis. Cureus 2023; 15:e43447. [PMID: 37711939 PMCID: PMC10498340 DOI: 10.7759/cureus.43447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/13/2023] [Indexed: 09/16/2023] Open
Abstract
Cancer patients' risk of developing venous thromboembolism (VTE) is four to seven times higher than the general population. Cancer-associated VTE (CA-VTE), is a leading cause of morbidity and mortality in cancer patients. Low Molecular Weight Heparin (LMWH) has historically been the mainstay treatment of CA-VTE; however, complications such as bleeding and recurrent VTE make it challenging to manage these patients. Recent randomized controlled trials (RCTs) have proven that direct oral anticoagulants (DOACs) are as efficacious as LMWHs in treating CA-VTE. We conducted a systematic review and meta-analysis to ascertain the efficacy and safety of LMWH and Apixaban for the treatment of CA-VTE. A systematic review was conducted using Medline, Embase, and Scopus, databases for all cohort studies, case-control studies, and RCTs in English comparing cancer patients undergoing treatment with Apixaban or LMWH to treat CA-VTE from inception-May 2023. The Review Manager program, version 5.4.1, was used for statistical analysis and the Mantel-Haenszel fixed-effects models to calculate the risk ratio (RR) and 95% confidence intervals (CIs) and the inverse variance approach to get the weighted mean difference for the continuous outcomes. Q-test for heterogeneity was used to examine statistical heterogeneity and an I2 statistics value >50% was defined as significant heterogeneity. A total of four studies were included, and the total number of patients was 1,632 across all studies. The Apixaban group was associated with a statistically significant increase in minor bleeding (RR 1.57; 95% CI (1.12, 2.21); p=0.009; I2=0%), but not for major and total bleeding. The Apixaban group showed a statistically significant lower risk of recurrent VTE when compared to the LMWH group (RR: 0.61; 95% CI (0.41, 0.92); p=0.02; I2 = 7%), and there was no statistically significant difference in terms of mortality between the two groups (RR: 0.89; 95% CI (0.73, 1.09); I2=0). Our findings suggest that Apixaban may be a favorable anticoagulant option for managing cancer-associated thromboembolism, as it demonstrated a lower risk of recurrent VTE. The risk of bleeding with DOAC in gastrointestinal cancers warrants further investigation.
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Affiliation(s)
- Maryam F Baloch
- Department of Community Medicine, Allama Iqbal Medical College, Lahore, PAK
| | | | - Vaibhavkumar Falki
- School of Medicine, Corewell Health University Hospital, Grand Rapids, USA
| | - Mohsin Hajjaj
- Department of Internal Medicine, Jinnah Hospital Lahore, Lahore, PAK
| | - Tatiana Habet
- School of Medicine, Universidad de Ciencias Médicas, San Jose, CRI
| | - Karina Habet
- School of Medicine, American University of Antigua, Antigua, ATG
| | - Amtul Mahrosh
- School of Medicine, Dr. VRK Womens Medical College, Hyderabad, IND
| | - Sumana Kundu
- Department of Research, R.G. Kar Medical College and Hospital, Kolkata, IND
| | - Janvi Kataria
- School of Medicine, DY Patil University, Mumbai, IND
| | - Midhun Mathew
- Department of Internal Medicine, Pennsylvania Hospital, Philadelphia, USA
| | - Tugba Saka
- School of Medicine, Istinye University, Istanbul, TUR
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6
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Kobayashi RL, Cetatoiu MA, Esteso P, Ventresco C, Hawkins B, Daly KP, Blume ED, Fynn-Thompson F, VanderPluym C. Apixaban Anticoagulation in Children and Young Adults Supported With the HeartMate 3 Ventricular Assist Device. ASAIO J 2023; 69:e267-e269. [PMID: 36763905 DOI: 10.1097/mat.0000000000001889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
There is a growing population of pediatric and adult patients supported with the HeartMate 3 ventricular assist device (HM3 VAD) all of whom require anticoagulation. Apixaban is an anticoagulant requiring less testing than warfarin which has been shown to be effective in other indications. We report five pediatric and young adult patients managed on HM3 VAD with apixaban anticoagulation for 1589 days of VAD support between January 6, 2019 and January 7, 2022. The median age was 17 years and the weight was 69 kg. Four patients had congenital heart disease (2 single-ventricle Fontan circulation, and 2 biventricular circulations) and one had dilated cardiomyopathy. Apixaban was initiated at a median of 7 days postoperatively and doses were titrated based on peak apixaban-specific anti-Xa chromogenic analysis levels (goal 150-250 ng/ml). All patients received aspirin 81 mg daily. There was one major hemocompatibility-related event observed (outflow graft thrombus in the setting of medication nonadherence and chronic VAD infection); there was no major bleeding, death, or stroke. Three patients underwent heart transplantation and two remain on VAD support. In this limited series, apixaban paired with a level-based dosing regimen and low-dose aspirin provided safe and effective antithrombosis with only one hemocompatibility-related event related to medication non-adherence.
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Affiliation(s)
- Ryan L Kobayashi
- From the Department of Cardiology, Boston Children's Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Maria A Cetatoiu
- From the Department of Cardiology, Boston Children's Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Paul Esteso
- From the Department of Cardiology, Boston Children's Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Courtney Ventresco
- From the Department of Cardiology, Boston Children's Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Beth Hawkins
- From the Department of Cardiology, Boston Children's Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin P Daly
- From the Department of Cardiology, Boston Children's Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Elizabeth D Blume
- From the Department of Cardiology, Boston Children's Hospital Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Francis Fynn-Thompson
- Department of Cardiovascular Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; §Department of Cardiology, Harvard School of Medicine, Boston Children's Hospital, Boston, MA
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7
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Zhao M, Bao Y, Jiang C, Chen L, Xu L, Liu X, Li J, Yang Y, Jiang G, Li J, She Y, Chen Q, Shen L, Chen C. Rivaroxaban versus nadroparin for thromboprophylaxis following thoracic surgery for lung cancer: A randomized, noninferiority trial. Am J Hematol 2023. [PMID: 37139837 DOI: 10.1002/ajh.26945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 05/05/2023]
Abstract
The benefit of rivaroxaban in thromboprophylaxis after oncologic lung surgery remains unknown. To evaluate the efficacy and safety of rivaroxaban, patients who underwent thoracic surgery for lung cancer were enrolled, and randomly assigned to rivaroxaban or nadroparin groups in a 1:1 ratio; anticoagulants were initiated 12-24 h after surgery and continued until discharge. Four hundred participants were required according to a noninferiority margin of 2%, assuming venous thromboembolism (VTE) occurrence rates of 6.0% and 12.6% for patients in the rivaroxaban and nadroparin groups, respectively. The primary efficacy outcome was any VTE during the treatment and 30-day follow-up periods. The safety outcome was any on-treatment bleeding event. Finally, 403 patients were randomized (intention-to-treat [ITT] population), with 381 included in per-protocol (PP) population. The primary efficacy outcomes occurred in 12.5% (25/200) of the rivaroxaban group and 17.7% (36/203) of the nadroparin group (absolute risk reduction, -5.2%; 95% confidence interval [CI], [-12.2-1.7]), indicating the noninferiority of rivaroxaban in ITT population. Sensitivity analysis was performed in the PP population and yielded similar results, confirming the noninferiority of rivaroxaban. In the safety analysis population, the incidence of any on-treatment bleeding events did not differ significantly between the groups (12.2% for rivaroxaban vs. 7.0% for nadroparin; relative risk [RR], 1.9; 95% CI, [0.9-3.7]; p = .08), including major bleeding (9.7% vs. 6.5%; RR, 1.6 [95% CI, 0.9-3.7]; p = .24), and nonmajor bleeding (2.6% vs. 0.5%; RR, 5.2 [95% CI, 0.6-45.2]; p = .13). Rivaroxaban for thromboprophylaxis after oncologic lung surgery was shown to be noninferior to nadroparin.
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Affiliation(s)
- Mengmeng Zhao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi Bao
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chao Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Linsong Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lisha Xu
- Department of Ultrasound, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaogang Liu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jiaqi Li
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jian Li
- Clinical Research Center, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yunlang She
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qiankun Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Shen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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8
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Gutiérrez-Martínez A, López-Zabala L, Moronta-Franco M, Fernández-Betances O, López-Fañas R, Arias-Díaz D, Tejada-Toribio F, Warden F, López P, Colón-Arias F. [Sustainable anticoagulation in COVID-19: Review of severity prediction and clinical reasoning]. Rev Salud Publica (Bogota) 2023; 22:373-380. [PMID: 36753166 DOI: 10.15446/rsap.v22n3.87321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/30/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE To identify the procoagulant phenomenon in SARS-CoV-2 patients and propose sustainable therapeutic guidance for low-income countries. METHODS A systematic review was conducted. It identified 5 observational studies from a scrutiny from 78 results. 712 patients were examined and the results were grouped according to mortality and severity. The comparison of the groups was interpreted using descriptive statistics. RESULTS D-dimer values were significantly associated with greater severity and mortality. Prothrombin was associated in some observations with higher mortality, but in terms of severity it was inconclusive. CONCLUSION COVID-19 disease has significant procoagulant activity and its timely treatment can alter the prognosis. The explored evidence supports sustainable methods. More evidence is needed to improve management. An early systematic approach to patients with sustainable therapeutic measures tailored to the health system is recommended.
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Affiliation(s)
| | - Luis López-Zabala
- LL: MD. Pontificia Universidad Católica Madre y Maestra, Santiago, República Dominicana.
| | | | | | - Raúl López-Fañas
- RL: MD. Pontificia Universidad Católica Madre y Maestra. Santiago, República Dominicana.
| | - Danny Arias-Díaz
- DA: MD. Pontificia Universidad Católica Madre y Maestra. Santiago, República Dominicana.
| | | | - Fausto Warden
- FW: MD. Internista-Cardiólogo. SODOCARDIO. Santo Domingo, República Dominicana.
| | - Persio López
- PL: MD. Internista-Cardiólogo. Clínica Corominas. Santiago, República Dominicana.
| | - Franklyn Colón-Arias
- FC: MD. Internista-Cardiólogo - Hemodinamista. Clínica Corominas. Santiago, República Dominicana.
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9
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Comparison of the efficacy and safety of rivaroxaban and low-molecular-weight heparin in Chinese lung cancer patients with nonhigh-risk pulmonary embolism. Thromb J 2023; 21:16. [PMID: 36732741 PMCID: PMC9893535 DOI: 10.1186/s12959-023-00453-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/18/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Data that guide selection of differing anticoagulant regimens for specific cancer-associated venous thromboembolism (VTE) are lacking. We aimed to compare the efficacy and safety of rivaroxaban and low-molecular-weight heparin (LMWH) against nonhigh-risk pulmonary embolism (PE) in Chinese lung cancer patients. METHODS Four hundred forty-six Chinese lung cancer patients with nonhigh-risk PE who initiated treatment with rivaroxaban or LMWH were identified from Zhongshan Hospital database from 2016 to 2020. The primary outcomes were the composite event of VTE recurrence or major bleeding, and all-cause mortality. The secondary outcomes were VTE recurrence, major bleeding and clinically relevant non-major bleeding (CRNMB). Propensity score matching was used to balance baseline covariates. We conducted sensitivity analysis by stabilized inverse probability of treatment weighting and competing risk analysis by a Fine and Gray subdistribution hazard model. RESULTS In propensity score-matched cohorts, rivaroxaban was similar to LMWH in the risks of the composite outcome (hazard ratio (HR), 0.73; 95% confidence interval (CI), 0.45-1.21; P = 0.22), VTE recurrence (HR, 0.69; 95% CI, 0.36-1.34; P = 0.28), major bleeding (HR, 0.79; 95% CI, 0.37-1.68; P = 0.54) and CRNMB (HR, 1.13; 95% CI, 0.62-2.09; P = 0.69). All-cause mortality was significantly lower in rivaroxaban group than LMWH group (HR, 0.52; 95% CI, 0.36-0.75; P < 0.001). The primary and secondary outcomes favored rivaroxaban over LMWH in all the subgroups expect for central PE and intermediate-risk PE. The sensitivity analysis yielded similar results, and competing risk analysis was in accordance with the primary findings. CONCLUSIONS Rivaroxaban might be a promising alternative to LMWH as initial treatment for nonhigh-risk PE in lung cancer patients.
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10
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Coleman CI, Caroti KS, Abdelgawwad K, Psaroudakis G, Fatoba S, Rivera M, Schaefer B, Brobert G, Khorana AA, Becattini C, Lee AY, Ekbom A, Carrier M, Brescia C, Cohen AT. Effectiveness and Safety of Rivaroxaban and Low Molecular-Weight Heparin in Cancer-Associated Venous Thromboembolism. JACC: CARDIOONCOLOGY 2023; 5:189-200. [PMID: 37144109 PMCID: PMC10152194 DOI: 10.1016/j.jaccao.2022.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 02/10/2023]
Abstract
Background Direct-acting oral anticoagulants (DOACs) are alternatives to low molecular weight heparin (LMWH) in most cancer-associated thrombosis (CAT) patients. Objectives This study sought to compare the effectiveness and safety of rivaroxaban and LMWH for venous thromboembolism (VTE) treatment in patients with an active cancer type not associated with a high risk of DOAC bleeding. Methods An analysis of electronic health records from January 2012 to December 2020 was performed. Patients were adults, had active cancer, experienced an index CAT event, and were treated with rivaroxaban or LMWH. Patients with cancers with an established high risk of bleeding on DOACs were excluded. Baseline covariates were balanced using propensity score-overlap weighting. HRs with 95% CIs were calculated. Results We identified 3,708 CAT patients treated with rivaroxaban (29.5%) or LMWH (70.5%). The median (25th-75th percentiles) time on anticoagulation was 180 (69-365) and 96 (40-336) days for rivaroxaban and LMWH patients. At 3 months, rivaroxaban was associated with a 31% reduced risk of recurrent VTE vs LMWH (4.2% vs 6.1%; HR: 0.69; 95% CI: 0.51-0.92). No difference in bleeding-related hospitalizations or all-cause mortality was observed (HR: 0.79; 95% CI: 0.55-1.13 and HR: 1.07; 95% CI: 0.85-1.35, respectively). Rivaroxaban reduced the recurrent VTE risk (HR: 0.74; 95% CI: 0.57-0.97) but not bleeding-related hospitalizations or all-cause mortality at 6 months. At 12 months, no difference was observed between cohorts for any of the previously mentioned outcomes. Conclusions Among active cancer patients experiencing VTE and not at high risk of bleeding on DOACs, rivaroxaban was associated with a reduced risk of recurrent VTE versus LMWHs at 3 and 6 months but not 12 months. (Observational Study in Cancer-Associated Thrombosis for Rivaroxaban-United States Cohort [OSCAR-US]; NCT04979780).
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Affiliation(s)
- Craig I. Coleman
- School of Pharmacy, University of Connecticut, Storrs, Connecticut, USA
- Address for correspondence: Dr Craig I. Coleman, School of Pharmacy, University of Connecticut, Hartford Hospital, Evidence-Based Practice Center, 80 Seymour Street, Hartford, Connecticut 06102, USA.
| | | | | | | | | | | | | | | | - Alok A. Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, Ohio, USA
| | - Cecilia Becattini
- Department of Internal and Emergency Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Agnes Y.Y. Lee
- University of British Columbia and BC Cancer, Vancouver, Canada
| | - Anders Ekbom
- Unit of Clinical Epidemiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
| | | | - Alexander T. Cohen
- Department of Haematological Medicine, Guy’s and St Thomas’ National Health Service Foundation Trust, King’s College London, London, United Kingdom
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11
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Alsheef M, Bazarbashi S, Warsi A, Alfraih F, Almoomen A, Osman A, Owaidah T. The Saudi Consensus for the Management of Cancer-Associated Thromboembolism: A Modified Delphi-Based Study. TH OPEN : COMPANION JOURNAL TO THROMBOSIS AND HAEMOSTASIS 2023; 7:e14-e29. [PMID: 36751300 PMCID: PMC9825204 DOI: 10.1055/s-0042-1758856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/10/2022] [Indexed: 01/09/2023]
Abstract
Background Cancer is a well-known risk factor of preventable thromboembolic disease. This study aims to provide guidance on the prevention and management of cancer-associated thrombosis (CT) that tailors prophylactic and therapeutic options for medical and surgical oncology patients presenting to health care settings in Saudi Arabia. Methods The present consensus was developed in concordance with the modified Delphi-based approach, which incorporates a face-to-face meeting between two voting rounds to gain experts' feedback on the proposed statements. All experts were either oncologists, hematologists, or hemato-oncologist with an active clinical and research profile in hemato-oncology. Results The experts highlighted that the comparatively high incidence of inherited thrombophilia among the Saudi population may account for a higher CT burden in the Kingdom than in other parts of the world. However, due to the lack of literature that assesses CT in Saudi Arabia, primary venous thromboembolism prophylaxis should be tailored according to a valid risk assessment of cancer patients and should be implemented in routine practice. For hospitalized medical oncology patients, the experts agreed that prophylaxis with low-molecular-weight heparin (LMWH) should be offered, regardless of the presence of acute illness. For ambulatory medical oncology patients, LMWH or direct oral anticoagulants (DOACs) prophylaxis should be offered for high-risk patients. Concerning surgical patients, they agreed that all oncology patients undergoing surgery should be offered thromboprophylaxis. In terms of secondary prophylaxis, the experts recommended continuing a prophylactic dose of anticoagulant (LMWH or DOAC), for an appropriate period depending on the cancer type and stage. Finally, they also provided a set of statements on management of CT in Saudi Arabia. Conclusion The present modified Delphi-based study combined the best available evidence and clinical experience with the current health care policies and settings in Saudi Arabia to build a consensus statement on the epidemiology, prevention, and management of CT.
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Affiliation(s)
- Mohammed Alsheef
- Department of Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Shouki Bazarbashi
- College of Medicine, Al-Faisal University Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ashraf Warsi
- Department of Haematology, Ministry of National Guard-Health Affairs, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia,Department of Medicine, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia
| | - Feras Alfraih
- College of Medicine, Al-Faisal University Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - Ahmed Osman
- Pfizer Pharmaceuticals, Riyadh, Saudia Arabia
| | - Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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12
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Gould Rothberg BE, Quest TE, Yeung SCJ, Pelosof LC, Gerber DE, Seltzer JA, Bischof JJ, Thomas CR, Akhter N, Mamtani M, Stutman RE, Baugh CW, Anantharaman V, Pettit NR, Klotz AD, Gibbs MA, Kyriacou DN. Oncologic emergencies and urgencies: A comprehensive review. CA Cancer J Clin 2022; 72:570-593. [PMID: 35653456 DOI: 10.3322/caac.21727] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/15/2022] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
Patients with advanced cancer generate 4 million visits annually to emergency departments (EDs) and other dedicated, high-acuity oncology urgent care centers. Because of both the increasing complexity of systemic treatments overall and the higher rates of active therapy in the geriatric population, many patients experiencing acute decompensations are frail and acutely ill. This article comprehensively reviews the spectrum of oncologic emergencies and urgencies typically encountered in acute care settings. Presentation, underlying etiology, and up-to-date clinical pathways are discussed. Criteria for either a safe discharge to home or a transition of care to the inpatient oncology hospitalist team are emphasized. This review extends beyond familiar conditions such as febrile neutropenia, hypercalcemia, tumor lysis syndrome, malignant spinal cord compression, mechanical bowel obstruction, and breakthrough pain crises to include a broader spectrum of topics encompassing the syndrome of inappropriate antidiuretic hormone secretion, venous thromboembolism and malignant effusions, as well as chemotherapy-induced mucositis, cardiomyopathy, nausea, vomiting, and diarrhea. Emergent and urgent complications associated with targeted therapeutics, including small molecules, naked and drug-conjugated monoclonal antibodies, as well as immune checkpoint inhibitors and chimeric antigen receptor T-cells, are summarized. Finally, strategies for facilitating same-day direct admission to hospice from the ED are discussed. This article not only can serve as a point-of-care reference for the ED physician but also can assist outpatient oncologists as well as inpatient hospitalists in coordinating care around the ED visit.
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Affiliation(s)
- Bonnie E Gould Rothberg
- Yale Cancer Center Innovations Laboratory, Yale Comprehensive Cancer Center, New Haven, Connecticut
| | - Tammie E Quest
- Department of Emergency Medicine, Emory University, Atlanta, Georgia
| | - Sai-Ching J Yeung
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lorraine C Pelosof
- Office of Oncologic Diseases, US Food and Drug Administration, Silver Spring, Maryland
| | - David E Gerber
- Division of Hematology-Oncology, Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical School, Dallas, Texas
| | - Justin A Seltzer
- Department of Emergency Medicine, University of California San Diego, San Diego, California
| | - Jason J Bischof
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Charles R Thomas
- Department of Radiation Oncology, Geisel School of Medicine at Dartmouth, Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Nausheen Akhter
- Department of Medicine, Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mira Mamtani
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Robin E Stutman
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Venkataraman Anantharaman
- Department of Emergency Medicine, Singapore General Hospital, SingHealth Duke-National University of Singapore Academic Medical Center, Singapore, Singapore
| | - Nicholas R Pettit
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Adam D Klotz
- Department of Medicine, Division of Urgent Care Services, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michael A Gibbs
- Department of Emergency Medicine, Atrium Health-Carolinas Medical Center, Charlotte, North Carolina
| | - Demetrios N Kyriacou
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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13
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Lee LH, Danchaivijitr P, Uaprasert N, Gill H, Sacdalan DL, Ho GF, Parakh R, Pai P, Lee JK, Rey N, Cohen AT. Safe and effective treatment of venous Thromboembolism associated with Cancer: focus on direct Oral Anticoagulants in Asian patients. Exp Hematol Oncol 2022; 11:79. [PMID: 36303259 PMCID: PMC9615183 DOI: 10.1186/s40164-022-00331-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/10/2022] Open
Abstract
Cancer-associated thrombosis (CAT) poses a significant disease burden and the incidence in Asian populations is increasing. Anticoagulation is the cornerstone of treatment, but can be challenging due to the high bleeding risk in some cancers and the high risk of recurrent venous thromboembolism (VTE) in patients with malignancies. Direct oral anticoagulants (DOACs) are well established as first-choice treatments for VTE in non-cancer patients, offering a more convenient and less invasive treatment option than low-molecular-weight heparin (LMWH). Asian patients have exhibited comparable efficacy and safety outcomes with other races in trials of DOACs for VTE in the general population. Although no specific data are available in Asian patients with CAT, results from randomized controlled trials of apixaban, edoxaban, or rivaroxaban versus the LMWH, dalteparin, indicate that DOACs are a reasonable alternative to LMWH for anticoagulation in Asian patients with CAT. This is further supported by analyses of real-world data in Asian populations demonstrating the efficacy and safety of DOACs in Asian patients with CAT. Apixaban, edoxaban, or rivaroxaban are recommended in the most recently updated international guidelines as first-line therapy for CAT in patients without gastrointestinal or genitourinary cancers and at low risk of bleeding. An increased risk of major gastrointestinal bleeding was evident with edoxaban or rivaroxaban, but not apixaban, versus dalteparin in the clinical trials, suggesting that apixaban could be a safe alternative to LMWH in patients with gastrointestinal malignancies. Determining the optimal anticoagulant therapy for patients with CAT requires careful consideration of bleeding risk, tumor type, renal function, drug-drug interactions, financial costs, and patients' needs and preferences.
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Affiliation(s)
- Lai Heng Lee
- Haematology Department, Singapore General Hospital, Bukit Merah, Singapore
| | - Pongwut Danchaivijitr
- Division of Medical Oncology, Department of Internal Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Noppacharn Uaprasert
- Research Unit in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Harinder Gill
- Department of Medicine, The University of Hong Kong, 102 Pokfulam Road, Pokfulam Hong Kong, Pokfulam, Hong Kong, China.
| | | | - Gwo Fuang Ho
- Clinical Oncology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Rajiv Parakh
- Division of Peripheral Vascular & Endovascular Service, Medanta-Medicity, Gurgaon, Haryana, India
| | - Paresh Pai
- Vascular and Endovascular Surgery, The Vascular Clinic, Mumbai, India
| | - Jen-Kuang Lee
- Cardiology Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Nannette Rey
- de La Salle Medical and Health Sciences Institute, Dasmarinas Cavite, Philippines
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, NHS Trust, King's College, London, UK
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14
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Wysokinska EM, Houghton DE, Vlazny DT, Ashrani AA, Froehling DA, Meverden R, Hodge DO, Peterson LG, McBane RD, Wysokinski WE, Casanegra AI. Incidental pulmonary embolism in cancer and noncancer patients: Prospective cohort study. Eur J Haematol Suppl 2022; 110:88-98. [PMID: 36210612 DOI: 10.1111/ejh.13877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/08/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Clinical picture and outcome of incidental pulmonary embolism (iPE) compared to symptomatic pulmonary embolism (sPE) remain unclear. METHODS Demographics, recurrent venous thromboembolism (VTE), mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) were compared between iPE and sPE patients who were followed prospectively at Mayo Thrombophilia Clinic (March 1, 2013 to August 1, 2020). RESULTS Out of 3576 VTE patients, 1417 (39.6%) had PE: 562 (39.7%) iPE and 855 sPE. Patients with cancer were more likely to have iPE (400 iPE vs. 314 sPE) compared to those without cancer (162 iPE vs. 541 sPE). VTE recurrence rate (all per 100 person-years) was similar in all iPE and sPE patients (3.34 vs. 3.68, p = .50), with cancer (4.16 vs. 4.89, p = .370), and without cancer patients (0.89 vs. 2.80, p = .25). Higher mortality observed in all patients with iPE compared to sPE (46.45 vs. 23.47, p < .001) and with cancer (56.41 vs. 45.77, p = .03) became not significant after adjustment for age, antiplatelet therapy, metastases, and cancer location. Noncancer iPE patients had higher mortality (15.95 vs. 7.18, p = .006) even after adjustment (p = .05). The major bleeding rate was also higher in all patients iPE compared to sPE (7.10 vs. 3.68, p = .03), but not after adjustment (p = .974); higher major bleeding rate in noncancer patients (6.49 vs. 1.25, p = .007) remained significant after adjustment (.02). CRNMB rate was similar to iPE and sPE patients. CONCLUSION iPE represents a more serious clinical condition compared to sPE as indicated by the higher mortality and major bleeding but these differences reflect underlying comorbidities rather than the seriousness of the embolic event.
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Affiliation(s)
| | - Damon E Houghton
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Danielle T Vlazny
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Aneel A Ashrani
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David A Froehling
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Ryan Meverden
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida, USA
| | - Lisa G Peterson
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert D McBane
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Waldemar E Wysokinski
- Hematology Division, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana I Casanegra
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, Minnesota, USA
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15
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Zhang M, Zhang X, Wang C, Shen Y, Fu J. The Role of Jinhuang Powder to Prevent Adverse Effects of Subcutaneous Injection of Enoxaparin Sodium. Emerg Med Int 2022; 2022:7806659. [PMID: 36059558 PMCID: PMC9433242 DOI: 10.1155/2022/7806659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/28/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To determine the role of Jinhuang Powder to prevent adverse effects of subcutaneous injection of enoxaparin sodium. Methods The clinical data of 97 patients with cervical cancer who were treated with subcutaneous injection of enoxaparin through the lower margin of the deltoid muscle of the upper arm in Zhejiang Tumor Hospital from August 2020 to August 2021 were retrospectively analyzed. All patients were divided into the control group (n = 39) and the research group (n = 58) according to the different use time periods of Jinhuang Powder. The research group was treated with Jinhuang Powder and enoxaparin sodium at the same time. The control group started to use Jinhuang Powder after the adverse reactions occurred. The induration, subcutaneous bleeding events, and pain were statistically analyzed. Results The incidence of induration (3.4% vs 15.4%, P=0.036) and subcutaneous hemorrhage (37.9% vs 76.9%, P=0.003) in the research group was significantly lower than that in the control group. The pain in the research group was lighter than that in the control group (grade 0-4 pain: 70% vs 28.2%, 19% vs 30.8%, 8.6% vs 23.1%, 1.7% vs 12.8%, 1.7% vs 5.1%, P=0.001). Conclusion Preventive use of Jinhuang Powder can significantly reduce the incidence of subcutaneous induration and subcutaneous bleeding and can effectively alleviate the local pain of injection. It is worthy of further study to clarify its role and mechanism.
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Affiliation(s)
- Meng Zhang
- Department of Gynecological Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Xiang Zhang
- Department of Gynecological Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Chunlan Wang
- Department of Gynecological Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Yangfang Shen
- Department of Gynecological Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
| | - Jianan Fu
- Department of Gynecological Radiation Oncology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Hangzhou, China
- Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, China
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Zhao T, Li X, Chen Y, Du J, Chen X, Wang D, Wang L, Zhao S, Wang C, Meng Q, Sun H, Liu K, Wu J. Risk assessment and molecular mechanism study of drug-drug interactions between rivaroxaban and tyrosine kinase inhibitors mediated by CYP2J2/3A4 and BCRP/P-gp. Front Pharmacol 2022; 13:914842. [PMID: 36071847 PMCID: PMC9441481 DOI: 10.3389/fphar.2022.914842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/14/2022] [Indexed: 11/21/2022] Open
Abstract
Cancer patients generally has a high risk of thrombotic diseases. However, anticoagulant therapy always aggravates bleeding risks. Rivaroxaban is one of the most widely used direct oral anticoagulants, which is used as anticoagulant treatment or prophylaxis in clinical practice. The present study aimed to systemically estimate the combination safety of rivaroxaban with tyrosine kinase inhibitors (TKIs) based on human cytochrome P450 (CYPs) and efflux transporters and to explore the drug–drug interaction (DDI) mechanisms in vivo and in vitro. In vivo pharmacokinetic experiments and in vitro enzyme incubation assays and bidirectional transport studies were conducted. Imatinib significantly increased the rivaroxaban Cmax value by 90.43% (p < 0.05) and the area under the curve value by 119.96% (p < 0.01) by inhibiting CYP2J2- and CYP3A4-mediated metabolism and breast cancer resistance protein (BCRP)- and P-glycoprotein (P-gp)-mediated efflux transportation in the absorption phase. In contrast, the combination of sunitinib with rivaroxaban reduced the exposure in vivo by 62.32% (p < 0.05) and the Cmax value by 72.56% (p < 0.05). In addition, gefitinib potently inhibited CYP2J2- and CYP3A4-mediated rivaroxaban metabolism with Ki values of 2.99 μΜ and 4.91 μΜ, respectively; however, it almost did not affect the pharmacokinetics of rivaroxaban in vivo. Taken together, clinically significant DDIs were observed in the combinations of rivaroxaban with imatinib and sunitinib. Imatinib increased the bleeding risks of rivaroxaban, while sunitinib had a risk of reducing therapy efficiency. Therefore, more attention should be paid to aviod harmful DDIs in the combinations of rivaroxaban with TKIs.
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Affiliation(s)
- Tingting Zhao
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
| | - Xuening Li
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
| | - Yanwei Chen
- Department of Pharmacy, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Jie Du
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
| | - Xiaodong Chen
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
| | - Dalong Wang
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
| | - Liyan Wang
- Department of Pharmacy, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Shan Zhao
- Dalian Institute of Chemical Physics, Chinese Academy of Sciences, Dalian, China
| | - Changyuan Wang
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
- Provincial Key Laboratory for Pharmacokinetics and Transport, Liaoning Dalian Medical University, Dalian, China
| | - Qiang Meng
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
- Provincial Key Laboratory for Pharmacokinetics and Transport, Liaoning Dalian Medical University, Dalian, China
| | - Huijun Sun
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
- Provincial Key Laboratory for Pharmacokinetics and Transport, Liaoning Dalian Medical University, Dalian, China
| | - Kexin Liu
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
- Provincial Key Laboratory for Pharmacokinetics and Transport, Liaoning Dalian Medical University, Dalian, China
| | - Jingjing Wu
- Department of Clinical Pharmacology, College of Pharmacy, Dalian Medical University, Dalian, China
- Provincial Key Laboratory for Pharmacokinetics and Transport, Liaoning Dalian Medical University, Dalian, China
- *Correspondence: Jingjing Wu,
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Angelini DE, Khorana AA. Building a CAT clinic - real-world systems approaches to prevention and treatment. Thromb Res 2022; 213 Suppl 1:S84-S86. [DOI: 10.1016/j.thromres.2021.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 10/18/2022]
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Dong Y, Duan G, Wang H, Ru J, Cui Y. A Cohort Study of Rivaroxaban Combined with D-Dimer Dynamic Monitoring in the Prevention of Deep Venous Thrombosis after Knee Arthroplasty. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3965039. [PMID: 35495880 PMCID: PMC9042632 DOI: 10.1155/2022/3965039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 12/23/2022]
Abstract
Objective To explore the cohort study of rivaroxaban combined with D-dimer dynamic monitoring in the prevention of deep venous thrombosis (DVT) after knee arthroplasty. Methods Eighty-four patients with knee osteoarthritis who went through total knee arthroplasty from June 2019 to June 2021 in our hospital were arbitrarily assigned into the study group and the control group. The patients in the control group were cured with rivaroxaban anticoagulation after operation, and the study group was cured with dynamic monitoring of D-dimer on the basis of the control group. The incidence of postoperative DVT, pulmonary embolism (PE), and bleeding complications (incision ecchymosis and bleeding events) were compared. The related indexes such as drainage volume and blood transfusion volume were compared. The levels of activated partial prothrombin time (APPT), prothrombin time (PT), and D-dimer were dynamically monitored before and after operation. Visual analogue scale (VAS) was adopted to assess the degree of postoperative incision pain, the level of limb swelling before and after operation was measured, the circumference difference of affected limb was calculated, the ecchymosis area was assessed in the form of nine-palace grid, and the scores were compared. Results According to the comparison of VAS score, there exhibited no remarkable difference before operation and on the first day after operation, but the VAS score decreased after operation, and the VAS score of the study group on the 3rd day, 7th day, and 14th day after operation was remarkably lower compared to the control group (P < 0.05). There exhibited no remarkable difference in drainage volume (P > 0.05), but the blood transfusion volume and total blood loss in the study group were remarkably lower (P < 0.05). There exhibited no remarkable difference in the level of PT on the 3rd day before operation and on the 3rd day after operation, but on the 7th day and 14th day after operation, the level of PT in the study group was remarkably higher (P < 0.05). The level of PT in the study group was remarkably higher (P < 0.05). There exhibited no remarkable difference in the level of APPT on the 3rd day before operation and on the 3rd day after operation, but on the 7th day and 14th day after operation, the level of APPT in the study group was remarkably higher (P < 0.05). The level of APPT in the study group was remarkably higher (P < 0.05). There exhibited no remarkable difference in the level of plasma D-dimer before operation (P > 0.05). The level of plasma D-dimer in the study group was lower (P < 0.05). In terms of the postoperative ecchymosis area score, the ecchymosis area score decreased remarkably after operation. Furthermore, the ecchymosis area score of the study group was remarkably lower (P < 0.05). In terms of the swelling degree of the affected limb, there exhibited no remarkable difference in thigh circumference and calf circumference before operation (P > 0.05), but after operation, the thigh circumference difference and calf circumference difference decreased, and the thigh circumference difference and calf circumference difference in the study group were lower (P < 0.05). The incidence of DVT in the study group was 16.67%, while that in the control group was 38.10%. No PE occurred in the two groups at the early stage after operation. There were 3 cases of incision ecchymosis, 1 case of bleeding event (incision oozing) in the study group, 11 cases of incisional ecchymosis, and 2 cases of bleeding event in the control group. In 3 patients with incisional bleeding, there were no obvious abnormalities in routine blood examination and blood coagulation indexes. The patients were given wound pressure bandaging and stopped using anticoagulants and changing wound dressings every day, all of which disappeared within 5 days. The incidence of early postoperative DVT and bleeding complications in the study group was lower (P < 0.05). Conclusion Rivaroxaban combined with D-dimer dynamic monitoring has high clinical value in preventing DVT after knee arthroplasty and can effectively reduce the amount of blood loss during operation and the incidence of postoperative DVT, PE, and bleeding complications, which is worth popularizing to reduce the area of ecchymosis and the degree of pain after operation and shorten the recovery process.
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Affiliation(s)
- Yongyong Dong
- Jincheng People's Hospital Orthopaedic Ward 1 Shanxi 048026, Orthopaedic Ward of Jincheng People's Hospital, No. 456 Wenchang East Street, Jincheng District, Shanxi Province, China
| | - Guangbin Duan
- Jincheng People's Hospital Orthopaedic Ward 1 Shanxi 048026, Orthopaedic Ward of Jincheng People's Hospital, No. 456 Wenchang East Street, Jincheng District, Shanxi Province, China
| | - Huihui Wang
- Jincheng People's Hospital Orthopaedic Ward 1 Shanxi 048026, Orthopaedic Ward of Jincheng People's Hospital, No. 456 Wenchang East Street, Jincheng District, Shanxi Province, China
| | - Jia Ru
- Jincheng People's Hospital Orthopaedic Ward 1 Shanxi 048026, Orthopaedic Ward of Jincheng People's Hospital, No. 456 Wenchang East Street, Jincheng District, Shanxi Province, China
| | - Yong Cui
- Jincheng People's Hospital Orthopaedic Ward 1 Shanxi 048026, Orthopaedic Ward of Jincheng People's Hospital, No. 456 Wenchang East Street, Jincheng District, Shanxi Province, China
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Building a CAT Clinic - real-world systems approaches to prevention and treatment. Thromb Res 2022. [DOI: 10.1016/j.thromres.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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20
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Clinical Efficacy of Conventional Heparin Anticoagulation Combined with Apixaban in the Treatment of Patients with Cerebral Venous Thrombosis and Its Effect on Serum D-Dimer and FIB Expression. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2021:4979210. [PMID: 35003321 PMCID: PMC8741378 DOI: 10.1155/2021/4979210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/29/2021] [Accepted: 12/06/2021] [Indexed: 12/14/2022]
Abstract
Objective The aim of this study was to explore the clinical efficacy of conventional heparin anticoagulation in combination with apixaban in the treatment of patients with cerebral venous thrombosis (CVT) and its influence on serum D-dimer (D-D) and fibrinogen (FIB). Methods One hundred and fifty-seven consecutive CVT patients admitted to our hospital from January 1, 2006, to December 31, 2013, were allocated into two groups according to the different treatment methods, of which 95 cases received standard anticoagulation therapy (standard group (SG)) and the remaining 62 cases were given apixaban therapy (research group (RG)). The curative effects and the changes of coagulation function during the treatment, as well as the incidence of adverse reactions, were analyzed in the two groups. The changes of D-D and FIB levels before treatment and at days 1, 4, and 7 posttreatment were detected. Results In treatment efficacy, RG was superior to SG. No evident difference was observed in the incidence of adverse events or coagulation function between the two groups. At day 1 posttreatment, D-D level was increased largely in both SG and RG, but the increase was much more significant in RG. However, D-D level was decreased gradually with time in both groups, and the reduction was more notable in RG. The FIB level in SG declined gradually with time after treatment and was higher than that in RG at the same time point. In RG, FIB was decreased gradually at day 1 and day 4 posttreatment, and its level at day 7 posttreatment showed no difference compared with that at day 4 posttreatment. Spearman's analysis identified that the higher the D-D level or the lower the FIB level at day 1 posttreatment was, the better the treatment efficacy was. After seven-day treatment, the lower the level of D-D and FIB was, the better the therapeutic effect was. Logistic analysis indicated that age, time of diagnosis, deep vein thrombosis (DVT), Glasgow Coma Scale (GCS) score, infection, Apixaban, D-D, and FIB all independently affect the treatment effect of patients. Conclusions The combined use of Apixaban with heparin is high-performing and safe in the treatment of CVT. The changes of D-D and FIB levels during the treatment are strongly linked to the therapeutic effect, which can be used as plausible evaluation indexes for the efficacy of CVT.
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Hirao-Try Y, Vlazny DT, Meverden R, Houghton DE, Casanegra AI, Froehling DA, Hodge DO, Peterson LG, McBane RD, Wysokinski WE. Single versus multiple and incidental versus symptomatic subsegmental pulmonary embolism: clinical characteristics and outcome. J Thromb Thrombolysis 2022; 54:82-90. [PMID: 34993715 DOI: 10.1007/s11239-021-02623-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 11/30/2022]
Abstract
It remains unexplored if the clinical picture and outcome of subsegmental pulmonary embolism (SSPE) differ between single versus multiple, and incidental versus symptomatic embolism. Consecutive patients anticoagulated for SSPE at the Mayo Thrombophilia Clinic (03/01/2013-12/31/2020) were followed forward to assess venous thromboembolism (VTE) recurrence, mortality, major bleeding, and clinically relevant non-major bleeding (CRNMB); expressed as a rate per 100 person-years. Among 3878 VTE patients, 1541 had pulmonary embolism including 224 (14.6%) with SSPE either single (n = 139) or multiple (n = 85; 46 bilateral and 39 unilateral emboli); 134 had incidental and 90 symptomatic SSPE. Patients with single were less often symptomatic and less often had coexisting DVT than multiple SSPE. Patients with incidental had a two-fold higher frequency of cancer compared to symptomatic SSPE. During the study period, 1 patient with single and 2 with multiple SSPE had VTE recurrence (rate of 1.14 vs 3.63, p = 0.280). Single SSPE patients experienced 2 episodes of major bleeding (rate of 2.36) while the multiple SSPE group had no major bleeding. Seven patients in each group had CRNMB events (rate of 8.20 vs 13.58 for single and multiple SSPE, respectively, p = 0.282). Patients with single SSPE had a higher death rate compared to multiple SSPE (43.07 vs 22.22, p = 0.031) but no difference was noted after adjusting for cancer (p = 0.388). Also, incidental had similar clinical outcomes to symptomatic SSPE.Interpretation Anticoagulated SSPE patients with single and multiple as well as incidental and symptomatic have a different clinical profile but similar clinical outcomes.
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Affiliation(s)
- Yumiko Hirao-Try
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Danielle T Vlazny
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Ryan Meverden
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Damon E Houghton
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Ana I Casanegra
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - David A Froehling
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - David O Hodge
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, FL, USA
| | - Lisa G Peterson
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Robert D McBane
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA.,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA
| | - Waldemar E Wysokinski
- Vascular Medicine Division, Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA. .,Gonda Vascular Center, Department of Cardiovascular Diseases, Mayo Clinic, 200 First Street, Rochester, MN, 55905, USA.
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Maraveyas A, Beyer‐Westendorf J, Lee AY, Mantovani LG, De Sanctis Y, Abdelgawwad K, Fatoba S, Bach M, Cohen AT. Cancer-Associated ThrOmboSIs - Patient-Reported OutcoMes With RivarOxaban (COSIMO) - Baseline characteristics and clinical outcomes. Res Pract Thromb Haemost 2021; 5:e12604. [PMID: 34877446 PMCID: PMC8633229 DOI: 10.1002/rth2.12604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 08/04/2021] [Accepted: 08/31/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patients with cancer-associated thrombosis (CAT) have a high risk of recurrent venous thromboembolic events, which contribute to significant morbidity and mortality. Direct oral anticoagulants may provide a convenient treatment option for these patients. OBJECTIVES To assess clinical characteristics and outcomes of patients with active cancer changing to rivaroxaban after ≥4 weeks of standard therapy for the treatment of venous thromboembolism (VTE) in clinical practice. This analysis focused on secondary outcomes of Cancer-associated thrOmboSIs - Patient-reported outcoMes with rivarOxaban (COSIMO). PATIENTS COSIMO was a multinational, prospective, noninterventional, single-arm cohort study. Overall, 505 patients received at least one dose of rivaroxaban; 96.6% changing from low-molecular-weight heparin, 1.6% from a vitamin K antagonist, and 1.8% from fondaparinux. RESULTS Most patients had solid tumors (n = 449; 88.9%) and approximately half of these patients had metastases. The qualifying venous thromboembolic event was deep vein thrombosis (DVT) in 45.3% of patients, pulmonary embolism (PE) in 37.2% of patients, DVT with PE in 9.7% of patients, and catheter-associated DVT in 7.5% of patients. Approximately 75.1% of patients received rivaroxaban for at least 3 months; 150 (29.7%) patients received concomitant chemotherapy during the study. VTE recurrence, major bleeding, nonmajor bleeding, and major adverse cardiovascular events occurred in 18 (3.6%), 18 (3.6%), 81 (16.0%), and 12 (2.4%) patients, respectively. CONCLUSIONS In patients with CAT who changed to rivaroxaban treatment after ≥4 weeks of standard therapy, the observed incidence proportions of recurrent VTE and bleeding events were in keeping with the recognized effectiveness and safety profile of rivaroxaban for the treatment of CAT.
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Affiliation(s)
- Anthony Maraveyas
- Joint Centre for Cancer StudiesHull York Medical SchoolQCOHCastle Hill HospitalHullUK
| | - Jan Beyer‐Westendorf
- Thrombosis Research UnitDepartment of Medicine IDivision HematologyUniversity Hospital “Carl Gustav Carus” DresdenDresdenGermany
| | - Agnes Y. Lee
- Division of HematologyUniversity of British ColumbiaBritish Columbia Cancer AgencyVancouverBCCanada
| | | | | | | | | | | | - Alexander T Cohen
- Department of Haematological MedicineGuys and St Thomas' NHS Foundation TrustKing's College LondonLondonUK
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Cheong EJY, Ng DZW, Chin SY, Wang Z, Chan ECY. Application of a PBPK Model of Rivaroxaban to Prospective Simulations of Drug-Drug-Disease Interactions with Protein Kinase Inhibitors in CA-VTE. Br J Clin Pharmacol 2021; 88:2267-2283. [PMID: 34837258 DOI: 10.1111/bcp.15158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/24/2021] [Accepted: 11/08/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Rivaroxaban is a viable anticoagulant for the management of cancer associated venous thromboembolism (CA-VTE). A previously verified physiologically-based pharmacokinetic (PBPK) model of rivaroxaban established how its multiple pathways of elimination via both CYP3A4/2J2-mediated hepatic metabolism and organic anion transporter 3 (OAT3)/P-glycoprotein-mediated renal secretion predisposes rivaroxaban to drug-drug-disease interactions (DDDIs) with clinically relevant protein kinase inhibitors (PKIs). We proposed the application of PBPK modelling to prospectively interrogate clinically significant DDIs between rivaroxaban and PKIs (erlotinib and nilotinib) for dose adjustments in CA-VTE. EXPERIMENTAL APPROACH The inhibitory potencies of the PKIs on CYP3A4/2J2-mediated metabolism of rivaroxaban were characterized. Using prototypical OAT3 inhibitor ketoconazole, in vitro OAT3 inhibition assays were optimized to ascertain the in vivo relevance of derived transport inhibitory constants (Ki ). Untested DDDIs between rivaroxaban and erlotinib or nilotinib were simulated. KEY RESULTS Mechanism-based inactivation (MBI) of CYP3A4-mediated rivaroxaban metabolism by both PKIs and MBI of CYP2J2 by erlotinib were established. The importance of substrate specificity and nonspecific binding to derive OAT3-inhibitory Ki values of ketoconazole and nilotinib for the accurate prediction of interactions was illustrated. When simulated rivaroxaban exposure variations with concomitant erlotinib and nilotinib therapy were evaluated using published dose-exposure equivalence metrics and bleeding risk analyses, dose reductions from 20 mg to 15 mg and 10 mg in normal and mild renal dysfunction, respectively, were warranted. CONCLUSION AND IMPLICATIONS We established a PBPK-DDDI model to prospectively evaluate clinically relevant interactions between rivaroxaban and PKIs for the safe and efficacious management of CA-VTE.
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Affiliation(s)
- Eleanor Jing Yi Cheong
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Daniel Zhi Wei Ng
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Sheng Yuan Chin
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Ziteng Wang
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Eric Chun Yong Chan
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
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Angelini DE, Khorana AA. Building a CAT clinic - real-world systems approaches to prevention and treatment. Thromb Res 2021; 208:173-175. [PMID: 34801921 DOI: 10.1016/j.thromres.2021.11.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 10/19/2022]
Abstract
Cancer patients have an increased risk of developing venous thrombosis. The implementation of a cancer associated thrombosis clinic can be instrumental for the prevention, early recognition, and management of venous thromboembolism in this vulnerable population. Cancer thrombosis clinics rely on a multidisciplinary approach to care and require standardization along with a dedicated team of healthcare professionals. Cancer thrombosis clinics have the potential to improve patient outcomes and lower healthcare expenditure. Herein, we describe a successful model of a cancer thrombosis clinic and highlight the potential impact on clinical outcomes.
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Affiliation(s)
- Dana E Angelini
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, United States of America.
| | - Alok A Khorana
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, United States of America
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25
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Houghton DE, Vlazny DT, Casanegra AI, Brunton N, Froehling DA, Meverden RA, Hodge DO, Peterson LG, McBane RD, Wysokinski WE. Bleeding in Patients With Gastrointestinal Cancer Compared With Nongastrointestinal Cancer Treated With Apixaban, Rivaroxaban, or Enoxaparin for Acute Venous Thromboembolism. Mayo Clin Proc 2021; 96:2793-2805. [PMID: 34425962 DOI: 10.1016/j.mayocp.2021.04.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/13/2021] [Accepted: 04/27/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the bleeding risk in patients with gastrointestinal (GI) cancer with that in patients with non-GI cancer treated with anticoagulation for acute cancer-associated venous thromboembolism (Ca-VTE). PATIENTS AND METHODS Consecutive patients with Ca-VTE seen at the Mayo Thrombophilia Clinic between March 1, 2013, and April 20, 2020, were observed prospectively to assess major bleeding and clinically relevant nonmajor bleeding (CRNMB). RESULTS In the group of 1392 patients with Ca-VTE, 499 (35.8%) had GI cancer including 272 with luminal GI cancer (lower GI, 208; upper GI, 64), 176 with pancreatic cancer, and 51 with hepatobiliary cancer. The rate of major bleeding and CRNMB in patients with GI cancer was similar to that in 893 (64.2%) patients with non-GI cancer treated with apixaban, rivaroxaban, or enoxaparin. Apixaban had a higher rate of major bleeding in luminal GI cancer compared with the non-GI cancer group (15.59 vs 3.26 per 100 person-years; P=.004) and compared with enoxaparin in patients with luminal GI cancer (15.59 vs 3.17; P=.04). Apixaban had a lower rate of CRNMB compared with rivaroxaban in patients with GI cancer (3.83 vs 9.40 per 100 person-years; P=.03). Patients treated with rivaroxaban in the luminal GI cancer group had a major bleeding rate similar to that of patients with non-GI cancer (2.04 vs 4.91 per 100 person-years; P=.37). CONCLUSION Apixaban has a higher rate of major bleeding in patients with luminal GI cancer compared with patients with non-GI cancer and compared with enoxaparin in patients with luminal GI cancer. Rivaroxaban shows no increased risk of major bleeding in patients with GI cancer or luminal GI cancer compared with patients with non-GI cancer. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03504007.
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Affiliation(s)
- Damon E Houghton
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Danielle T Vlazny
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ana I Casanegra
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - David A Froehling
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ryan A Meverden
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - David O Hodge
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, FL
| | - Lisa G Peterson
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Robert D McBane
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Thrombophilia Clinic, Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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Banik N, Yang SB, Kang TB, Lim JH, Park J. Heparin and Its Derivatives: Challenges and Advances in Therapeutic Biomolecules. Int J Mol Sci 2021; 22:ijms221910524. [PMID: 34638867 PMCID: PMC8509054 DOI: 10.3390/ijms221910524] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 12/13/2022] Open
Abstract
Heparin has been extensively studied as a safe medicine and biomolecule over the past few decades. Heparin derivatives, including low-molecular-weight heparins (LMWH) and heparin pentasaccharide, are effective anticoagulants currently used in clinical settings. They have also been studied as functional biomolecules or biomaterials for various therapeutic uses to treat diseases. Heparin, which has a similar molecular structure to heparan sulfate, can be used as a remarkable biomedicine due to its uniquely high safety and biocompatibility. In particular, it has recently drawn attention for use in drug-delivery systems, biomaterial-based tissue engineering, nanoformulations, and new drug-development systems through molecular formulas. A variety of new heparin-based biomolecules and conjugates have been developed in recent years and are currently being evaluated for use in clinical applications. This article reviews heparin derivatives recently studied in the field of drug development for the treatment of various diseases.
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Affiliation(s)
- Nipa Banik
- Department of Integrated Biosciences, Graduate School, BK21 Program, Konkuk University, Chungju 27478, Korea; (N.B.); (S.-B.Y.); (T.-B.K.); (J.-H.L.)
| | - Seong-Bin Yang
- Department of Integrated Biosciences, Graduate School, BK21 Program, Konkuk University, Chungju 27478, Korea; (N.B.); (S.-B.Y.); (T.-B.K.); (J.-H.L.)
| | - Tae-Bong Kang
- Department of Integrated Biosciences, Graduate School, BK21 Program, Konkuk University, Chungju 27478, Korea; (N.B.); (S.-B.Y.); (T.-B.K.); (J.-H.L.)
| | - Ji-Hong Lim
- Department of Integrated Biosciences, Graduate School, BK21 Program, Konkuk University, Chungju 27478, Korea; (N.B.); (S.-B.Y.); (T.-B.K.); (J.-H.L.)
- Department of Biomedical Chemistry, College of Biomedical & Health Science, Konkuk University, Chungju 27478, Korea
| | - Jooho Park
- Department of Integrated Biosciences, Graduate School, BK21 Program, Konkuk University, Chungju 27478, Korea; (N.B.); (S.-B.Y.); (T.-B.K.); (J.-H.L.)
- Department of Biomedical Chemistry, College of Biomedical & Health Science, Konkuk University, Chungju 27478, Korea
- Correspondence:
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The Role of Direct Oral Anticoagulants in Cancer-Associated Thrombosis According to the Current Literature. MEDICINA-LITHUANIA 2021; 57:medicina57090960. [PMID: 34577883 PMCID: PMC8471429 DOI: 10.3390/medicina57090960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 11/16/2022]
Abstract
Venous thromboembolism (VTE) is a common complication among patients suffering from malignancies, leading to an increased mortality rate. Novel randomized trials have added valuable information regarding cancer-associated thrombosis (CAT) management using direct oral anticoagulants (DOACs). The aim of this study is to present an overview of the current literature and recommendations in CAT treatment. A few randomized control trials (RCTs) have been integrated suggesting that DOACs may be effectively applied in CAT patients compared to low molecular weight heparins (LMWHs) with a decreased mortality and VTE recurrence rate. However, the risk of bleeding is higher, especially in patients with gastrointestinal malignancies. Real-world data are in accordance with these RCT findings, while in the currently available recommendations, DOACs are suggested as a reliable alternative to LMWH during the initial, long-term, and extended phase of treatment. Data retrieved from the current literature, including RCTs and “real-world” studies, aim to clarify the role of DOACs in CAT management, by highlighting their benefits and remarking upon the potential adverse outcomes. Current recommendations suggest the use of DOACs in well-selected patients with an increasing level of evidence through years.
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Cohen AT, Keshishian A, Lee T, Rosenblatt L, Hlavacek P, Sah J, Luo X. Effectiveness and safety of apixaban, LMWH, and warfarin among high-risk subgroups of VTE patients with active cancer. Curr Med Res Opin 2021; 37:1467-1482. [PMID: 34030541 DOI: 10.1080/03007995.2021.1932448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/13/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This pooled claims database study evaluated the risk of recurrent Venous Thromboembolism (VTE) and major bleeding (MB) among patients with VTE and active cancer prescribed apixaban, low-molecular weight heparin (LMWH), or warfarin stratified by high-risk subgroups. METHODS Patients diagnosed with VTE in the setting of active cancer who initiated apixaban, LMWH, or warfarin were identified using four US commercial claims databases from 01SEP2014 to the end of the study period (MarketScan: 01MAR2014-30JUNE2017; Optum and Humana: 01MAR2014-31DEC2017; PharMetrics: 01MAR2014-31MAR2018). Stabilized inverse probability treatment weighting (IPTW) was used to balance treatment cohorts. Cox proportional hazard models were used to evaluate the risk of recurrent VTE and MB for each subgroup stratification: VTE risk level based on cancer types, metastatic diagnosis, cancer treatment, chemotherapy, gastrointestinal cancer, and index VTE event type (PE vs. DVT). Statistical significance (p < .10) of the interaction between treatment effects and subgroups was evaluated. RESULTS Eligible subjects included 3393 apixaban, 6108 LMWH, and 4585 warfarin patients. After IPTW, all patient characteristics were balanced. Analyses stratified by the VTE risk level, metastatic diagnosis, cancer treatment, chemotherapy, gastrointestinal cancer and index VTE event type showed generally consistent results according to the respective subgroup (most of the p values for interaction >0.10). Two significant interactions were observed between apixaban vs. LMWH and VTE risk level (interaction p = .051) and metastatic diagnosis (interaction p < .001) for recurrent VTE; one significant interactions were observed between apixaban vs. LMWH and cancer treatment for MB (interaction p = .074). Additionally, for warfarin vs. LMWH, two significant interactions were observed between treatment and VTE risk level (interaction p = .005) and metastatic diagnosis (interaction p = .002) for recurrent VTE. CONCLUSIONS Across these high-risk subgroups of VTE cancer patients, treatment outcomes associated with apixaban were generally positive compared to LMWH and warfarin.
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Affiliation(s)
- Alexander T Cohen
- Department of Hematological Medicine, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | | | | | | | | | - Janvi Sah
- STATinMED Research, Ann Arbor, MI, USA
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Salerno DM, Thornberg ME, Lange NW, Hedvat J, Robbins H, Brown RS, Jennings D, Scheffert J. Less bleeding associated with apixaban versus other direct acting oral anticoagulation in solid organ transplant recipients. Clin Transplant 2021; 35:e14396. [PMID: 34165845 DOI: 10.1111/ctr.14396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/19/2021] [Accepted: 06/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate outcomes of bleeding and thrombosis resulting from the use of DOACs in a large cohort of SOT recipients. METHODS This was a single center, retrospective cohort study of adult kidney, heart, lung, and liver transplant recipients transplanted between August 2009 and May 2018. Patients were stratified into two groups: those who received apixaban (apixaban group) or those patients receiving either rivaroxaban or dabigatran (non-apixaban group). The primary endpoint was the cumulative incidence of bleeding while receiving DOAC therapy. The secondary endpoints were incidence of major bleeding and thrombosis at any time while receiving DOAC therapy. RESULTS A total of 106 patients were included; 70 patients received apixaban and 36 patients received non-apixaban anticoagulation. Cumulative incidence of any bleeding was lower in the apixaban group compared to the non-apixaban group at both 90 days (4.9% versus 16.1%) and 180 days (11.4% versus 24.9%, P = 0.034). Cumulative incidence of major bleeding (P = 0.686) and thrombosis (P = 0.515) were similar between groups. DOAC dosing congruent with the package insert(s) was associated with a lower risk of thrombosis. CONCLUSION Apixaban-based anticoagulation was associated with a lower cumulative incidence of any bleeding compared to non-apixaban DOACs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
| | - Megan E Thornberg
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
| | - Nicholas W Lange
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
| | - Jessica Hedvat
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
| | - Hilary Robbins
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, 10032, USA
| | - Robert S Brown
- Department of Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, 10065, USA
| | - Douglas Jennings
- Long Island University Department of Pharmacy Practice, New York, 11201, USA
| | - Jenna Scheffert
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, 10065, USA
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A systematic review of apixaban in prevention and treatment of cancer-associated venous thromboembolism. J Am Pharm Assoc (2003) 2021; 61:e26-e38. [PMID: 34229946 DOI: 10.1016/j.japh.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 06/02/2021] [Accepted: 06/07/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is the second leading cause of death in patients with cancer after disease progression. Thus, timely initiation of anticoagulation after diagnosis of a VTE is required to prevent significant sequelae. Direct oral anticoagulants (DOACs) are newer anticoagulant options for cancer associated VTE (CA-VTE), which historically has been treated with low molecular weight heparin. OBJECTIVE The objective of this study was to review the available literature evaluating the use of apixaban for CA-VTE. METHODS A systematic review (following PRISMA Guidelines) of MEDLINE and EMBASE using the search terms "apixaban" AND "cancer" AND "VTE" was performed from database inception through May 20, 2020. Articles were eligible for inclusion if they were full articles fulfilling the following criteria: (1) randomized controlled trial (RCT) or prospective cohort study, or (2) subgroup analysis of an RCT, and (3) reported clinical outcomes associated with apixaban for prevention or treatment of VTE in patients with cancer. RESULTS A total of 532 articles were identified. After duplicates were removed, 423 articles were screened, and 12 articles were eligible for full-text review. Of the 12 articles, 2 were excluded for having no comparator group, and 2 were excluded for being abstracts only. Ultimately, 8 articles met the inclusion criteria. CONCLUSIONS The available literature supports the safety and efficacy of apixaban for the treatment and prevention of CA-VTE. With the recent publication of the CARAVAGGIO trial, we anticipate that apixaban will be uniformly recommended in national guidelines as a treatment option for CA-VTE.
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Mohamed MFH, ElShafei MN, Ahmed MB, Abdalla LO, Ahmed I, Elzouki AN, Danjuma MIM. The Net Clinical Benefit of Rivaroxaban Compared to Low-Molecular-Weight Heparin in the Treatment of Cancer-Associated Thrombosis: Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2021; 27:1076029620940046. [PMID: 33651658 PMCID: PMC7930650 DOI: 10.1177/1076029620940046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cancer-associated thrombosis (CAT) carries significant morbidity and mortality. Low-molecular-weight heparin (LMWH) remains the standard of care, with recent systematic studies suggesting the efficacy and safety of rivaroxaban in the treatment of CAT. Uncertainty, however, remains regarding rivaroxaban efficacy and safety in real-world settings. We performed a systematic review and meta-analysis of studies comparing rivaroxaban to LMWH. We searched PubMed, MEDLINE, and EMBASE. The primary outcome was the net clinical benefit (NCB), while rates of major bleeding (MB), venous thromboembolism (VTE), clinically relevant nonmajor bleeding (CRNMB), and all-cause mortality events were secondary outcomes. Seventeen studies were included in the final analysis. Rivaroxaban had a better NCB (relative risk [RR] = 0.82; 95% CI = 0.75-0.89, Q = 10.51, I 2 = 0%), less VTE events (RR = 0.73, 95% CI = 0.65-0.82, Q = 6.76, I 2 = 0%), and lower all-cause mortality (RR = 0.72, 95% CI = 0.57-0.91, Q = 32.8, I 2 = 79%) compared to LMWH. Additionally, comparable MB events (RR = 1.07, 95% CI = 0.85-1.33, Q = 16.9, I 2 = 11%). However, CRNMB events were higher in the rivaroxaban group (RR = 2.02, 95% CI = 1.46-2.80, Q = 9.9, I 2 = 19%). Additional analyses demonstrated consistency of results. Our review encompassing data from randomized and real-world data suggested rivaroxaban superiority compared to LMWH in terms of a better NCB, fewer VTE events, lower all-cause mortality, and comparable MB risk while carrying a higher risk of CRNMB. These findings support the use of rivaroxaban in the treatment of CAT. Additionally, it warrants a sizable randomized controlled study testing the superiority of rivaroxaban versus LMWH formulation and ascertaining bleeding outcomes according to cancer type and site.
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Affiliation(s)
- Mouhand F H Mohamed
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | | | | | - Lina O Abdalla
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | - Israa Ahmed
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | - Abdel-Naser Elzouki
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar.,473226Qatar University, College of Medicine, QU Health, Doha, Qatar
| | - Mohammed Ibn-Mas'ud Danjuma
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar.,473226Qatar University, College of Medicine, QU Health, Doha, Qatar
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Song X, Liu Z, Zeng R, Shao J, Liu B, Zheng Y, Liu C, Ye W. Treatment of venous thromboembolism in cancer patients: a systematic review and meta-analysis on the efficacy and safety of different direct oral anticoagulants (DOACs). ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:162. [PMID: 33569464 PMCID: PMC7867886 DOI: 10.21037/atm-20-8156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background To evaluate the efficacy and safety of different direct oral anticoagulants (DOACs) compared with low molecular weight heparins (LMWHs) in the treatment of venous thromboembolism (VTE) in cancer patients. Methods Literature was searched in databases including Cochrane Library, EMBASE (Ovid), and MEDLINE (PubMed). Eligible studies were included, and data were collected independently by 2 reviewers. We conducted a systematic review of the efficacy and safety of DOACs in the treatment of VTE in cancer patients. The odds ratios (ORs) of different DOACs compared with LMWHs for VTE, deep vein thrombosis (DVT), pulmonary embolism (PE) recurrence, major bleeding, and clinically relevant non-major bleeding (CRNMB), were calculated in meta-analyses and subgroup analyses. Results A total of 18 articles were eligible for analyses, including 4 randomized controlled trials (RCTs) and 14 retrospective studies. Both RCTs and retrospective studies confirmed that DOACs decreased the risk of VTE recurrence [RCTs: OR, 0.60; 95% confidence interval (CI), 0.45–0.80; retrospective studies: OR, 0.73; 95% CI, 0.59–0.90] and DVT recurrence (RCTs: OR, 0.54; 95% CI, 0.36–0.80; retrospective studies: OR, 0.20; 95% CI, 0.06–0.63), but not PE recurrence or fatal PE in cancer patients. Subgroup analyses revealed an important role of rivaroxaban in decreasing recurrent VTE. Meanwhile, major bleeding events were not increased in the DOAC group, but the risks of CRNMBs were significantly elevated. Subgroup analyses confirmed the role of rivaroxaban in increasing the risk of major bleeding events and CRNMBs. Conclusions Compared with LMWHs, DOACs (especially rivaroxaban) significantly reduce the risk of VTE and DVT, but not PE recurrence, in patients with cancer. Although DOACs did not increase the major bleeding events in pooled analysis, rivaroxaban showed an elevated risk of this adverse effect in subgroup analysis. In addition, the risk of CRNMB events was increased after the application of DOACs including rivaroxaban.
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Affiliation(s)
- Xiaojun Song
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zhili Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Rong Zeng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Jiang Shao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Changwei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Wei Ye
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
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O'Connell C, Escalante CP, Goldhaber SZ, McBane R, Connors JM, Raskob GE. Treatment of Cancer-Associated Venous Thromboembolism with Low-Molecular-Weight Heparin or Direct Oral Anticoagulants: Patient Selection, Controversies, and Caveats. Oncologist 2020; 26:e8-e16. [PMID: 33275319 DOI: 10.1002/onco.13584] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/22/2020] [Indexed: 12/19/2022] Open
Abstract
The treatment of venous thromboembolism (VTE) in patients with cancer is challenging because these patients have increased risks of both recurrent VTE and major bleeding, along with patient-specific and cancer-related factors that influence the approach to treatment. Historically, anticoagulant therapy with low-molecular-weight heparin (LMWH), given for both initial and long-term treatment, has been the preferred approach recommended by practice guidelines. Most recently, the National Comprehensive Cancer Network (NCCN) guidelines indicate that the direct oral anticoagulants (DOACs) apixaban, edoxaban, or rivaroxaban are preferred for patients without gastric or gastroesophageal lesions. DOACs have been associated with an increased risk of major bleeding in patients with gastrointestinal and possibly genitourinary cancers, and DOACs should either not be used (especially in those with intact intraluminal tumors) or be used with caution in patients with these cancers. Fatal or life-threatening bleeding occurs with similar frequency with DOACs or LMWH, and most major bleeding with DOACs can be managed with transfusion and standard measures. The patient's willingness and ability to comply with LMWH injections, and their treatment preference, should also be considered. Patients with cancer who have VTE should be treated with anticoagulation for a minimum of 6 months. Anticoagulation should be continued indefinitely while cancer is active or under treatment or if there are persistent risk factors for recurrent VTE. This article summarizes the evidence from clinical trials of LMWH and DOACs that underpins the NCCN guideline recommendations, addresses several controversies and caveats regarding anticoagulant treatment, and offers evidence-based, practical suggestions on patient selection for treatment with DOACs. IMPLICATIONS FOR PRACTICE: Several randomized trials support the addition of direct oral anticoagulants (DOACs) to the therapeutic armamentarium for cancer-associated venous thromboembolism (VTE). These agents come with unique risks and patient- and cancer-specific variables that must be evaluated during the course of a patient's cancer care. This narrative review discusses findings from clinical trials of low-molecular-weight heparin and DOACs for the treatment of cancer-associated VTE, evidence that supports the recent National Comprehensive Cancer Network guideline recommendations. A personalized approach to treatment is proposed that addresses patient selection for treatment with DOACs, factors that influence efficacy and safety, controversies and caveats, and suggestions for their resolution in clinical practice.
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Affiliation(s)
- Casey O'Connell
- Jane Anne Nohl Division of Hematology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carmen P Escalante
- Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert McBane
- Division of Vascular Cardiology, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean M Connors
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gary E Raskob
- Hudson College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Cohen A, Keshishian A, Lee T, Wygant G, Rosenblatt L, Hlavacek P, Mardekian J, Wiederkehr D, Sah J, Luo X. Effectiveness and Safety of Apixaban, Low-Molecular-Weight Heparin, and Warfarin among Venous Thromboembolism Patients with Active Cancer: A U.S. Claims Data Analysis. Thromb Haemost 2020; 121:383-395. [PMID: 33171521 PMCID: PMC7895542 DOI: 10.1055/s-0040-1718728] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background
This study primarily evaluates the risk of recurrent venous thromboembolism (VTE) and major bleeding (MB) among patients with VTE and active cancer prescribed apixaban, low-molecular-weight heparin (LMWH), or warfarin, with claims data.
Methods
Four U.S. commercial insurance claims databases were used to identify patients with VTE and active cancer who initiated apixaban, LMWH, or warfarin within 30 days following the first VTE event. Stabilized inverse-probability treatment weighting (IPTW) was used to balance treatment cohorts. Cox proportional hazard models were used to evaluate risk of recurrent VTE and MB.
Results
All eligibility criteria were fulfilled by 3,393 apixaban, 6,108 LMWH, and 4,585 warfarin patients. After IPTW, all patient characteristics were balanced. When the follow-up was censored at 6 months, apixaban patients had a lower risk of recurrent VTE (hazard ratio [HR]: 0.61; 95% confidence interval [CI]: 0.47–0.81) and MB (HR: 0.63; 95% CI: 0.47–0.86) versus LMWH. Apixaban patients had a lower risk of recurrent VTE (HR: 0.68; 95% CI: 0.52–0.90) and similar risk of MB (HR: 0.73; 95% CI: 0.53–1.00) versus warfarin. Warfarin patients had a similar risk of recurrent VTE (HR: 0.91; 95% CI: 0.72–1.15) and MB (HR: 0.87; 95% CI: 0.68–1.12) versus LMWH. The trends were similar for the entire follow-up; however, apixaban patients had a lower risk of MB versus warfarin patients.
Conclusion
Patients with VTE and active cancer who initiated apixaban had a lower risk of recurrent VTE and MB compared with LMWH patients. Apixaban patients also had a lower risk of recurrent VTE compared with warfarin patients.
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Affiliation(s)
- Alexander Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, Westminster Bridge Road, London, United Kingdom
| | | | | | - Gail Wygant
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States
| | - Lisa Rosenblatt
- Bristol-Myers Squibb Company, Lawrenceville, New Jersey, United States
| | | | | | | | - Janvi Sah
- SIMR, LLC, Ann Arbor, Michigan, United States
| | - Xuemei Luo
- Pfizer Inc., Groton, Connecticut, United States
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Hannevik TL, Brekke J, Enden T, Frøen H, Garresori H, Jacobsen EM, Paulsen PQ, Porojnicu AC, Ree AH, Torfoss D, Velle EO, Wik HS, Ghanima W, Sandset PM, Dahm AEA. Thrombosis and bleedings in a cohort of cancer patients treated with apixaban for venous thromboembolism. Thromb Res 2020; 196:238-244. [PMID: 32919178 DOI: 10.1016/j.thromres.2020.08.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/26/2020] [Accepted: 08/27/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The direct oral anti-coagulants (DOAC) edoxaban and rivaroxaban are suggested treatment alternatives for cancer-associated venous thromboembolism (VTE) together with low molecular-weight heparins. New studies indicate that the DOAC apixaban also is an option for cancer-associated VTE. The current study assessed recurrent VTE, arterial thrombosis, bleedings and adverse events in a cohort of apixaban treated cancer patients with VTE. MATERIALS AND METHODS Single-arm, interventional study of apixaban as treatment of cancer-associated VTE. Inclusion criteria were cancer with objectively verified VTE. Patients received apixaban 10 mg bid for seven days, then 5 mg bid for six months. Primary efficacy and safety outcomes were recurrent VTE and bleeding respectively. This trial is registered with ClinicalTrials.gov identifier NCT02581176. RESULTS We recruited 298 cancer patients with VTE. During six months treatment, recurrent VTE or death related to VTE occurred in 12 patients (4.0%, 95% confidence interval (CI) 2.1-6.9%). Major bleeding occurred in 16 patients (5.4%, 95% CI 2.8-7.9), most frequently gastrointestinal bleeding. There were no overrepresentation of major bleedings among patients with gastrointestinal cancer (7/126, 5.5%, 95% CI 2.3-11%). Twenty-six patients experienced one or more clinically relevant non-major bleedings (8.9%, 95% CI 5.5-12%). Twelve patients had arterial thrombosis (4.0%, 95% CI 2.1-6.9%), of which the majority were strokes in patients with pancreatic cancer. Death occurred in 35 patients (12%, 95% CI 8.3-16%). CONCLUSION The frequency of recurrent VTE and major bleedings are in line with other studies on apixaban in cancer-associated VTE. Arterial thrombosis was a frequent serious adverse event.
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Affiliation(s)
- Trine-Lise Hannevik
- Institute of Clinical Medicine, University of Oslo, P.O. BOX. 1171 Blindern, N-0318 Oslo, Norway; Department of Haematology, Akershus University Hospital, P.O. BOX 1000, N-1478 Lørenskog, Norway.
| | - Jorunn Brekke
- Department of Oncology, Haukeland University Hospital, P.O. BOX. 1400, N-5021 Bergen, Norway.
| | - Tone Enden
- Department of Radiology, Oslo University Hospital, P.O. BOX. 4950 Nydalen, N-0424 Oslo, Norway.
| | - Hege Frøen
- Department of Medicine, Baerum Hospital, Vestre Viken Hospital Trust, P.O. BOX. 800, N-3004 Drammen, Norway.
| | - Herish Garresori
- Department of Oncology, Stavanger University Hospital, P.O. BOX. 8100, N-4068 Stavanger, Norway.
| | - Eva Marie Jacobsen
- Department of Haematology, Oslo University Hospital, P.O. BOX. 4950 Nydalen, N-0424 Oslo, Norway.
| | - Petter Quist Paulsen
- Department of Hematology, St. Olav's University Hospital, P.O. BOX. 3250 Torgarden, N-7006 Trondheim, Norway.
| | - Alina Carmen Porojnicu
- Department of Oncology, Drammen Hospital, Vestre Viken Hospital Trust, P.O.BOX. 800, N-3004 Drammen, Norway.
| | - Anne Hansen Ree
- Institute of Clinical Medicine, University of Oslo, P.O. BOX. 1171 Blindern, N-0318 Oslo, Norway; Department of Oncology, Akershus University Hospital, P.O. BOX. 1000, N-1478 Lørenskog, Norway.
| | - Dag Torfoss
- Department of Oncology, Oslo University Hospital, P.O. BOX. 4950 Nydalen, N-0424 Oslo, Norway.
| | - Elin Osvik Velle
- Department of Medicine, Volda Hospital, Møre and Romsdal Hospital Trust Volda, P.O. BOX 1600, N-6026 Ålesund, Norway.
| | - Hilde Skuterud Wik
- Department of Haematology, Oslo University Hospital, P.O. BOX. 4950 Nydalen, N-0424 Oslo, Norway.
| | - Waleed Ghanima
- Institute of Clinical Medicine, University of Oslo, P.O. BOX. 1171 Blindern, N-0318 Oslo, Norway; Clinic of Internal Medicine, Østfold Hospital, P.O. BOX 300, N-1714 Grålum, Norway
| | - Per Morten Sandset
- Institute of Clinical Medicine, University of Oslo, P.O. BOX. 1171 Blindern, N-0318 Oslo, Norway.
| | - Anders Erik Astrup Dahm
- Institute of Clinical Medicine, University of Oslo, P.O. BOX. 1171 Blindern, N-0318 Oslo, Norway; Department of Haematology, Akershus University Hospital, P.O. BOX 1000, N-1478 Lørenskog, Norway.
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Adverse Events and Mortality in Anticoagulated Patients with Different Categories of Pulmonary Embolism. Mayo Clin Proc Innov Qual Outcomes 2020; 4:249-258. [PMID: 32542216 PMCID: PMC7283932 DOI: 10.1016/j.mayocpiqo.2020.02.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Objective To determine whether the pulmonary embolism (PE) categories of massive, submassive, PE with no right ventricle dysfunction (NRVD), and subsegmental only (SSO) adequately predict clinical outcome. Methods Patients treated for acute PE (March 1, 2013, through July 31, 2019) were followed forward prospectively to compare venous thromboembolism (VTE) recurrence, all-cause mortality, major bleeding, and clinically relevant nonmajor bleeding (CRNMB) across 4 PE categories. Results Of 2703 patients with VTE, 1188 (44%) had PE, of which 1021 (85.9%) completed at least 3 months of therapy or had clinical outcomes precluding further treatment (27 with massive, 217 submassive, 557 NRVD, and 220 SSO PE). One patient with massive, 8 with submassive, 23 with NRVD, and 5 with SSO PE had recurrent VTE (3.90, 5.33, 5.36, and 3.66 per 100 person-years, respectively; P=.84). There were 3 deaths in massive, 27 in submassive, 140 in NRVD, and 34 in SSO PE groups (11.59, 17.37, 31.74, and 24.74 per 100 person-years, respectively; P=.02); when adjusted for cancer, the relationship was no longer significant (P=.27). One patient with massive, 5 with submassive, 22 with NRVD, and 5 with SSO PE had major bleeding (3.90, 3.31, 5.24, and 3.75 per 100 person-years, respectively; P=.66). Similar cumulative rates for CRNMB were observed (P=.87). Three-month rates of VTE recurrence, death, major bleeding, and CRNMB did not differ by PE category. Conclusion In the setting of anticoagulation therapy with maximal standardization and evidence-based practice, there is no evidence of a difference between PE categories and outcomes. Trial Registration clinicaltrials.gov Identifier: NCT03504007.
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Key Words
- AHA, American Heart Association
- CRNMB, clinically relevant nonmajor bleeding
- CT, computed tomography
- DVT, deep vein thrombosis
- HR, hazard ratio
- NRVD, no right ventricle dysfunction
- PE, pulmonary embolism
- PESI, Pulmonary Embolism Severity Index
- RV, right ventricle
- SSO, subsegmental only
- VTE, venous thromboembolism
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Lobastov КV, Schastlivtsev IV. The Current Status of Direct Oral Anticoagulants in Cancer-Related Venous Thromboembolism Treatment. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2020. [DOI: 10.20996/1819-6446-2020-04-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This article is a review of epidemiology, pathogenesis and treatment of venous thromboembolism (VTE) in cancer patients. In accordance with actual guidelines, the duration of anticoagulant therapy of cancer-related venous thrombosis should be at least 6 months. The use of vitamin K antagonists (VKA) is associated with an increased risk of VTE recurrence and bleeding, so low molecular weight heparin (LMWH), in particular dalteparin, has been the "gold standard" until recently. Compared to VKA, prolonged use of LMWH can reduce the incidence of VTE recurrence without affecting the risk of bleeding or death. The main disadvantage of LMWH is low compliance, leading to premature discontinuation of treatment or switching to alternative anticoagulants. Direct oral anticoagulants (DOACs) have changed the situation. Compared to VKA, they demonstrated higher efficacy with a similar (or improved for individual DOACs) safety in patients with cancer-related VTE. Recently, the results of studies comparing the use of DOACs with dalteparin in cancer patients have been published: SELECT-D (rivaroxaban), HOKUSAI-VTE Cancer (edoxaban), ADAM VTE (apixaban), CARAVAGGIO (apixaban). Rivaroxaban showed higher efficacy than dalteparin with a similar risk of major bleeding, but an increased risk of clinically relevant non-major (CRNM) bleeding. Edoxaban had the same efficacy as dalteparin but increased risk of major but not CRNM bleeding. Apixaban showed similar efficacy and safety as dalteparin in the CARAVAGGIO study, but did not provide higher safety in the ADAM VTE study. It was noted that gastrointestinal and urogenital bleeding dominated in the structure of hemorrhagic complications of DOACs. The results of published trials are reflected in the current guidelines of the specialized societies. DOACs (particularly, rivaroxaban and edoxaban) are recommended for the VTE treatment in cancer patients.
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Bauersachs R, Khorana AA, Lee AYY, Soff G. Cancer-associated venous thromboembolism: Treatment and prevention with rivaroxaban. Res Pract Thromb Haemost 2020; 4:532-549. [PMID: 32548552 PMCID: PMC7292665 DOI: 10.1002/rth2.12327] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/17/2020] [Accepted: 02/22/2020] [Indexed: 12/17/2022] Open
Abstract
Cancer-associated venous thromboembolism (VTE) is a frequent, potentially life-threatening event that complicates cancer management. Anticoagulants are the cornerstone of therapy for the treatment and prevention of cancer-associated thrombosis (CAT); factor Xa-inhibiting direct oral anticoagulants (DOACs; apixaban, edoxaban, and rivaroxaban), which have long been recommended for the treatment of VTE in patients without cancer, have been investigated in this setting. The first randomized comparisons of DOACs against low-molecular-weight heparin for the treatment of CAT indicated that DOACs are efficacious in this setting, with findings reflected in recent updates to published guidance on CAT treatment. However, the higher risk of bleeding events (particularly in the gastrointestinal tract) with DOACs highlights the need for appropriate patient selection. Further insights will be gained from additional studies that are ongoing or awaiting publication. The efficacy and safety of DOAC thromboprophylaxis in ambulatory patients with cancer at a high risk of VTE have also been assessed in placebo-controlled randomized controlled trials of apixaban and rivaroxaban. Both studies showed efficacy benefits with DOACs, but both studies also showed a nonsignificant increase in major bleeding events while on treatment. This review summarizes the evidence base for rivaroxaban use in CAT, the patient profile potentially most suited to DOAC use, and ongoing controversies under investigation. We also describe ongoing studies from the CALLISTO (Cancer Associated thrombosis-expLoring soLutions for patients through Treatment and Prevention with RivarOxaban) program, which comprises several randomized clinical trials and real-world evidence studies, including investigator-initiated research.
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Affiliation(s)
- Rupert Bauersachs
- Department of Vascular MedicineKlinikum Darmstadt GmbHDarmstadtGermany
- Center of Thrombosis and HemostasisUniversity of MainzMainzGermany
| | - Alok A. Khorana
- Hematology and Medical OncologyTaussig Cancer InstituteCleveland ClinicClevelandOHUSA
| | - Agnes Y. Y. Lee
- British Columbia Cancer AgencyUniversity of British ColumbiaVancouverBCCanada
| | - Gerald Soff
- Memorial Sloan Kettering Cancer CenterNew YorkNYUSA
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