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da Costa IHF, de Pádua CAM, de Miranda Drummond PL, Silveira LP, Malta JS, Dos Santos RMM, Reis AMM. Incidence of thromboembolism and associated factors in multiple myeloma patients treated with immunomodulatory drugs: a retrospective analysis in Belo Horizonte, Brazil. Support Care Cancer 2023; 32:35. [PMID: 38103099 DOI: 10.1007/s00520-023-08251-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE The use of immunomodulators in the treatment of multiple myeloma (MM) patients has been associated with venous thromboembolism (VTE). Due to the increase in mortality of cancer patients, venous thromboembolism is an important concern for newly diagnosed multiple myeloma (NDMM) patients. The aim of this study was to determine the incidence of thromboembolic events and evaluate associated risk factors among Brazilian NDMM patients using immunomodulators. METHODS Real-life retrospective cohort study in two Brazilian institutions with newly diagnosed multiple myeloma (NDMM) patients treated with immunomodulators from January 2009 to December 2019. Data was collected from patients' medical records for the period of 1 year, and Cox regression was performed to identify risk factors on the development of VTE. RESULTS We included 131 patients of which there was a mean age of 61.5 years (SD 11.3), 51.9% female, and predominantly using thalidomide (97.7%) as immunomodulator. We found 9 VTE episodes among our patients, with a 12-month cumulative incidence of 6.97% (95% CI 3.41-12.24). Associated factors after multivariate analysis were recent sepsis, recent traumatic injury, previous VTE, and thromboprophylaxis. CONCLUSION Our real-life retrospective cohort presented a low incidence of VTE among Brazilian NDMM patients treated with immunomodulators.
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Affiliation(s)
- Iwyson Henrique Fernandes da Costa
- Programa de pós-graduação em medicamentos e assistência farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Cristiane Aparecida Menezes de Pádua
- Programa de pós-graduação em medicamentos e assistência farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Faculdade de Farmácia da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Paula Lana de Miranda Drummond
- Programa de pós-graduação em medicamentos e assistência farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Fundação Ezequiel Dias, Belo Horizonte, Minas Gerais, Brazil
| | - Lívia Pena Silveira
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Jéssica Soares Malta
- Faculdade de Farmácia da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Adriano Max Moreira Reis
- Programa de pós-graduação em medicamentos e assistência farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Faculdade de Farmácia da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Baljevic M, Sborov DW. Understanding risks and refining strategies for thromboembolism prophylaxis in hematopoietic stem cell transplant recipients. Bone Marrow Transplant 2023; 58:1177-1178. [PMID: 37626266 DOI: 10.1038/s41409-023-02044-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/05/2023] [Accepted: 07/13/2023] [Indexed: 08/27/2023]
Affiliation(s)
- Muhamed Baljevic
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Douglas W Sborov
- Huntsman Cancer Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
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Li X, Sun X, Fang B, Leng Y, Sun F, Wang Y, Wang Q, Jin J, Yang M, Xu B, Fang Z, Chen L, Chen Z, Yang Q, Zhang K, Ye Y, Geng H, Sun Z, Hao D, Huang H, Wang X, Jing H, Ma L, Pan X, Chen W, Li J. Development and validation of a new risk assessment model for immunomodulatory drug-associated venous thrombosis among Chinese patients with multiple myeloma. Thromb J 2023; 21:105. [PMID: 37794471 PMCID: PMC10552366 DOI: 10.1186/s12959-023-00534-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 08/19/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Individuals with multiple myeloma (MM) receiving immunomodulatory drugs (IMiDs) are at risk of developing venous thromboembolism (VTE), a serious complication. There is no established clinical model for predicting VTE in the Chinese population. We develop a new risk assessment model (RAM) for IMiD-associated VTE in Chinese MM patients. METHODS We retrospectively selected 1334 consecutive MM patients receiving IMiDs from 16 medical centers in China and classified them randomly into the derivation and validation cohorts. A multivariate Cox regression model was used for analysis. RESULTS The overall incidence of IMiD-related VTE in Chinese MM patients was 6.1%. Independent predictive factors of VTE (diabetes, ECOG performance status, erythropoietin-stimulating agent use, dexamethasone use, and VTE history or family history of thrombosis) were identified and merged to develop the RAM. The model identified approximately 30% of the patients in each cohort at high risk for VTE. The hazard ratios (HRs) were 6.08 (P < 0.001) and 6.23 (P < 0.001) for the high-risk subcohort and the low-risk subcohort, respectively, within both the derivation and validation cohorts. The RAM achieved satisfactory discrimination with a C statistic of 0.64. The stratification approach of the IMWG guidelines yielded respective HRs of 1.77 (P = 0.053) and 1.81 (P = 0.063). The stratification approach of the SAVED score resulted in HRs of 3.23 (P = 0.248) and 1.65 (P = 0.622), respectively. The IMWG guideline and the SAVED score-based method yielded C statistics of 0.58 and 0.51, respectively. CONCLUSIONS The new RAM outperformed the IMWG guidelines and the SAVED score and could potentially guide the VTE prophylaxis strategy for Chinese MM patients.
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Affiliation(s)
- Xiaozhe Li
- Department of Haematology, First Affiliated Hospital of Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510000, Guangdong, China
| | - Xiuli Sun
- Department of Haematology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Baijun Fang
- Department of Haematology, Henan Cancer Hospital, Zhengzhou, China
| | - Yun Leng
- Department of Haematology, Beijing Chaoyang Hospital, Beijing, China
| | - Fangfang Sun
- Department of Haematology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yaomei Wang
- Department of Haematology, Henan Cancer Hospital, Zhengzhou, China
| | - Qing Wang
- Department of Haematology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jie Jin
- Department of Haematology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Yang
- Department of Haematology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bing Xu
- Department of Haematology, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhihong Fang
- Department of Haematology, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Lijuan Chen
- Department of Haematology, Jiangsu Provincial People's Hospital, Nanjing, China
| | - Zhi Chen
- Department of Haematology, Jiangsu Provincial People's Hospital, Nanjing, China
| | - Qimei Yang
- Department of Haematology, Shantou Central Hospital, Shantou, China
| | - Kejie Zhang
- Department of Haematology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Yinhai Ye
- Department of Haematology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Hui Geng
- Department of Haematology, Affiliated Hospital of Qinghai University, Xining, China
| | - Zhiqiang Sun
- Department of Haematology, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Dan Hao
- Department of Haematology, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Hongming Huang
- Department of Haematology, Nantong University Hospital, Nantong, China
| | - Xiaotao Wang
- Department of Haematology, Second Affiliated Hospital of Guilin Medical College, Guilin, China
| | - Hongmei Jing
- Department of Haematology, Peking University Third Hospital, Beijing, China
| | - Lan Ma
- Department of Haematology, Peking University Third Hospital, Beijing, China
| | - Xueyi Pan
- Department of Haematology, First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Wenming Chen
- Department of Haematology, Beijing Chaoyang Hospital, Beijing, China.
| | - Juan Li
- Department of Haematology, First Affiliated Hospital of Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510000, Guangdong, China.
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da Costa IHF, de Pádua CAM, de Miranda Drummond PL, Silveira LP, Malta JS, Dos Santos RMM, Reis AMM. Comparison of three risk assessment models for thromboembolism in multiple myeloma patients receiving immunomodulators: a Brazilian historical cohort. J Thromb Thrombolysis 2023:10.1007/s11239-023-02817-7. [PMID: 37133703 DOI: 10.1007/s11239-023-02817-7] [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: 04/11/2023] [Indexed: 05/04/2023]
Abstract
Venous thromboembolism (VTE) is among the complications of Multiple Myeloma (MM) and may occur in up to 10% of this patient population. However, medications used in MM therapy such as immunomodulators (IMID) may raise these rates. Thus, risk prediction models have been developed to quantify the risk of VTE in MM patients. The aim of this study is to compare the performance of three risk assessment models for VTE in newly diagnosed MM (NDMM) patients using immunomodulatory agents. A historical cohort study during a 10-year period in a Brazilian metropolis with NDMM treated with IMID. Data were collected from patient's medical charts for the period of one year to calculate the scores using IMPEDE VTE, SAVED, and International Myeloma Working Group (IMWG) guidelines. The area under the curve (AUC) of the Receiver Operating Characteristic curve analysis was calculated to assess the discriminative power of three risk assessment models. We included 131 patients (9 in the VTE group versus 122 in the non VTE group). According to IMPEDE, 19.1, 62.6, and 18.3% of patients were considered low, intermediate, and high risk, respectively. SAVED classified 32.1% as high risk and 64.9% had ≥2 risk factors based on IMWG guidelines. The AUC of the IMPEDE VTE score was 0.80 (95% CI 0.66-0.95, p = 0.002), of the SAVED score was 0.69 (95% CI 0.49-0.89, p = 0.057), and of the IMWG risk score was 0.68 (95% CI 0.48-0.88, p = 0.075). IMPEDE VTE was the most accurate in predicting the development of VTE in Brazilian patients on IMID therapy. The SAVED score and the IMWG guidelines did not show discriminative ability in predicting VTE based on the population involved in this study.
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Affiliation(s)
- Iwyson Henrique Fernandes da Costa
- Programa de Pós-Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
| | - Cristiane Aparecida Menezes de Pádua
- Programa de Pós-Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Paula Lana de Miranda Drummond
- Programa de Pós-Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Fundação Ezequiel Dias, Belo Horizonte, Minas Gerais, Brazil
| | - Lívia Pena Silveira
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Jéssica Soares Malta
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | | | - Adriano Max Moreira Reis
- Programa de Pós-Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
- Faculdade de Farmácia, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
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Falanga A, Ay C, Di Nisio M, Gerotziafas G, Jara-Palomares L, Langer F, Lecumberri R, Mandala M, Maraveyas A, Pabinger I, Sinn M, Syrigos K, Young A, Jordan K. Venous thromboembolism in cancer patients: ESMO Clinical Practice Guideline. Ann Oncol 2023; 34:452-467. [PMID: 36638869 DOI: 10.1016/j.annonc.2022.12.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 12/09/2022] [Accepted: 12/11/2022] [Indexed: 01/11/2023] Open
Affiliation(s)
- A Falanga
- Division of Immunohaematology and Transfusion Medicine, Haemostasis and Thrombosis Center, Department of Oncology and Haematology, Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, Department of Medicine and Surgery, Monza, Italy
| | - C Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - M Di Nisio
- Department of Medicine and Ageing Sciences, G. d'Annunzio University, Chieti, Italy
| | - G Gerotziafas
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics", Group "Cancer-Hemostasis-Angiogenesis", Institut Universitaire de Cancérologie, Consultation Thrombosis in Oncology (COTHON), Tenon-Saint Antoine Hospital, AP-HP, Paris, France
| | - L Jara-Palomares
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - F Langer
- Centre for Oncology, University Cancer Centre Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Centre Eppendorf, Hamburg, Germany
| | - R Lecumberri
- Servicio de Hematología, Clínica Universidad de Navarra, Pamplona (Navarra); CIBER-CV, Instituto de Salud Carlos III, Madrid, Spain
| | - M Mandala
- University of Perugia, Unit of Medical Oncology, Santa Maria Misericordia Hospital, Perugia, Italy
| | - A Maraveyas
- Queen's Centre for Oncology and Haematology, Faculty of Health Sciences, Hull York Medical School and Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - I Pabinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - M Sinn
- Centre for Oncology, University Cancer Centre Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Centre Eppendorf, Hamburg, Germany
| | - K Syrigos
- Oncology Unit, 3rd Department of Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A Young
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - K Jordan
- Department of Hematology, Oncology and Palliative Medicine, Ernst von Bergmann Hospital, Potsdam, Germany; Department of Rheumatology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
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Enhanced thrombin generation detected with ST-Genesia analyzer in patients with newly diagnosed multiple myeloma. J Thromb Thrombolysis 2023; 55:464-473. [PMID: 36630029 DOI: 10.1007/s11239-022-02765-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2022] [Indexed: 01/12/2023]
Abstract
The issue of how to identify newly diagnosed multiple myeloma (NDMM) patients requiring thromboprophylaxis remains unsolved. Several changes in thrombin generation (TG)-derived parameters have been described in multiple myeloma (MM) patients recently. Assessment of prothrombotic risk with a fully automated TG analyzer could reduce interlaboratory variability. Our objective was to determine whether ST-Genesia® could reveal a hypercoagulable state in NDMM compared to healthy controls. We conducted a multicenter observational study of NDMM requiring initial treatment to compare TG parameters obtained with ST-Genesia® analyzer and ST-ThromboScreen® reagent with a control group. Clinical data were obtained from medical records and blood samples were collected before initial anti-myeloma therapy. A thrombophilia panel was performed in all patients. Compared to age- and sex-matched controls (n = 83), NDMM patients (n = 83) had significantly higher peak height, higher velocity index, shorter time-to-peak and lower percentage of endogenous thrombin potential (ETP) inhibition after adding thrombomodulin (TM) (ETP%inh). NDMM on prophylactic low molecular weight heparin (LMWH) showed reduced both peak height and velocity index compared to NDMM who had not yet started VTE prophylaxis, similar to that of controls. Moreover, partial correction of ETP%inh was observed in MM patients on LMWH. The presence of a thrombophilia did not modify the TG phenotype. Untreated NDMM patients showed an enhanced TG, regardless of their thrombophilia status. They generate a higher peak of thrombin, take less time to produce it, and exhibit resistance to TM inhibition. Our findings suggest that standard prophylactic dose of LMWH may reduce TG at levels of healthy controls.
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Adrianzen-Herrera D, Lutsey PL, Giorgio K, Walker RF, Zakai NA. Bleeding risk in patients with multiple myeloma treated for venous thromboembolism: a MarketScan analysis. Res Pract Thromb Haemost 2023; 7:100024. [PMID: 36873562 PMCID: PMC9982328 DOI: 10.1016/j.rpth.2022.100024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/15/2022] [Accepted: 11/22/2022] [Indexed: 01/15/2023] Open
Abstract
Background Multiple myeloma (MM) is associated with high risk of venous thromboembolism (VTE). Thromboprophylaxis is thoroughly studied in MM. Contrarily, studies assessing the risk of bleeding in people with MM on anticoagulation are lacking. Objectives To determine the rate of serious bleeding in patients with MM receiving anticoagulation for VTE and the clinical factors associated with bleeding risk. Methods Using the MarketScan commercial database, we identified 1298 people with MM treated with anticoagulation for incident VTE events between 2011 and 2019. Hospitalized bleeding was identified using the Cunningham algorithm. Rates of bleeding were calculated and Cox regression identified risk factors for bleeding. Results Bleeding occurred in 51 (3.9%) cases during median follow-up of 1.13 years. Rate of bleeding among patients with MM on anticoagulation was 24.0 per 1000 person-years. In adjusted regression, factors associated with increased bleeding included age (HR, 1.31 per 10-year increase; 95% CI, 1.03-1.65), Charlson comorbidity index (HR, 1.29 per SD increase; 95% CI, 1.02-1.58), use of antiplatelet agents (HR, 2.4; 95% CI, 1.03-5.68), diabetes (HR, 1.85; 95% CI, 1.06-3.26), and renal disease (HR, 1.80; 95% CI, 1.05-3.16). Cumulative incidence of bleeding was 4.7%, 3.2%, and 3.4% for warfarin, low molecular weight heparin, and direct oral anticoagulants, respectively. Conclusion In this real-world analysis, the rate of bleeding in people with MM on anticoagulation was comparable to those in other subsets of cancer-related VTE. Bleeding rate was lower with low molecular weight heparin and direct oral anticoagulants than warfarin. Higher comorbidity index, diabetes, antiplatelet agent use, and renal disease were risk factors for serious bleeding.
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Affiliation(s)
- Diego Adrianzen-Herrera
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, USA
| | - Katherine Giorgio
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, USA
| | - Robert F Walker
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, USA
| | - Neil A Zakai
- Department of Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA.,Department of Pathology & Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
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Fotiou D, Dimopoulos MA, Kastritis E. Approach to Contemporary Risk Assessment, Prevention and Management of Thrombotic Complications in Multiple Myeloma. Cancers (Basel) 2022; 14:cancers14246216. [PMID: 36551701 PMCID: PMC9777181 DOI: 10.3390/cancers14246216] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Multiple myeloma (MM) is associated with an increased risk of thrombotic complications, which remains substantial despite the implementation of thromboprophylaxis. The procoagulant state that characterizes the disease is multifactorial, and a greater understanding of the underlying pathophysiology is required to inform appropriate thrombosis prevention. Currently, there is a shift towards using direct oral anticoagulants (DOACs) in this setting; head-to-head comparisons in the context of controlled clinical trials between class agents are still missing. MM-specific VTE risk assessment scores have been developed to optimize management and minimize the associated mortality/morbidity. Their clinical utility remains to be evaluated. The value of adding biomarkers to clinical scores to optimize their performance and increase their discriminatory power is also under assessment.
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Baljevic M, Sborov DW, Lim MY, Hillengass J, Martin T, Castillo JJ, Streiff MB, Kumar SK, Callander NS. Optimizing Thromboembolism Prophylaxis for the Contemporary Age of Multiple Myeloma. J Natl Compr Canc Netw 2022; 20:91-95. [PMID: 34991076 DOI: 10.6004/jnccn.2021.7112] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/08/2021] [Indexed: 11/17/2022]
Abstract
Venous thromboembolism (VTE) is a major complication in all patients with cancer. Compared with the general population, patients with multiple myeloma (MM) have a 9-fold increase in VTE risk, likely because of their malignancy, its treatments, and other additional patient-related factors. In MM, thromboembolism events tend to occur within 6 months of treatment initiation, regardless of treatment regimen; however, the use of immunomodulatory agents such as thalidomide or lenalidomide, especially in combination with dexamethasone or multiagent chemotherapy, is known to create a significant risk for VTE. Currently, official recommendations for VTE prophylaxis in MM outlined in various national guidelines or multidisciplinary society panels are based on expert opinion, because data from randomized controlled trials are scarce. Large studies which have mainly focused on the efficacy of thromboprophylaxis in patients with cancer at higher risk for VTE either had a very low representation of patients with MM, or excluded them all together, limiting our ability to draw evidence-based conclusions on how to effectively protect MM population from VTE. In this brief perspective, we highlight some of the greatest challenges that have hampered the field concerning the availability of high-quality clinical trial data for the formulation of best VTE prophylaxis strategies in patients with newly diagnosed MM, as well as the rationale for the latest updates in the NCCN Guidelines on this topic.
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Affiliation(s)
- Muhamed Baljevic
- 1Division of Hematology/Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Douglas W Sborov
- 2Division of Hematology and Hematologic Malignancies, University of Utah, Huntsman Cancer, Salt Lake City, Utah
| | - Ming Y Lim
- 2Division of Hematology and Hematologic Malignancies, University of Utah, Huntsman Cancer, Salt Lake City, Utah
| | - Jens Hillengass
- 3Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Thomas Martin
- 4UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Jorge J Castillo
- 5Dana-Farber/Brigham and Women's Cancer Center, Boston, Massachusetts
| | - Michael B Streiff
- 6Division of Hematology, Department of Medicine and Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shaji K Kumar
- 7Mayo Clinic Cancer Center, Rochester, Minnesota; and
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Santoro M, Romano A, Mancuso S, Siragusa S, DI Raimondo F, Martinelli G, Cerchione C. Prevention of venous thromboembolic events occurring in myeloma patients treated with second-generation novel agents. Panminerva Med 2020; 63:1-6. [PMID: 32955183 DOI: 10.23736/s0031-0808.20.04133-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Thrombosis and neoplasms are strictly linked, and the diagnosis of a malignancy is a relevant risk factor for venous thromboembolism (VTE). In particular, between gammopathies, the VTE risk is known to be increased in both monoclonal gammopathy of uncertain significance and in multiple myeloma, with a 3- and 9-fold increase respectively, when compared to the general population. The risk appears to be further increased in patients treated with immunomodulating drugs, such as thalidomide, especially when in combination with dexamethasone or conventional cytotoxic chemotherapies, and lenalidomide. In 2008 the International Myeloma Working Group put out thrombosis prophylaxis recommendations for myeloma patients treated with IMiDs. Current recommendations for thromboprophylaxis suggest the use of low-dose acetylsalicylic acid in patients with low risk for thrombosis and therapeutic dose anticoagulation with LMWH or warfarin for high-risk patients. However, these recommendations have been frequently not followed in the clinical practice, due to various reasons that involve the patients' will, the level of evidence of the recommendations and some selection biases in the studies that were taken as basis for writing down the indications. The new direct oral anticoagulants have been preliminarily evaluated for the prophylaxis of thrombotic events in IMiDs-treated myelomas, being promising, even if more expensive. Currently, the most reliable tool for a correct thrombotic risk stratification appears to be the complete clinical and anamnestic evaluation of the myeloma patients added to a strong physician awareness of the evidences that the literature contains until now.
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Affiliation(s)
- Marco Santoro
- Department of Surgery, Stomatology and Experimental Oncology, University of Palermo, Palermo, Italy -
| | - Alessandra Romano
- Department of Surgery and Medical Surgical Specialty, University of Catania, Catania, Italy
| | - Salvatrice Mancuso
- Unit of Hematology, G. D'Alessandro Department of Health Promotion, Maternal-Child, Internal Medicine and Specialist Excellence, University of Palermo, Palermo, Italy
| | - Sergio Siragusa
- Unit of Hematology, G. D'Alessandro Department of Health Promotion, Maternal-Child, Internal Medicine and Specialist Excellence, University of Palermo, Palermo, Italy
| | - Francesco DI Raimondo
- Department of Surgery and Medical Surgical Specialty, University of Catania, Catania, Italy.,Unit of Hematology, A.O.U. Policlinico Rodolico-San Marco, Catania, Italy
| | - Giovanni Martinelli
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Claudio Cerchione
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
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Assessing the risk of venous thromboembolism in multiple myeloma. Thromb Res 2020; 191 Suppl 1:S74-S78. [PMID: 32736783 DOI: 10.1016/s0049-3848(20)30401-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/23/2019] [Accepted: 01/03/2020] [Indexed: 12/20/2022]
Abstract
Patients with multiple myeloma (MM) have an increased risk of venous thromboembolism (VTE) compared to the general population. This risk is highest during the first year of diagnosis and subsequently decreases over time. Development of VTE in patients with MM is associated with inferior outcomes, with patients with VTE and MM having an increased risk of death compared to those with MM without VTE. Primary thromboprophylaxis has the potential to decrease risk of VTEksanfilippo@wustl.edu (K.M. Sanfilippo) in MM and improve outcomes. Current studies assessing thromboprophylaxis in MM excluded patients at high risk of VTE. A meta-analysis of trials of primary thromboprophylaxis in ambulatory cancer patients at high risk of VTE identified by use of a risk-prediction score found a reduction in risk of VTE with prophylaxis with no significant increase in risk of major bleeding. However, these trials contained relatively few patients with MM. Three clinical risk prediction scores are available to assess risk of VTE in MM: 1) the International Myeloma Working Group (IMWG)/National Comprehensive Cancer Network (NCCN); 2) the SAVED score; and 3) the IMPEDE VTE score. The latter two have recently been shown to outperform the IMWG/ NCCN score for predicting VTE in MM. Biomarkers have the potential to improve prediction of VTE in patients with MM. Future research should focus on the addition of biomarkers to available risk scores in MM to improve discrimination in this high-risk patient population.
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Multiple Myeloma and Thrombosis: Prophylaxis and Risk Prediction Tools. Cancers (Basel) 2020; 12:cancers12010191. [PMID: 31940972 PMCID: PMC7016665 DOI: 10.3390/cancers12010191] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 12/19/2022] Open
Abstract
Thromboembolism in multiple myeloma (MM) patients remains a common complication that renders the optimization of our thromboprophylaxis practice necessary. This review aims to make clear the need for the development of more accurate risk assessment tools and means of thrombosis prevention. Current clinical practice is guided by available guidelines published by the IMWG in 2014, but the extent to which these are implemented is unclear. Recently, several groups developed clinical scores for thrombosis risk in MM in an attempt to improve risk stratification, but these have not been validated or used in clinical practice so far. Research in this field is increasingly focusing on understanding the unique coagulation profile of the MM patient, and data on potential biomarkers that accurately reflect hypercoagulability is emerging. Finally, promising evidence on the effectiveness of direct oral anticoagulants (DOACs) in the context of thrombosis prevention in MM patients is increasingly becoming available. The critical appraisal of the above research areas will establish the necessity of combining disease-specific clinical risk factors with coagulation biomarkers to allow more effective risk stratification that will eventually lead to the reduction of this significant complication. Results from ongoing clinical trials on the role of DOACs are much anticipated.
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Fotiou D, Gavriatopoulou M, Ntanasis-Stathopoulos I, Migkou M, Dimopoulos MA, Terpos E. Updates on thrombotic events associated with multiple myeloma. Expert Rev Hematol 2019; 12:355-365. [DOI: 10.1080/17474086.2019.1604214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Baker HA, Brown AR, Mahnken JD, Shireman TI, Webb CE, Lipe BC. Application of risk factors for venous thromboembolism in patients with multiple myeloma starting chemotherapy, a real-world evaluation. Cancer Med 2019; 8:455-462. [PMID: 30585435 PMCID: PMC6346245 DOI: 10.1002/cam4.1927] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 11/23/2018] [Accepted: 11/26/2018] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Within the first year of diagnosis, up to 1 in 3 multiple myeloma (MM) patients will experience a venous thromboembolism (VTE). The International Myeloma Working Group (IMWG) has thromboprophylaxis guidelines that stratify patients into low or high risk for thrombosis and subsequently recommend thromboprophylaxis, but it is unknown if these recommendations are being followed or if they are effective. The purpose of this study was to assess efficacy of the IMWG guidelines and investigate other potential VTE risk factors. METHODS Study participants were treated at the University of Kansas Medical Center between 2007 and 2013, and charts were reviewed to extract data. Cases (MM and VTE) were matched to controls (MM and no VTE) at approximately 1:3 ratio based on gender, age (±5 years), and time of MM diagnosis (±5 years). RESULTS A total of 80 cases and 211 controls were matched. Most patients (82%) were considered high risk for experiencing a VTE at the time of their MM diagnosis and 18% were considered low risk. Neither risk category (P = 0.16) nor thromboprophylaxis at baseline (P = 0.37) predicted VTE, though cases were more likely than controls to have an increased risk of thrombosis at the time of clot compared to their baseline risk (P = 0.09). CONCLUSION Our results suggest that IMWG guidelines are not being consistently followed and therefore could not be validated. Additional risk factors were not identified, but risk for VTE may change over time suggesting patients may require ongoing assessment of VTE risk and thromboprophylaxis throughout the disease course.
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Affiliation(s)
| | | | | | | | | | - Brea C. Lipe
- University of Rochester Medical CenterRochesterNew York
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