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Gasperoni L, Giunta EF, Montanari D, Masini C, De Giorgi U. New-generation androgen receptor signaling inhibitors (ARSIs) in metastatic hormone-sensitive prostate cancer (mHSPC): pharmacokinetics, drug-drug interactions (DDIs), and clinical impact. Expert Opin Drug Metab Toxicol 2024:1-12. [PMID: 38778707 DOI: 10.1080/17425255.2024.2353749] [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: 03/10/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION The therapeutic scenario of metastatic hormone-sensitive prostate cancer (mHSPC) has dramatically changed in recent years, with the approval of new-generation Androgen Receptor Signaling Inhibitors (ARSIs), in combination with the androgen deprivation therapy (ADT), which was the previous standard of care. Despite showing a similar clinical efficacy, ARSIs, all of which are administered orally, are different in terms of pharmacokinetic and drug-drug interactions (DDIs). AREAS COVERED This review covers the main pharmacokinetic characteristics of ARSIs that have been approved for the first-line therapy of mHSPC patients, underlying the differences among these molecules and focusing on the known or possible interactions with other drugs. Full-text articles and abstracts were searched in PubMed. EXPERT OPINION Since prostate cancer occurs mainly in older age, comorbidities and the consequent polypharmacy increase the DDI risk in mHSPC patients who are candidates for ARSI. Waiting for new therapeutic options, in the absence of direct comparisons, pharmacokinetic knowledge is essential to guide clinicians in prescribing ARSI in this setting.
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Affiliation(s)
- Lorenzo Gasperoni
- Oncological Pharmacy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) 'Dino Amadori', Meldola (FC), Italy
| | - Emilio Francesco Giunta
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) 'Dino Amadori', Meldola (FC), Italy
| | - Daniela Montanari
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) 'Dino Amadori', Meldola (FC), Italy
| | - Carla Masini
- Oncological Pharmacy Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) 'Dino Amadori', Meldola (FC), Italy
| | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) 'Dino Amadori', Meldola (FC), Italy
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2
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Mokart D, Serre E, Bruneel F, Kouatchet A, Lemiale V, Chow-Chine L, Faucher M, Sannini A, Valade S, Bisbal M, Gonzalez F, Servan L, Darmon M, Azoulay E. Acute pulmonary embolism in cancer patients admitted to intensive care unit: Impact of anticoagulant treatment on 90-day mortality and risk factors, results of a multicentre retrospective study. Thromb Res 2024; 237:129-137. [PMID: 38583310 DOI: 10.1016/j.thromres.2024.03.027] [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: 02/16/2024] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a life-threatening situation in cancer patients. In this situation, anticoagulant therapy is complex to administer due to the risk of bleeding. Only few studies have been conducted when these patients are admitted to the intensive care unit (ICU). The aim of this study was to assess the association between anticoagulation strategies as well as other factors with 90-day mortality in patients with cancer and PE admitted to ICU. Major bleeding was also evaluated according to the type of anticoagulation. METHODS Retrospective study carried out in 4 ICUs in France over a 12-year period (2009-2021). All patients with cancer and PE were included. An overlap propensity score weighting analysis was performed in the subgroup of patients treated with either unfractionated heparins (UFH) alone or low-molecular-weight heparins (LMWH) alone on 90-day mortality and major bleeding. RESULTS A total of 218 consecutive cancer patients admitted to ICU and presenting PE were included. The 90-day mortality rate was 42 % for the global cohort. After propensity score analysis in the subgroup of patients treated with either "UFH alone" (n = 80) or "LMWH alone" (n = 71), the 90-day mortality was similar in patients treated with UFH alone (42.6 %) vs LMWH alone (39.9 %): OR = 1.124, CI 95 % [0.571-2.214], p = 0.750. There was a significant increased toward major bleeding rates in the "UFH alone" group (25.5 %) as compared to "LMWH alone" group (11.5 %), p = 0.04. CONCLUSION In 218 patients admitted to ICU and presenting PE, the 90-day mortality rate was 42 %. Treatment with UFH alone was associated with a mortality comparable to treatment with LMWH alone but it appeared to be more prone to major bleeding.
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Affiliation(s)
- Djamel Mokart
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France.
| | - Edouard Serre
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Fabrice Bruneel
- Medical Intensive Care Unit, University Hospital of Angers, Angers, France
| | - Achille Kouatchet
- Medical-Surgical Intensive Care Unit, Versailles Center, Mignot Hospital, Le Chesnay, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Laurent Chow-Chine
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Marion Faucher
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Antoine Sannini
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Sandrine Valade
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Magali Bisbal
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Frederic Gonzalez
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Luca Servan
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
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3
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Mahé I, Mayeur D, Couturaud F, Scotté F, Benhamou Y, Benmaziane A, Bertoletti L, Laporte S, Girard P, Mismetti P, Sanchez O. [Translation into French and republication of: "Anticoagulant treatment of cancer-associated thromboembolism"]. Rev Med Interne 2024; 45:210-225. [PMID: 38677976 DOI: 10.1016/j.revmed.2024.04.004] [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: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 04/29/2024]
Abstract
Venous thromboembolism (VTE) is a frequent and potentially fatal complication in patients with cancer. During the initial period after the thromboembolic event, a patient receiving anticoagulant treatment is exposed both to a risk of VTE recurrence and also to an elevated bleeding risk conferred by the treatment. For this reason, the choice of anticoagulant is critical. The choice should take into account patient-related factors (such as functional status, age, body mass index, platelet count and renal function), VTE-related factors (such as severity or site), cancer-related factors (such as activity and progression) and treatment related factors (such as drug-drug interactions), which all potentially influence bleeding risk, and patient preference. These should be evaluated carefully for each patient during a multidisciplinary team meeting. For most patients, apixaban or a low molecular-weight heparin is the most appropriate initial choice for anticoagulant treatment. Such treatment should be offered to all patients with active cancer for at least 6months. The patient and treatment should be re-evaluated regularly, and anticoagulant treatment changed when necessary. Continued anticoagulant treatment beyond 6months is justified if the cancer remains active or if the patient experienced recurrence of VTE in the first 6months. In other cases, the interest of continued anticoagulant treatment may be considered on an individual patient basis in collaboration with oncologists.
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Affiliation(s)
- I Mahé
- Service de médecine interne, hôpital Louis-Mourier, AP-HP, 92700 Colombes, France; Inserm UMR S1140, Innovations thérapeutiques en hémostase, université Paris Cité, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - D Mayeur
- Département d'oncologie médicale, centre Georges-François-Leclerc, Dijon, France
| | - F Couturaud
- F-CRIN INNOVTE network, Saint-Étienne, France; Département de médecine interne, médecine vasculaire et pneumologie, Inserm U1304-Getbo, université de Brest, CHU de Brest, Brest, France
| | - F Scotté
- Département interdisciplinaire d'organisation des parcours patients (DIOPP), institut Gustave-Roussy, Villejuif, France
| | - Y Benhamou
- F-CRIN INNOVTE network, Saint-Étienne, France; UniRouen, U1096, service de médecine interne, CHU Charles-Nicolle, Normandie université, Rouen, France
| | - A Benmaziane
- Département d'oncologie et de soins de supports, hôpital Foch, Suresnes, France
| | - L Bertoletti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, Inserm, UMR1059, équipe dysfonction vasculaire et hémostase, université Jean-Monnet, Inserm CIC-1408, CHU de Saint-Étienne, Saint-Étienne, France
| | - S Laporte
- F-CRIN INNOVTE network, Saint-Étienne, France; Sainbiose Inserm U1059, unité de Recherche clinique, innovation et pharmacologie, hôpital Nord, CHU de Saint-Étienne, université Jean-Monnet, Saint-Étienne, France
| | - P Girard
- F-CRIN INNOVTE network, Saint-Étienne, France; Institut du thorax Curie-Montsouris, Institut mutualiste Montsouris, Paris, France
| | - P Mismetti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France
| | - O Sanchez
- Inserm UMR S1140, Innovations thérapeutiques en hémostase, université Paris Cité, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France
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4
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Wojtukiewicz MZ, Tesarova P, Karetová D, Windyga J. In Search of the Perfect Thrombosis and Bleeding-Associated Cancer Scale. Semin Thromb Hemost 2024; 50:443-454. [PMID: 37852295 DOI: 10.1055/s-0043-1776003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Thrombosis and bleeding are commonly observed in cancer patients, and their management is crucial for positive patient outcomes. A comprehensive, prophylactic, and therapeutic management of venous thrombosis should focus on identifying the patients who would benefit most from treatment to reduce mortality and minimize the risk of thrombosis recurrence without significantly increasing the risk of bleeding. Existing cancer scales provide valuable information for assessing the overall burden of cancer and guiding treatment decisions, but their ability to predict thrombotic and bleeding events remains limited. With increasing knowledge of the pathophysiology of cancer and the availability of advanced anticancer therapies, new risk factors for cancer-associated thrombosis and bleeding are being identified. In this report, we analyze the current literature and identify new risk factors for venous thrombosis and bleeding which are not included in routinely used risk scores. While some existing cancer scales partially capture the risk of thrombosis and bleeding, there is a need for more specific and accurate scales tailored to these complications. The development of such scales could improve risk stratification, aid in treatment selection, and enhance patient care. Therefore, further research and development of novel cancer scales focused on thrombosis and bleeding are warranted to optimize patient management and outcomes.
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Affiliation(s)
- Marek Z Wojtukiewicz
- Department of Oncology, Medical University of Bialystok, Bialystok, Poland
- Comprehensive Cancer Center, Bialystok, Poland
| | - Petra Tesarova
- Department of Oncology, Institute of Radiation Oncology, First Faculty of Medicine, Charles University and Bulovka University Hospital, Prague, Czech Republic
| | - Debora Karetová
- Second Department of Medicine-Department of Cardiovascular Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine in Warsaw, Warsaw, Poland
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5
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Olie RH, Winckers K, Rocca B, Ten Cate H. Oral Anticoagulants Beyond Warfarin. Annu Rev Pharmacol Toxicol 2024; 64:551-575. [PMID: 37758192 DOI: 10.1146/annurev-pharmtox-032823-122811] [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] [Indexed: 10/03/2023]
Abstract
Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists, mostly warfarin, for the main indications for oral anticoagulation, prevention and treatment of venous thromboembolism, and prevention of embolic stroke in atrial fibrillation. While DOACs offer practical, fixed-dose anticoagulation in many patients, specific restrictions or contraindications may apply. DOACs are not sufficiently effective in high-thrombotic risk conditions such as antiphospholipid syndrome and mechanical heart valves. Patients with cancer-associated thrombosis may benefit from DOACs, but the bleeding risk, particularly in those with gastrointestinal or urogenital tumors, must be carefully weighed. In patients with frailty, excess body weight, and/or moderate-to-severe chronic kidney disease, DOACs must be cautiously administered and may require laboratory monitoring. Reversal agents have been developed and approved for life-threatening bleeding. In addition, the clinical testing of potentially safer anticoagulants such as factor XI(a) inhibitors is important to further optimize anticoagulant therapy in an increasingly elderly and frail population worldwide.
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Affiliation(s)
- Renske H Olie
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Kristien Winckers
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Hugo Ten Cate
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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6
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Mahé I, Mayeur D, Couturaud F, Scotté F, Benhamou Y, Benmaziane A, Bertoletti L, Laporte S, Girard P, Mismetti P, Sanchez O. Anticoagulant treatment of cancer-associated thromboembolism. Arch Cardiovasc Dis 2024; 117:29-44. [PMID: 38092578 DOI: 10.1016/j.acvd.2023.11.010] [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] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Venous thromboembolism (VTE) is a frequent and potentially fatal complication in patients with cancer. During the initial period after the thromboembolic event, a patient receiving anticoagulant treatment is exposed both to a risk of VTE recurrence and also to an elevated bleeding risk conferred by the treatment. For this reason, the choice of anticoagulant is critical. The choice should take into account patient-related factors (such as functional status, age, body mass index, platelet count and renal function), VTE-related factors (such as severity or site), cancer-related factors (such as activity and progression) and treatment-related factors (such as drug-drug interactions), which all potentially influence bleeding risk, and patient preference. These should be evaluated carefully for each patient during a multidisciplinary team meeting. For most patients, apixaban or a low molecular-weight heparin is the most appropriate initial choice for anticoagulant treatment. Such treatment should be offered to all patients with active cancer for at least six months. The patient and treatment should be re-evaluated regularly and anticoagulant treatment changed when necessary. Continued anticoagulant treatment beyond six months is justified if the cancer remains active or if the patient experienced recurrence of VTE in the first six months. In other cases, the interest of continued anticoagulant treatment may be considered on an individual patient basis in collaboration with oncologists.
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Affiliation(s)
- Isabelle Mahé
- Service de Médecine Interne, Hôpital Louis-Mourier, AP-HP, Colombes, France; Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France.
| | - Didier Mayeur
- Département d'Oncologie Médicale, Centre Georges-François-Leclerc, Dijon, France
| | - Francis Couturaud
- Département de Médecine Interne, Médecine Vasculaire et Pneumologie, CHU de Brest, Inserm U1304 -GETBO, université de Brest, Brest, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Florian Scotté
- Département Interdisciplinaire d'Organisation des Parcours Patients (DIOPP), Institut Gustave-Roussy, Villejuif, France
| | - Ygal Benhamou
- UNI Rouen U1096, service de médecine interne, Normandie université, CHU Charles-Nicolle, Rouen, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Asmahane Benmaziane
- Département d'Oncologie et de Soins de Supports, Hôpital Foch, Suresnes, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Étienne, INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Inserm CIC-1408, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Silvy Laporte
- SAINBIOSE INSERM U1059, unité de recherche clinique, innovation et pharmacologie, hôpital Nord, université Jean-Monnet, CHU de Saint-Étienne, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Philippe Girard
- Institut du Thorax Curie-Montsouris, Institut Mutualiste Montsouris, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU Saint-Etienne, Hôpital Nord, Saint-Etienne, France; F-CRIN INNOVTE network, Saint-Etienne, France
| | - Olivier Sanchez
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de Pneumologie et de Soins Intensifs, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France; F-CRIN INNOVTE network, Saint-Etienne, France
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7
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Bolek H, Ürün Y. Cancer-associated thrombosis and drug-drug interactions of antithrombotic and antineoplastic agents. Cancer 2023; 129:3216-3229. [PMID: 37401828 DOI: 10.1002/cncr.34937] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 07/05/2023]
Abstract
Venous thromboembolism (VTE) is often associated with malignant diseases and notably contributes to morbidity and mortality in patients with cancer. Cancer-associated thrombosis (CAT) brings additional costs to health expenditures and has a negative impact on oncological outcomes. Either the recurrence rate of VTE or bleeding complications are also higher in patients with cancer. Prophylactic anticoagulation has been recommended in peri-surgical periods, inpatient settings, and high-risk ambulatory patients. Although various risk stratification scores are used, none are ideal for identifying patients who can benefit from anticoagulant prophylaxis. New risk scoring systems or biomarkers are needed to identify patients who are more likely to benefit from prophylaxis with low bleeding risk. The questions about the patients who will be given prophylaxis and those who develop thromboembolism, with which drug, and how long they will be treated are still not fully answered. Anticoagulation is the cornerstone of the treatment, but management of CAT remains complex. Low molecular weight heparins and direct oral anticoagulants are effective and safe options for the treatment of CAT. Recognizing adverse effects, drug-drug interactions, and accompanying conditions that cause dose adjustment is crucial. Prevention and treatment of VTE in patients with cancer require a multidisciplinary and patient-based approach. PLAIN LANGUAGE SUMMARY: Cancer-associated thrombosis is a significant cause of mortality and morbidity in patients with cancer. Chemotherapy, surgery, and/or use of central venous access remarkably increase the risk of thrombosis. Prophylactic anticoagulation should be considered not only in inpatient follow-up and during peri-surgical period but also ambulatory patients with a high risk of thrombosis. Many parameters, such as drug-drug interactions, primary side of cancer, and comorbidities of patients should be considered when selecting anticoagulant drugs. More accurate risk stratification scores or biomarkers are still an unmet need.
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Affiliation(s)
- Hatice Bolek
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
- Ankara University Cancer Research Institute, Ankara, Turkey
| | - Yüksel Ürün
- Department of Medical Oncology, Ankara University School of Medicine, Ankara, Turkey
- Ankara University Cancer Research Institute, Ankara, Turkey
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8
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Elalamy I, Cohen-Solal A, Hanon O, Mirabel M, Mismetti P, Spano JP. Primary prevention of cancer-associated venous thrombosis: Rationale and challenges in clinical practice. Curr Res Transl Med 2023; 71:103405. [PMID: 37478777 DOI: 10.1016/j.retram.2023.103405] [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: 02/17/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/23/2023]
Abstract
Cancer-associated venous thrombosis (CAT) is a common, multifactor event known to complicate the course of cancer and jeopardize a patient's prognosis. The current guidelines regarding the prevention of CAT are sometimes considered insufficiently precise about specific situations, or are poorly applied. The expected benefits of thromboprophylaxis are balanced by the risk of major bleeding induced by anticoagulation, which implies a need to accurately identify ambulatory patients at high risk of thrombosis or hemorrhage. The Khorana score is commonly used for this, but is limited by the non-reproducibility of predicted performance across cancer types, and by the fact that antitumor treatment and cardiovascular risks are not included. The COMPASS-CAT score, which includes those two aspects, was found to be a more accurate predictor of venous thromboembolism in patients with lung cancer, and to better distinguish between patients at low or high risk of thrombosis. The frailty of patients with cancer is also a major issue, and should be taken into account when thromboprophylaxis is considered. According to current guidelines, CAT prophylaxis should be considered for hospitalized patients, those for whom surgery is scheduled, or those with pancreatic cancers. In ambulatory patients, decisions should be made according to patient, cancer and antitumoral treatment characteristics. Low molecular weight heparin is the gold standard of CAT prophylaxis. Despite increased risks of bleeding or drug-drug interactions in cancer patients, direct oral anticoagulants could be alternate options for high-risk ambulatory patients that should be accompanied by a careful global analysis of benefits, harms, and patient preferences.
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Affiliation(s)
- Ismail Elalamy
- Thrombosis Center, Hematology Department (DMU BioGeM), Assistance Publique Hôpitaux de Paris, Sorbonne University of Medicine, Paris, France; Research Group "Cancer, Haemostasis and Angiogenesis", INSERM U938, Research Centre Saint-Antoine, University Institute of Cancerology, Sorbonne University of Medicine, Paris, France; The First I.M. Sechenov Moscow State Medical University, Moscow, Russia.
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM Unité 942 MASCOT, AP-HP, Département de cardiologie et maladies vasculaires, Hôpital Lariboisière, Paris, France
| | - Olivier Hanon
- Université Paris Cité, EA4468, AP-HP, hôpitaux Universitaires Paris Centre, Département de Gériatrie, Hôpital Broca, Paris, France
| | - Mariana Mirabel
- Département de Cardiologie, Institut mutualiste Montsouris, Paris, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire, Saint Etienne, France
| | - Jean-Philippe Spano
- Service d'Oncologie médicale, APHP-SU, IUC, Hôpital La Pitié-Salpêtrière, Paris, France
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9
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Aquino M, Tinoco M, Bicker J, Falcão A, Rocha M, Fortuna A. Therapeutic Drug Monitoring of Amikacin in Neutropenic Oncology Patients. Antibiotics (Basel) 2023; 12:antibiotics12020373. [PMID: 36830283 PMCID: PMC9952017 DOI: 10.3390/antibiotics12020373] [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: 01/17/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
Amikacin is the antibiotic of choice for the treatment of Gram-negative infections, namely, those in neutropenic oncology patients. No populational pharmacokinetic studies are currently available reporting amikacin pharmacokinetics in neutropenic oncology patients despite their specific pathophysiological features and treatments. A large-scale retrospective study was herein conducted to specifically investigate the effects that tumor diseases have on the pharmacokinetic parameters of amikacin and identify whether chemotherapy, the lag time between administration of chemotherapy and amikacin, age and renal function contribute to amikacin pharmacokinetics in neutropenic cancer patients. A total of 1180 pharmacokinetic analysis from 629 neutropenic patients were enrolled. The daily dose administered to oncology patients was higher than that administered to non-oncology patients (p < 0.0001). No statistical differences were found in amikacin concentrations, probably because drug clearance was increased in cancer patients (p < 0.0001). Chemotherapy influenced amikacin pharmacokinetics and drug clearance decreased as the lag time enhanced. The elderly group revealed no statistical differences between the doses administered to both the oncology groups, suggesting that the impact of ageing is stronger than chemotherapy. Our research suggests that cancer patients require higher initial doses of amikacin, as well as when chemotherapy is received less than 30 days before amikacin treatment has started.
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Affiliation(s)
- Maria Aquino
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Maria Tinoco
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Joana Bicker
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- CIBIT—Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Amílcar Falcão
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- CIBIT—Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, 3000-548 Coimbra, Portugal
| | - Marília Rocha
- Centro Hospitalar e Universitário de Coimbra (CHUC, EPE), 3000-548 Coimbra, Portugal
| | - Ana Fortuna
- Laboratory of Pharmacology, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal
- CIBIT—Coimbra Institute for Biomedical Imaging and Translational Research, University of Coimbra, 3000-548 Coimbra, Portugal
- Correspondence:
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10
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Malka D, Girard N, Smadja DM, Chevreau C, Culine S, Lesur A, Rouzier R, Rozet F, Spano JP, Blay JY. [Prophylaxis and management of cancer-associated thrombosis: Practical issues about anticoagulant use]. Bull Cancer 2023; 110:212-224. [PMID: 36494243 DOI: 10.1016/j.bulcan.2022.10.008] [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: 06/16/2022] [Revised: 10/13/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022]
Abstract
Cancer-associated thrombosis (CAT) is a common complication resulting from various vascular mechanisms related to cancer, antitumoral therapy and patient status, and is associated with a poor prognosis. Anticoagulants recommended for CAT treatment or prevention mainly include low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs). Regarding thromboprophylaxis, a situation for which LMWH is a preferred option due to a lower risk of hemorrhage especially in patients with unresected gastro-intestinal and genito-urinary malignancies, the identification of patients at risk is a major issue. For patients with established CAT, the main issue is the choice of the most appropriate anticoagulant therapy. Because of the convenience of oral formulation, DOACs are an attractive option, and their efficacy has been shown in randomized trials. However, such studies are limited by selection biases, which make the analyzed population not representative of the real-life setting, as for instance cancers associated with a high risk of hemorrhage, or antitumoral therapies (e.g., tyrosine kinase inhibitors) known to interact with DOACs and then modifying their bioavailability. Caution associated with DOAC use is highlighted by most updated guidelines that recommend a case-by-case-based approach. The aim of the present paper is to help the oncologists make the most appropriate decision regarding the choice of anticoagulant therapy in a context of thromboprophylaxis or established CAT management in a patient with a solid tumor. The main issues are addressed through key practical questions, the answers of which are based on the current guidelines and additional published data or expert opinions.
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Affiliation(s)
- David Malka
- Institut mutualiste Montsouris, département d'oncologie médicale, Paris, France; Université Paris-Saclay, unité dynamique des cellules tumorales INSERM U1279, Gustave Roussy, Villejuif, France.
| | - Nicolas Girard
- Institut Curie, institut du Thorax Curie-Montsouris, Paris, France
| | - David M Smadja
- Université de Paris, INSERM innovations thérapeutiques en hémostase, Paris, France; Hôpital Européen Georges-Pompidou, AP-HP, département d'hématologie, Paris, France; Réseau F-CRIN INNOVTE, Paris, France
| | | | - Stéphane Culine
- Université Paris Cité, service d'oncologie médicale, AP-HP Saint-Louis, Paris, France
| | - Anne Lesur
- Mutuelle générale éducation nationale, Nancy, France
| | - Roman Rouzier
- Centre François Baclesse, département de Chirurgie, Caen, France
| | - François Rozet
- Institut mutualiste Montsouris, département d'urologie, Paris, France
| | - Jean-Philippe Spano
- Hôpital La Pitié-Salpêtrière, service d'oncologie médicale, AP-HP-SU, IUC, Paris, France
| | - Jean-Yves Blay
- Centre Leon Bérard and UCBL1, département d'oncologie médicale, Lyon, France
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11
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Practical Considerations for the Management of Cancer-Associated Venous Thromboembolism: A Guide for the General Oncology Practitioner. Curr Oncol 2022; 29:6419-6432. [PMID: 36135074 PMCID: PMC9497708 DOI: 10.3390/curroncol29090505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/31/2022] [Accepted: 09/02/2022] [Indexed: 11/16/2022] Open
Abstract
Cancer-associated venous thromboembolism is a devastating complication of cancer and is associated with significant morbidity and mortality. The cornerstone of cancer-associated venous thromboembolism treatment is anticoagulation, and in recent years, there have been notable randomized clinical trials that have revealed insights into the efficacy and safety of direct oral anticoagulants and low-molecular-weight heparin in the treatment of cancer-associated thrombosis. Deciding on the ideal anticoagulation treatment plan for a patient with a cancer-associated thrombosis is a complex task that requires an understanding of clinical trial data, society guidelines, and, most importantly, consideration of many cancer-related, treatment-related, and patient-related factors. This article summarizes important factors to consider when deciding on anticoagulation therapy for a patient with cancer-associated thrombosis.
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12
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Complexity and clinical significance of drug-drug interactions (DDIs) in oncology: challenging issues in the care of patients regarding cancer-associated thrombosis (CAT). Support Care Cancer 2022; 30:8559-8573. [PMID: 35932318 PMCID: PMC9512854 DOI: 10.1007/s00520-022-07235-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 06/14/2022] [Indexed: 11/07/2022]
Abstract
Cancer patients have an increased risk of developing venous thromboembolic events. Anticoagulation management includes prophylactic or therapeutic doses of low molecular weight heparins (LMWHs) or direct oral anticoagulants (DOACs). However, the management of thrombosis in patients with cancer is complex due to various individual and disease-related factors, including drug–drug interactions (DDIs). Furthermore, DDIs may impact both, cancer and venous thrombosis, treatment effectiveness and safety; their relevance is highlighted by the advances in cancer therapeutics. Given that these new oncology drugs are extensively used, more attention should be given to monitoring potential DDIs to minimize risks. Recognition of DDIs is of utmost importance in an era of rapid developments in cancer treatments and introduction of novel treatments and protocols. When managing cancer-associated thrombosis (CAT), the concomitant use of a DOAC and a moderate or strong modulator (inhibitor or inducer) of CYP3A4 or a P-glycoprotein (P-gp) is most likely to be associated with significant DDIs. Therefore, LMWHs remain the first-line option for the long-term management of CAT under these circumstances and physicians must consider utilizing LMWHs as first line. This review describes the risk of DDIs and their potential impact and outcomes in patients with cancer associated thrombosis (CAT) receiving anticoagulation.
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13
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Hanigan S, Park JM. Evaluating pharmacokinetic drug-drug interactions of direct oral anticoagulants in patients with renal dysfunction. Expert Opin Drug Metab Toxicol 2022; 18:189-202. [PMID: 35543017 DOI: 10.1080/17425255.2022.2074397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Drug transporters, metabolic enzymes, and renal clearance play significant roles in the pharmacokinetics of direct oral anticoagulants (DOACs). Recommendations for DOAC drug-drug interactions (DDIs) by the product labeling are limited to selected CYP3A4 and P-glycoprotein inhibitors and lack considerations for concomitant renal dysfunction. AREAS COVERED This review focuses on: 1) current recommendations for the management of pharmacokinetic DOAC DDIs and the evidence used to support them; 2) alterations in DOAC exposure in the setting of concomitant DDIs and mild, moderate, and severe renal impairment; 3) clinical outcomes associated with this combination; and 4) expert recommendations for the management of pharmacokinetic DOAC DDIs. English-language, full-text articles on apixaban, dabigatran, rivaroxaban, and edoxaban with a publication date up to 30 September 2021 were retrieved from PubMed. EXPERT OPINION Given the lack of supporting clinical data, empiric dose adjustments based on pharmacokinetic data alone should be avoided. When a considerable increase in a DOAC exposure is anticipated, it may be advisable to use an alternative DOAC or anticoagulant from a different class. Future research on identification of DOAC therapeutic ranges and target patient populations is needed to inform clinical utility of DOAC level monitoring to guide the management of DDIs.
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Affiliation(s)
- Sarah Hanigan
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
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14
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Lafaie L, Hodin S, Saïb S, Bin V, Bertoletti L, Delavenne X. Tyrosine kinase inhibitors and direct oral anticoagulants: In vitro evaluation of drug-drug interaction mediated by P-glycoprotein. Fundam Clin Pharmacol 2022; 36:860-868. [PMID: 35174529 DOI: 10.1111/fcp.12769] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/06/2022] [Accepted: 02/15/2022] [Indexed: 12/21/2022]
Abstract
Direct oral anticoagulants (DOACs) are now an option in the prevention and treatment of venous thromboembolic events (VTE) in patients with active cancer. Pharmacokinetics of DOACs are largely influenced by efflux transporters derived from ABC transporters, notably by P-glycoprotein (P-gp). The aim of this study was to assess the potential P-gp-mediated drug-drug interactions between 11 tyrosine kinase inhibitors (TKIs) with apixaban and rivaroxaban. Bidirectional permeabilities of apixaban and rivaroxaban were investigated across MDCK-MDR1 models, to determine half maximal inhibitory concentration (IC50 ). Several categories of interaction risks based on IC50 values can be distinguished depending on the TKI and DOAC used. IC50 values of less than 10 μM were observed with the combination of erlotinib, nilotinib with both DOACs, and with dabrafenib and apixaban. IC50 values between 10 and 100 μM were seen for axitinib, crizotinib, dasatinib, imatinib, and lapatinib with apixaban, and for axitinib, crizotinib, dabrafenib, idelalisib, imatinib, and vemurafenib with rivaroxaban. A risk of drug-drug interaction was found in vitro between TKIs and DOACs. In vivo pharmacokinetic studies are needed to ensure the safety of prescribing DOACs in cancer patients on TKI therapy, in order to avoid major, potentially preventable bleeding events.
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Affiliation(s)
- Ludovic Lafaie
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université de Lyon, Saint-Etienne, France
| | - Sophie Hodin
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université de Lyon, Saint-Etienne, France
| | - Sonia Saïb
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université de Lyon, Saint-Etienne, France
| | - Valérie Bin
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université de Lyon, Saint-Etienne, France
| | - Laurent Bertoletti
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université de Lyon, Saint-Etienne, France.,Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Etienne, Saint-Etienne, France
| | - Xavier Delavenne
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université de Lyon, Saint-Etienne, France.,Laboratoire de Pharmacologie - Toxicologie - Gaz du Sang, CHU de Saint-Etienne, Saint-Etienne, France
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15
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Musgrave K, Power K, Laffan M, O’Donnell JS, Thachil J, Maraveyas A. Practical Treatment Guidance for Cancer-Associated Thrombosis – Managing the Challenging Patient: A Consensus Statement. Crit Rev Oncol Hematol 2022; 171:103599. [DOI: 10.1016/j.critrevonc.2022.103599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 01/07/2022] [Accepted: 01/17/2022] [Indexed: 02/07/2023] Open
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16
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Lafaie L, Célarier T, Monreal M, Mismetti P, Delavenne X, Bertoletti L. The impact of advanced age on anticoagulant therapy for acute venous thromboembolism. Expert Opin Drug Metab Toxicol 2022; 18:27-37. [PMID: 35195483 DOI: 10.1080/17425255.2022.2045273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Management of venous thromboembolic events (VTE) has been completely changed after the introduction of direct oral anticoagulants (DOAC). VTE is common in the geriatric population, but the management of DOACs remains complex because of the lack of specific data in this polymedicated fragile population.An exhaustive search of anticoagulants in the indication of VTE was performed on PubMed, including data from clinical trials, observational studies, real-world data, drug-drug interaction studies, as well as various guidelines from scientific societies. AREAS COVERED The present review aims to summarize our current knowledge on the era of DOACs in the management of VTE in the elderly. This involves learning the pharmacokinetics/pharmacodynamics of drugs specific to geriatrics, the problem of drug-drug interactions, and the main randomized clinical trials validating the use of DOACs. EXPERT OPINION DOACs have become an essential part of the management of VTE in the elderly, both for their efficacy and safety. However, we are faced with a list of unmet needs, such as the relevance of DOACs in the very elderly, cancer patients, and those with renal impairment. Clinicians and pharmacists must remain cautious about comedications, as well as about the patient's comorbidities.
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Affiliation(s)
- Ludovic Lafaie
- Loire, Inserm, UMR1059, Equipe Dysfonction Vasculaire Et Hémostase, Université de Lyon Saint-Etienne, Saint-Etienne, France.,Département de Gérontologie Clinique, Chu de Saint-Etienne, Saint-Etienne, France
| | - Thomas Célarier
- Département de Gérontologie Clinique, Chu de Saint-Etienne, Saint-Etienne, France
| | - Manuel Monreal
- Department of Internal Medicine, Universidad Católica de Murcia, Hospital Universitario Germans Trias I Pujol de Badalona, Spain
| | - Patrick Mismetti
- Loire, Inserm, UMR1059, Equipe Dysfonction Vasculaire Et Hémostase, Université de Lyon Saint-Etienne, Saint-Etienne, France.,Loire, Unité de Recherche Clinique Innovation Et Pharmacologie, Chu de Saint-Etienne, Saint-Etienne, France
| | - Xavier Delavenne
- Loire, Inserm, UMR1059, Equipe Dysfonction Vasculaire Et Hémostase, Université de Lyon Saint-Etienne, Saint-Etienne, France.,Loire, Laboratoire de Pharmacologie Toxicologie, Chu de Saint-Etienne, Saint-Etienne, France
| | - Laurent Bertoletti
- Loire, Inserm, UMR1059, Equipe Dysfonction Vasculaire Et Hémostase, Université de Lyon Saint-Etienne, Saint-Etienne, France.,Loire, Service de Médecine Vasculaire Et Thérapeutique, Chu de Saint-Etienne, Saint-Etienne, France
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17
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Tanaka Y, Sato Y, Suetsugu T, Mase J, Takaha R, Okumura N, Matsuhashi N, Takahashi T, Yoshida K. Treatment Strategy for Cancer-associated Venous Thromboembolism During Chemotherapy: The Keep ACT2 Concept. CANCER DIAGNOSIS & PROGNOSIS 2021; 1:417-422. [PMID: 35403169 PMCID: PMC8962864 DOI: 10.21873/cdp.10055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/01/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND/AIM The frequency of detecting cancer-associated venous thromboembolism (CAT) during chemotherapy is increasing. It is not desirable to discontinue chemotherapy for CAT. In this study, we investigated the feasibility of simultaneous progression of anticoagulant and anticancer therapy, focusing on drug interactions. PATIENTS AND METHODS We retrospectively evaluated patients with gastroenterological CAT from February 2017 to December 2020 at the Gifu University Hospital. When both chemotherapy and CAT treatments using edoxaban were performed in parallel and the thrombus disappeared, patients were defined as being Keep-ACT 2 (keeping anticancer therapy and anticoagulant therapy) successful. The effect and safety of treatment strategy focusing on cytochrome P450 (CYP) metabolism using edoxaban were evaluated. RESULTS A total of 114 patients with CAT during chemotherapy were treated with edoxaban. Keep-ACT 2 was successful in 101 (88.6%) cases. Clinically relevant non-major bleeding was observed in 5 cases (4.4%). All 114 patients were using some drug affected by CYP metabolism, and the median number of affected cases was 5. CONCLUSION Combined use of edoxaban for CAT may lead to sustainable therapy for gastroenterological cancer patients who are administered several drugs.
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Affiliation(s)
- Yoshihiro Tanaka
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Yuta Sato
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Tomonari Suetsugu
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Junichi Mase
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Ritsuki Takaha
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Naoki Okumura
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Nobuhisa Matsuhashi
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Takao Takahashi
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Kazuhiro Yoshida
- Department of Surgical Oncology, Graduate School of Medicine, Gifu University, Gifu, Japan
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18
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Frere C, Font C, Esposito F, Crichi B, Girard P, Janus N. Incidence, risk factors, and management of bleeding in patients receiving anticoagulants for the treatment of cancer-associated thrombosis. Support Care Cancer 2021; 30:2919-2931. [PMID: 34617159 DOI: 10.1007/s00520-021-06598-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/26/2021] [Indexed: 12/19/2022]
Abstract
Updated clinical practice guidelines recommend the long-term use of low-molecular-weight heparins or direct oral anticoagulants as the preferred option for the treatment of cancer-associated thrombosis (CAT), using a personalized approach matching the right drug to the right patient. In most cases, the benefit of anticoagulant therapy outweighs the risk. However, the long-term use of anticoagulants is associated with a non-negligible risk of bleeding, which constitutes a rare but serious adverse effect. Bleeding complications have been reported to be overall 2 to 3 times more frequent in cancer patients with CAT receiving anticoagulation than in non-cancer patients, with a reported incidence of major bleeding ranging from 2.4 to 16.0% in randomized controlled trials (RCT). In the absence of validated risk assessment model to predict the risk of bleeding in these patients, a careful evaluation of each individual profile, with adequate selection of the most appropriate anticoagulant for each individual patient, is warranted for overcoming management challenges, taking in account the numerous factors which may potentiate the overall bleeding risk in these complex patients, such as advanced or metastatic disease, older age, anemia, thrombocytopenia, renal impairment, liver dysfunction, and concomitant anticancer therapies. The purpose of this review is to call for awareness on bleeding complications as a major safety issue of CAT treatment and to summarize data from recent RCT and real-world studies on the incidence and risk factors for bleeding in this unique and challenging population to further help clinicians in decision-making.
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Affiliation(s)
- Corinne Frere
- Institute of Cardiometabolism And Nutrition, GRC 27 GRECO, Sorbonne Université, INSERM UMRS_1166, Paris, France
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Carme Font
- Department of Internal Medicine, Hospital Clinic, Barcelona, Spain
| | | | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 75010, Paris, France
| | - Philippe Girard
- Département Thoracique, Institut Mutualiste Montsouris, Paris, France
- FCRIN INNOVTE, Paris, France
| | - Nicolas Janus
- Global Thrombosis Strategy, Medical Affairs, Leo Pharma, Voisins-le-Bretonneux, France.
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19
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Arguments for Using Direct Oral Anticoagulants in Cancer-Related Venous Thromboembolism. Healthcare (Basel) 2021; 9:healthcare9101287. [PMID: 34682967 PMCID: PMC8535422 DOI: 10.3390/healthcare9101287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 12/18/2022] Open
Abstract
(1) Background: Patients with cancer with a hypercoagulable state present an increased incidence of venous thromboembolism (VTE). Neoplastic patients with concurrent VTE undergoing anticoagulant treatment face a series of issues. (2) The aim of the present paper is to systematically summarize current VTE management in patients with neoplasia and to review the current clinical evidence from meta-analyses of randomized controlled trials and guidelines regarding the administration of direct oral anticoagulants (DOACs) for cancer-associated VTE. (3) Search Strategy: We performed a review on meta-analyses of randomized controlled trials and guidelines in favor of the administration of DOACs in patients with cancer-associated VTE published in the last 6 years in the Medline (PubMed) and Embase databases. (4) Results: 21 meta-analyses, 14 randomized controlled studies comparing DOACs to VKAs and LMWH, and 7 national and international guidelines were identified. We identified five studies that show the antineoplastic effect of DOAC on experimental models. (5) Conclusions: DOACs can be seen as the first choice for VTE treatment in neoplastic patients who have a low risk of bleeding, who do not have severe renal impairment, and who are not undergoing treatments that could interact with DOAC’s mechanism of action.
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20
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Roffé A, Guedon A, Lallmahomed E. [Actual use of direct oral anticoagulants in venous thromboembolic disease]. Rev Med Interne 2021; 43:82-88. [PMID: 34176700 DOI: 10.1016/j.revmed.2021.06.005] [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: 01/20/2021] [Revised: 06/03/2021] [Accepted: 06/08/2021] [Indexed: 12/29/2022]
Abstract
Direct oral anticoagulants recently became the first-line choice for anticoagulation in venous thromboembolic disease. Many studies have shown its non-inferiority regarding the risk of thromboembolic recurrence compared to anti-vitamin K without increasing the risk of bleeding in the general population. However, specific populations such as patients with cancer, patients with kidney failure, patients with constitutional thrombophilia, elderly patients, or patients with extreme weight are at risk of intolerance to the use of direct oral anticoagulants. Precautions in use may be necessary as discussed in recently published guidelines about antiphospholipid syndrome. This review aims to list the main clinical trials investigating direct oral anticoagulants in venous thromboembolic disease in the general population and populations at risk, as well as to provide an update on current international and French guidelines.
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Affiliation(s)
- A Roffé
- Service de médecine vasculaire, hôpital Européen Georges-Pompidou, Paris, France.
| | - A Guedon
- Service de médecine vasculaire, hôpital Européen Georges-Pompidou, Paris, France
| | - E Lallmahomed
- Service de cardiologie, Centre hospitalier intercommunal Robert-Ballanger, Aulnay-sous-Bois, France
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21
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Thromboembolic events and thromboprophylaxis associated with immunomodulators in multiple myeloma patients: a real-life study. J Cancer Res Clin Oncol 2021; 148:975-984. [PMID: 34143239 DOI: 10.1007/s00432-021-03693-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/09/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE The aim of this study is to assess international guidelines implementation concerning thromboprophylaxis strategy in myeloma patients treated with immunomodulatory drugs. METHODS This retrospective study includes multiple myeloma patients treated with immunomodulatory drugs between 2014 and 2017 in the Hematology department of a teaching hospital (Hospices Civils de Lyon, France) and followed by the multidisciplinary care plan for cancer outpatients ONCORAL (ONCological care for outpatients with ORAL anticancer drugs). Data from immunomodulatory drugs administration, thromboprophylaxis strategy and thrombotic events were collected from medical files. Adherence to 2010 International Myeloma Working Group (IMWG) guidelines was assessed. RESULTS 213 patients received at least one immunomodulatory drug: lenalidomide (60.9%), pomalidomide (24.0%) and thalidomide (15.1%). About two third of treatment lines (66.2%) were in accordance with IMWG recommendations. Among the others, 30.5% and 69.5% had thromboprophylaxis, respectively, superior or inferior to IMWG recommendations. 37 venous thrombotic events and 4 arterial thromboembolisms (one patient experienced both a stroke and deep venous thrombosis simultaneously) were reported. CONCLUSION Thromboprophylaxis was systematically performed in myeloma patients treated with immunomodulatory drugs in this real-life retrospective cohort. However, the choice of anticoagulant or anti-platelet agent remains debatable, as adherence to existing guidelines was variable.
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22
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Sebuhyan M, Crichi B, Abdallah NA, Bonnet C, Deville L, Marjanovic Z, Farge D. Drug-drug interaction (DDI) with direct oral anticoagulant (DOAC) in patients with cancer. JOURNAL DE MEDECINE VASCULAIRE 2020; 45:6S31-6S38. [PMID: 33276942 DOI: 10.1016/s2542-4513(20)30517-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Cancer-associated thrombosis (CAT) is the second leading cause of death in cancer patients after tumor progression. The treatment of CAT is challenging because of a high risk of VTE recurrence, a high risk of bleeding, common presence of comorbidities, poly-medication, and potential drug-drug interactions (DDI). Since 2018, direct oral anticoagulants (DOACs) represent a promising therapeutic alternative and have been recently included into the 2019 update of the International Initiative on Thrombosis and Cancer (ITAC-CME) clinical practice guidelines for management of CAT. However, pharmacokinetic studies suggest that concomitant treatment with P-gp or CYP3A4 inhibitors will result in an increased exposure to rivaroxaban and apixaban, but the clinical relevance of these studies is unknown. In addition, there is an important inter-individual variability in drug absorption, distribution, metabolism and elimination, even more in cancer patients. Overall, the risk of pharmacokinetic DDI should be estimated based on several individual (patient age, renal and liver function, number of comedications) and diseases-related factors, including inflammation, sarcopenia, and low body weight. In this context, DDI with clinical implications could be expected with anti-neoplastic agents or supportive care treatments, especially with drugs known to be moderate or strong inhibitors/inducers of CYP3A4 and P-gp. Consequently, in the presence of potential DDIs through CYP3A4, and/or P-gp, LMWHs remain the first-line anticoagulant of choice for the long-term treatment of CAT. Multidisciplinary consultation meetings and therapeutic patient education should be emphasized in the complex management of CAT.
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Affiliation(s)
- M Sebuhyan
- Unité de médecine interne : maladies auto-immunes et pathologie vasculaire (UF04), hôpital Saint-Louis, Assistance publique des Hôpitaux de Paris (APHP), 1 avenue Claude-Vellefaux, 75010 Paris, France.
| | - B Crichi
- Unité de médecine interne : maladies auto-immunes et pathologie vasculaire (UF04), hôpital Saint-Louis, Assistance publique des Hôpitaux de Paris (APHP), 1 avenue Claude-Vellefaux, 75010 Paris, France
| | - N Ait Abdallah
- Unité de médecine interne : maladies auto-immunes et pathologie vasculaire (UF04), hôpital Saint-Louis, Assistance publique des Hôpitaux de Paris (APHP), 1 avenue Claude-Vellefaux, 75010 Paris, France
| | - C Bonnet
- Service d'oncologie médicale, hôpital Saint-Louis, Assistance publique des Hôpitaux de Paris (APHP), 1 avenue Claude-Vellefaux, 75010 Paris, France.
| | - L Deville
- Service de pharmacie, hôpital Saint-Louis, Assistance publique des Hôpitaux de Paris (APHP), 1 avenue Claude-Vellefaux, 75010 Paris, France
| | - Z Marjanovic
- Service d'hématologie clinique et thérapie cellulaire, hôpital Saint-Antoine, Assistance publique des Hôpitaux de Paris (APHP), 184 rue du Faubourg Saint-Antoine, 75012 Paris, France
| | - D Farge
- Unité de médecine interne : maladies auto-immunes et pathologie vasculaire (UF04), hôpital Saint-Louis, Assistance publique des Hôpitaux de Paris (APHP), 1 avenue Claude-Vellefaux, 75010 Paris, France; Université de Paris, IRSL, EA-3518, Recherche clinique appliquée à l'hématologie, F-75010 Paris, France; Department of Medicine, McGill University, Montreal, QC, Canada.
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Peixoto de Miranda ÉJF, Takahashi T, Iwamoto F, Yamashiro S, Samano E, Macedo AVS, Ramacciotti E. Drug-Drug Interactions of 257 Antineoplastic and Supportive Care Agents With 7 Anticoagulants: A Comprehensive Review of Interactions and Mechanisms. Clin Appl Thromb Hemost 2020; 26:1076029620936325. [PMID: 32862668 PMCID: PMC7466894 DOI: 10.1177/1076029620936325] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Data on drug–drug interactions (DDI) of antineoplastic drugs with anticoagulants is scarce. We aim to evaluate factors associated with DDI of antineoplastic and supportive care drugs with anticoagulants resulting in modification of pharmacokinetics of these last mentioned. A literature review on DDI databases and summaries of products characteristics (SmPC) was done. Drug–drug interactions of 257 antineoplastic and supportive care drugs with direct oral anticoagulants (DOACs), warfarin, enoxaparin, or fondaparinux were categorized as no clinically significant expected DDI, potentially weak DDI, potentially clinically significant DDI, and recommendation against coadministration. Logistic regression models were performed to analyze the association between the dependent variable potentially clinically significant interaction/recommendation against coadministration and the mechanisms of DDI. Of the 1799 associations, 84.4% were absence of DDI, 3.6% potentially weak DDI, 10.2% potentially clinically relevant DDI, and 2.0% recommendation against coadministration. Warfarin has higher DDI potential than other anticoagulants. Enoxaparin and fondaparinux have fewer DDI than others. There was no difference between DOACs. Drug–drug interactions with apixaban and rivaroxaban was independently associated with the absence of CYP3A4 competition, P-glycoprotein inhibition, CYP3A4 induction, and drug class of tyrosine kinase inhibitors. Drug–drug interactions with dabigatran and edoxaban was associated with inhibition of P-glycoprotein and tyrosine kinase inhibitors. Warfarin, induction of CYP3A4, and inhibition of CYP2C9. Enoxaparin and fondaparinux, only tyrosine kinase inhibitors. Direct oral anticoagulants did not differ regarding DDI with antineoplastic agents. Warfarin presented more DDI than other anticoagulants. P-glycoprotein inhibition and CYP3A4 induction were independently associated with DDI of antineoplastic agents with DOACs.
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Affiliation(s)
| | - Thamy Takahashi
- Medical Information, Medical Affairs, Bayer Brasil SA, Sao Paulo, Brazil
| | - Felipe Iwamoto
- Medical Information, Medical Affairs, Bayer Brasil SA, Sao Paulo, Brazil
| | - Suzete Yamashiro
- Medical Information, Medical Affairs, Bayer Brasil SA, Sao Paulo, Brazil
| | - Eliana Samano
- Cardiology, Medical Affairs, Bayer Brasil SA, Sao Paulo, Brazil
| | | | - Eduardo Ramacciotti
- Vascular Surgery, Hospital e Maternidade Dr. Christovão da Gama, Santo André, Sao Paulo, Brazil.,Thrombosis and Haemostasis, Loyola University Medical Center, Chicago, IL, USA
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24
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Wojtukiewicz MZ, Skalij P, Tokajuk P, Politynska B, Wojtukiewicz AM, Tucker SC, Honn KV. Direct Oral Anticoagulants in Cancer Patients. Time for a Change in Paradigm. Cancers (Basel) 2020; 12:cancers12051144. [PMID: 32370207 PMCID: PMC7281117 DOI: 10.3390/cancers12051144] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/30/2020] [Accepted: 04/30/2020] [Indexed: 12/31/2022] Open
Abstract
Thrombosis is a more common occurrence in cancer patients compared to the general population and is one of the main causes of death in these patients. Low molecular weight heparin (LMWH) has been the recognized standard treatment for more than a decade, both in cancer-related thrombosis and in its prevention. Direct oral anticoagulants (DOACs) are a new option for anticoagulation therapy. Recently published results of large randomized clinical trials have confirmed that DOAC may be a reasonable alternative to LMWH in cancer patients. The following review summarizes the current evidence on the safety and efficacy of DOAC in the treatment and prevention of cancer-related thrombosis. It also draws attention to the limitations of this group of drugs, knowledge of which will facilitate the selection of optimal therapy.
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Affiliation(s)
- Marek Z. Wojtukiewicz
- Department of Oncology, Medical University of Białystok, 12 Ogrodowa St., 15-027 Białystok, Poland; (P.S.); (P.T.)
- Department of Clinical Oncology, Comprehensive Cancer Center, 12 OgrodowaSt., 15-369 Białystok, Poland
- Correspondence:
| | - Piotr Skalij
- Department of Oncology, Medical University of Białystok, 12 Ogrodowa St., 15-027 Białystok, Poland; (P.S.); (P.T.)
- Department of Clinical Oncology, Comprehensive Cancer Center, 12 OgrodowaSt., 15-369 Białystok, Poland
| | - Piotr Tokajuk
- Department of Oncology, Medical University of Białystok, 12 Ogrodowa St., 15-027 Białystok, Poland; (P.S.); (P.T.)
- Department of Clinical Oncology, Comprehensive Cancer Center, 12 OgrodowaSt., 15-369 Białystok, Poland
| | - Barbara Politynska
- Department of Philosophy and Human Psychology, Medical University of Białystok, 37 Szpitalna St., 15-295 Białystok, Poland; (B.P.); (A.M.W.)
- Robinson College, University of Cambridge, Cambridge CB3 9AN, UK
| | - Anna M. Wojtukiewicz
- Department of Philosophy and Human Psychology, Medical University of Białystok, 37 Szpitalna St., 15-295 Białystok, Poland; (B.P.); (A.M.W.)
| | - Stephanie C. Tucker
- Bioactive Lipids Research Program, Department of Pathology-School of Medicine, Detroit, MI 48202, USA; (S.C.T.); (K.V.H.)
| | - Kenneth V. Honn
- Bioactive Lipids Research Program, Department of Pathology-School of Medicine, Detroit, MI 48202, USA; (S.C.T.); (K.V.H.)
- Department of Chemistry, Wayne State University, Detroit, MI 48202, USA
- Department of Oncology, Karmanos Cancer Institute, Detroit, MI 48202, USA
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25
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Auditeau C, Talbot A, Blandinières A, Smadja DM, Gendron N. Place des anticoagulants oraux directs dans la prise en charge de la maladie thromboembolique veineuse associée au cancer en 2020. Bull Cancer 2020; 107:574-585. [DOI: 10.1016/j.bulcan.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/17/2020] [Accepted: 02/19/2020] [Indexed: 11/27/2022]
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26
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Patel T, Iglesias DA. Venous Thromboembolism Treatment and Prevention in Cancer Patients: Can We Use Pills Yet? Curr Treat Options Oncol 2020; 21:43. [PMID: 32328793 DOI: 10.1007/s11864-020-00744-w] [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] [Indexed: 12/11/2022]
Abstract
OPINION STATEMENT Cancer increases a patient's risk for developing a venous thromboembolism (VTE) and is a relatively common finding in this population. Traditionally, anticoagulants used to treat VTE have included low molecular weight heparin (LMWH) or vitamin K antagonists (VKA). However, within the last several years, a newer class of anticoagulant, the direct oral anticoagulants (DOACs), has emerged as a potential option for pharmacologic thromboprophylaxis and for treatment of VTE in patients with cancer. While data is still limited and evolving, DOACs offer several benefits that are worth considering, including ease of administration and similar efficacy compared to LMWH in preventing recurrent VTE. However, some studies have reported a notable risk of increased bleeding associated with the use of DOACs. Additional studies are underway to evaluate the role of DOACs compared to LMWH in the setting of cancer. In our practice, based on existing data, we have been using DOACs for the chronic treatment of acute VTE and prevention of recurrent VTE in patients who do not have contraindications to anticoagulation and do not have severe renal insufficiency (creatinine clearance < 30 mL/min). For cancer patients admitted to the hospital with an acute medical illness, we use LMWH for primary prevention of VTE. In the perioperative setting, for patients undergoing major surgery with an active cancer, we prefer pharmacologic thromboprophylaxis with LMWH, although there is some emerging evidence that DOACs may be safe in this setting.
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Affiliation(s)
- Tulsi Patel
- Department of Obstetrics and Gynecology, Carilion Clinic, 1906 Belleview Ave Se, Roanoke, VA, 24016, USA
| | - David A Iglesias
- Division of Gynecologic Oncology, Carilion Clinic, 1 Riverside Circle, Suite 300, Roanoke, VA, 24016, USA.
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27
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Joulia ML, Carton E, Jouinot A, Allard M, Huillard O, Khoudour N, Peyromaure M, Zerbib M, Schoemann AT, Vidal M, Goldwasser F, Alexandre J, Blanchet B. Pharmacokinetic/Pharmacodynamic Relationship of Enzalutamide and Its Active Metabolite N-Desmethyl Enzalutamide in Metastatic Castration-Resistant Prostate Cancer Patients. Clin Genitourin Cancer 2020; 18:155-160. [DOI: 10.1016/j.clgc.2019.05.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 04/25/2019] [Accepted: 05/20/2019] [Indexed: 10/26/2022]
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28
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Farge D, Bournet B, Conroy T, Vicaut E, Rak J, Zogoulous G, Barkun J, Ouaissi M, Buscail L, Frere C. Primary Thromboprophylaxis in Pancreatic Cancer Patients: Why Clinical Practice Guidelines Should Be Implemented. Cancers (Basel) 2020; 12:E618. [PMID: 32155940 PMCID: PMC7139861 DOI: 10.3390/cancers12030618] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 02/27/2020] [Accepted: 03/04/2020] [Indexed: 12/13/2022] Open
Abstract
Exocrine pancreatic ductal adenocarcinoma, simply referred to as pancreatic cancer (PC) has the worst prognosis of any malignancy. Despite recent advances in the use of adjuvant chemotherapy in PC, the prognosis remains poor, with fewer than 8% of patients being alive at 5 years after diagnosis. The prevalence of PC has steadily increased over the past decades, and it is projected to become the second-leading cause of cancer-related death by 2030. In this context, optimizing and integrating supportive care is important to improve quality of life and survival. Venous thromboembolism (VTE) is a common but preventable complication in PC patients. VTE occurs in one out of five PC patients and is associated with significantly reduced progression-free survival and overall survival. The appropriate use of primary thromboprophylaxis can drastically and safely reduce the rates of VTE in PC patients as shown from subgroup analysis of non-PC targeted placebo-controlled randomized trials of cancer patients and from two dedicated controlled randomized trials in locally advanced PC patients receiving chemotherapy. Therefore, primary thromboprophylaxis with a Grade 1B evidence level is recommended in locally advanced PC patients receiving chemotherapy by the International Initiative on Cancer and Thrombosis clinical practice guidelines since 2013. However, its use and potential significant clinical benefit continues to be underrecognized worldwide. This narrative review aims to summarize the main recent advances in the field including on the use of individualized risk assessment models to stratify the risk of VTE in each patient with individual available treatment options.
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Affiliation(s)
- Dominique Farge
- Institut Universitaire d’Hématologie, Université de Paris, EA 3518, F-75010 Paris, France
- Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, F-75010 Paris, France
- Department of Medicine, McGill University, Montreal, Québec, QC H4A 3J1, Canada
| | - Barbara Bournet
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Thierry Conroy
- Institut de Cancérologie de Lorraine, Department of Medical Oncology, Université de Lorraine, APEMAC, EA4360, F-54519 Vandoeuvre-lès-Nancy, France;
| | - Eric Vicaut
- Department of Biostatistics, Université de Paris, F-75010 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Biostatistics, Fernand Widal Hospital, F-75010 Paris, France
| | - Janusz Rak
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - George Zogoulous
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Jefferey Barkun
- McGill University and the Research Institute of the McGill University Health Centre, Montreal, Québec, QC H4A 3J1, Canada; (J.R.)
| | - Mehdi Ouaissi
- Department of Digestive, Oncological, Endocrine, and Hepatic Surgery, and Hepatic Transplantation, Trousseau Hospital, CHRU Trousseau, F-37170 Chambray-les-Tours, France;
| | - Louis Buscail
- University of Toulouse, F-31059 Toulouse, France; (B.B.); (L.B.)
- CHU de Toulouse, Department of Gastroenterology and Pancreatology, F-31059 Toulouse, France
| | - Corinne Frere
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM UMRS_1166, GRC 27 GRECO, F-75013 Paris, France;
- Assistance Publique Hôpitaux de Paris, Department of Haematology, Pitié-Salpêtrière Hospital, F-75013 Paris, France
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29
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Rafii H, Frère C, Benzidia I, Crichi B, Andre T, Assenat E, Bournet B, Carpentier A, Connault J, Doucet L, Durant C, Emmerich J, Gris JC, Hij A, Le Hello C, Madelaine I, Messas E, Ndour A, Villiers S, Marjanovic Z, Ait Abdallah N, Yannoutsos A, Farge D. Management of cancer-related thrombosis in the era of direct oral anticoagulants: A comprehensive review of the 2019 ITAC-CME clinical practice guidelines. On behalf of the Groupe Francophone Thrombose et Cancer (GFTC). JOURNAL DE MEDECINE VASCULAIRE 2020; 45:28-40. [PMID: 32057323 DOI: 10.1016/j.jdmv.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/06/2019] [Indexed: 06/10/2023]
Abstract
Venous thromboembolism (VTE) is a common disease complication in cancer patients and the second cause of death after cancer progression. VTE management and prophylaxis are critical in cancer patients, but effective therapy can be challenging because these patients are at higher risk of VTE recurrence and bleeding under anticoagulant treatment. Numerous published studies report inconsistent implementation of existing evidence-based clinical practice guidelines (CPG), including underutilization of thromboprophylaxis, and wide variability in clinical practice patterns across different countries and various practitioners. This review aims to summarize the 2019 ITAC-CME evidence-based CPGs for treatment and prophylaxis of cancer-related VTE, which include recommendations on the use of direct oral anticoagulants specifically in cancer patients. The guidelines underscore the gravity of developing VTE in cancer and recommend the best approaches for treating and preventing cancer-associated VTE, while minimizing unnecessary or over-treatment. Greater adherence to the 2019 ITAC guidelines could substantially decrease the burden of VTE and improve survival of cancer patients.
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Affiliation(s)
- H Rafii
- Eurocord, Équipe 3 EA3518, hôpital Saint-Louis, Université de Paris, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - C Frère
- Inserm UMRS_1166, Department of Haematology, hôpital Pitié-Salpêtrière, Université de Paris, Sorbonne Paris-Cité, AP-HP, Paris, France
| | - I Benzidia
- Autoimmune and vascular disease unit, hôpital Saint-Louis, Internal Medicine (UF04), Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, EA3518, AP-HP, Sorbonne Paris-Cité, Paris, France
| | - B Crichi
- Autoimmune and vascular disease unit, hôpital Saint-Louis, Internal Medicine (UF04), Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, EA3518, AP-HP, Sorbonne Paris-Cité, Paris, France
| | - T Andre
- Hôpital Saint-Antoine, AP-HP, Paris, France
| | - E Assenat
- Montpellier school of Medicine, Saint-Eloi University Hospital, Montpellier, France
| | - B Bournet
- Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | | | | | - L Doucet
- Hôpital Saint-Louis, AP-HP, Paris, France
| | | | | | | | - A Hij
- Autoimmune and vascular disease unit, hôpital Saint-Louis, Internal Medicine (UF04), Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, EA3518, AP-HP, Sorbonne Paris-Cité, Paris, France
| | - C Le Hello
- CHU Saint-Étienne, Saint-Étienne, France
| | | | - E Messas
- Hôpital Européen Georges-Pompidou, AP-HP, Paris, France
| | - A Ndour
- Hôpital Saint-Louis, AP-HP, Paris, France
| | - S Villiers
- Hôpital Saint-Louis, AP-HP, Paris, France
| | | | - N Ait Abdallah
- Autoimmune and vascular disease unit, hôpital Saint-Louis, Internal Medicine (UF04), Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, EA3518, AP-HP, Sorbonne Paris-Cité, Paris, France
| | | | - D Farge
- Internal Medicine (UF04), Équipe 3 EA 3518, Autoimmune and Vascular Disease Unit, Saint-Louis Hospital, Center of reference for rare systemic autoimmune diseases (FAI2R), Université de Paris, AP-HP, Sorbonne Paris-Cité, Paris, France; Department of Medicine, McGill University, Montreal, QC, Canada
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30
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Debourdeau P, Cossou-Gbeto C, Takam-Sohwe T, Laroche JP. Héparines de bas poids moléculaires dans la maladie thromboembolique veineuse liée au cancer : quelle place en 2019 ? Bull Cancer 2020; 107:224-233. [DOI: 10.1016/j.bulcan.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 11/09/2019] [Accepted: 11/16/2019] [Indexed: 11/28/2022]
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31
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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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32
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2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol 2019; 20:e566-e581. [PMID: 31492632 DOI: 10.1016/s1470-2045(19)30336-5] [Citation(s) in RCA: 395] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/02/2019] [Accepted: 05/07/2019] [Indexed: 02/07/2023]
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33
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Mahé I, Elalamy I, Gerotziafas GT, Girard P. Treatment of Cancer-Associated Thrombosis: Beyond HOKUSAI. TH OPEN 2019; 3:e309-e315. [PMID: 31535076 PMCID: PMC6746618 DOI: 10.1055/s-0039-1696659] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/25/2019] [Indexed: 12/18/2022] Open
Abstract
Direct oral anticoagulants (DOACs) represent an attractive alternative to low-molecular-weight heparins (LMWHs) for the long-term treatment of cancer-associated thrombosis (CT) since they avoid the burden of daily injections. Analyses in subgroups of cancer patients from large randomized trials suggested that DOACs were at least as effective as vitamin K antagonists, while indirect comparisons suggested that DOACs' efficacy and safety profile were comparable to those of LMWHs. In the randomized controlled HOKUSAI-VTE Cancer study, currently the only completed phase III trial on DOACs in CT patients, edoxaban was shown noninferior to dalteparin on the composite primary endpoint of time to first recurrent venous thromboembolism or major bleeding during the 12 months after randomization. Study results suggest that both agents had comparable benefit/risk ratio in patients with CT. Even though this conclusion was valid from a strict statistical viewpoint, it was potentially misleading when interpreting benefit/risk ratios. Besides the obvious heterogeneity of the study population (e.g., 23% of patients no longer had cancer) and significantly different treatment durations between arms, secondary outcomes for efficacy were in favor of edoxaban for recurrent deep-vein thrombosis but not for recurrent pulmonary embolism, and major bleeding episodes were significantly more frequent in the edoxaban group, with an excess of gastrointestinal (GI) bleeding episodes observed mainly but not only in patients with GI cancers. More research is needed regarding specific patients' profiles, cancer types, and treatment period to better clarify the respective roles of DOACs and LMWHs in CT patients.
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Affiliation(s)
- Isabelle Mahé
- Université de Paris, Innovations Thérapeutiques en Hémostase, INSERM, Paris, France.,Service de médecine Interne, AH-HP, Hôpital Louis Mourier, Colombes, Université de Paris, France.,F-CRIN INNOVTE, Saint Etienne, France
| | - Ismaïl Elalamy
- F-CRIN INNOVTE, Saint Etienne, France.,Hematology and Thrombosis Center, Tenon University Hospital, Sorbonne University, INSERM U938, Paris, France.,Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Grigoris T Gerotziafas
- Research Group "Cancer, Haemostasis and Angiogenesis," INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Faculty of Medicine, Institut Universitaire de Cancérologie, Sorbonne Universities, Paris, France.,Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, APHP.6, Paris, France
| | - Philippe Girard
- F-CRIN INNOVTE, Saint Etienne, France.,Institut du Thorax Curie-Montsouris, l'Institut Mutualiste Montsouris, Paris, France
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López-Fernández T, Martín-García A, Roldán Rabadán I, Mitroi C, Mazón Ramos P, Díez-Villanueva P, Escobar Cervantes C, Alonso Martín C, Alonso Salinas GL, Arenas M, Arrarte Esteban VI, Ayala de La Peña F, Castro Fernández A, García Pardo H, García-Sanz R, González Porras JR, López de Sá E, Lozano T, Marco Vera P, Martínez Marín V, Mesa Rubio D, Montero Á, Oristrell G, Pérez de Prado A, Velasco del Castillo S, Virizuela Echaburu JA, Zatarain-Nicolás E, Anguita Sánchez M, Tamargo Menéndez J, Marín F, López-Sendón JL, Zamorano JL. Abordaje de la fibrilación auricular en pacientes con cáncer activo. Documento de consenso de expertos y recomendaciones. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2019.03.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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35
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López-Fernández T, Martín-García A, Roldán Rabadán I, Mitroi C, Mazón Ramos P, Díez-Villanueva P, Escobar Cervantes C, Alonso Martín C, Alonso Salinas GL, Arenas M, Arrarte Esteban VI, Ayala de La Peña F, Castro Fernández A, García Pardo H, García-Sanz R, González Porras JR, López de Sá E, Lozano T, Marco Vera P, Martínez Marín V, Mesa Rubio D, Montero Á, Oristrell G, Pérez de Prado A, Velasco Del Castillo S, Virizuela Echaburu JA, Zatarain-Nicolás E, Anguita Sánchez M, Tamargo Menéndez J. Atrial Fibrillation in Active Cancer Patients: Expert Position Paper and Recommendations. ACTA ACUST UNITED AC 2019; 72:749-759. [PMID: 31405794 DOI: 10.1016/j.rec.2019.03.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 03/28/2019] [Indexed: 12/13/2022]
Abstract
Improvements in survival among cancer patients have revealed the clinical impact of cardiotoxicity on both cardiovascular and hematological and oncological outcomes, especially when it leads to the interruption of highly effective antitumor therapies. Atrial fibrillation is a common complication in patients with active cancer and its treatment poses a major challenge. These patients have an increased thromboembolic and hemorrhagic risk but standard stroke prediction scores have not been validated in this population. The aim of this expert consensus-based document is to provide a multidisciplinary and practical approach to the prevention and treatment of atrial fibrillation in patients with active cancer. This is a position paper of the Spanish Cardio-Oncology working group and the Spanish Thrombosis working group, drafted in collaboration with experts from the Spanish Society of Cardiology, the Spanish Society of Medical Oncology, the Spanish Society of Radiation Oncology, and the Spanish Society of Hematology.
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Affiliation(s)
| | - Ana Martín-García
- Servicio de Cardiología, Complejo Asistencial Universitario de Salamanca (CAUSA), IBSAL, CIBERCV, Salamanca, Spain
| | | | - Cristina Mitroi
- Servicio de Cardiología, Hospital Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Pilar Mazón Ramos
- Servicio de Cardiología, Hospital Clínico Santiago de Compostela, CIBERCV, Santiago de Compostela, A Coruña, Spain
| | | | | | | | | | - Meritxell Arenas
- Servicio de Oncología Radioterápica, Hospital Universitario San Juan de Reus, Universidad Rovira i Virgili, Reus, Tarragona, Spain
| | | | | | | | - Héctor García Pardo
- Servicio de Cardiología, Hospital Santos Reyes, Aranda de Duero, Burgos, Spain
| | - Ramón García-Sanz
- Departamento de Hematología, Complejo Asistencial Universitario de Salamanca (CAUSA), IBSAL, Salamanca, Spain
| | - José Ramón González Porras
- Departamento de Hematología, Complejo Asistencial Universitario de Salamanca (CAUSA), IBSAL, Salamanca, Spain
| | - Esteban López de Sá
- Servicio de Cardiología, Hospital Universitario La Paz, IdiPAZ, CIBERCV, Madrid, Spain
| | - Teresa Lozano
- Servicio de Cardiología, Hospital General Universitario de Alicante, ISABIAL-FISABIO, Alicante, Spain
| | - Pascual Marco Vera
- Servicio de Hematología, Hospital General Universitario de Alicante, ISABIAL-FISABIO, Alicante, Spain
| | | | - Dolores Mesa Rubio
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Ángel Montero
- Servicio de Oncología Radioterápica, Centro Integral Oncológico Clara Campal (CIOCC), Hospital Universitario HM Sanchinarro, Madrid, Spain
| | - Gerard Oristrell
- Servicio de Cardiología, Hospital Universitario Vall d'Hebron, CIBERCV, Barcelona, Spain
| | | | | | | | - Eduardo Zatarain-Nicolás
- Servicio de Cardiología, Hospital General Universitario Gregorio Marañón, CIBERCV, Madrid, Spain
| | | | - Juan Tamargo Menéndez
- Departamento de Farmacología, Facultad de Medicina, Universidad Complutense, CIBERCV, Madrid, Spain
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Key NS, Khorana AA, Kuderer NM, Bohlke K, Lee AYY, Arcelus JI, Wong SL, Balaban EP, Flowers CR, Francis CW, Gates LE, Kakkar AK, Levine MN, Liebman HA, Tempero MA, Lyman GH, Falanga A. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol 2019; 38:496-520. [PMID: 31381464 DOI: 10.1200/jco.19.01461] [Citation(s) in RCA: 832] [Impact Index Per Article: 166.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To provide updated recommendations about prophylaxis and treatment of venous thromboembolism (VTE) in patients with cancer. METHODS PubMed and the Cochrane Library were searched for randomized controlled trials (RCTs) and meta-analyses of RCTs published from August 1, 2014, through December 4, 2018. ASCO convened an Expert Panel to review the evidence and revise previous recommendations as needed. RESULTS The systematic review included 35 publications on VTE prophylaxis and treatment and 18 publications on VTE risk assessment. Two RCTs of direct oral anticoagulants (DOACs) for the treatment of VTE in patients with cancer reported that edoxaban and rivaroxaban are effective but are linked with a higher risk of bleeding compared with low-molecular-weight heparin (LMWH) in patients with GI and potentially genitourinary cancers. Two additional RCTs reported on DOACs for thromboprophylaxis in ambulatory patients with cancer at increased risk of VTE. RECOMMENDATIONS Changes to previous recommendations: Clinicians may offer thromboprophylaxis with apixaban, rivaroxaban, or LMWH to selected high-risk outpatients with cancer; rivaroxaban and edoxaban have been added as options for VTE treatment; patients with brain metastases are now addressed in the VTE treatment section; and the recommendation regarding long-term postoperative LMWH has been expanded. Re-affirmed recommendations: Most hospitalized patients with cancer and an acute medical condition require thromboprophylaxis throughout hospitalization. Thromboprophylaxis is not routinely recommended for all outpatients with cancer. Patients undergoing major cancer surgery should receive prophylaxis starting before surgery and continuing for at least 7 to 10 days. Patients with cancer should be periodically assessed for VTE risk, and oncology professionals should provide patient education about the signs and symptoms of VTE.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
- Nigel S Key
- University of North Carolina, Chapel Hill, NC
| | | | - Nicole M Kuderer
- Advanced Cancer Research Group and University of Washington, Seattle, WA
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Agnes Y Y Lee
- BC Cancer Agency, Vancouver, British Columbia, Canada
| | | | | | | | | | - Charles W Francis
- James P Wilmot Cancer Center and University of Rochester, Rochester, NY
| | | | - Ajay K Kakkar
- Thrombosis Research Institute and University College, London, United Kingdom
| | | | - Howard A Liebman
- University of Southern California and Norris Comprehensive Cancer Center, Los Angeles, CA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the University of Washington, Seattle, WA
| | - Anna Falanga
- Hospital Papa Giovanni XXIII, Bergamo; and University of Milan Bicocca, Milan, Italy
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37
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Frydman GH, Ellett F, Van Cott EM, Hayden D, Majmudar M, Vanderburg CR, Dalzell H, Padmanabhan DL, Davis N, Jorgensen J, Toner M, Fox JG, Tompkins RG. A New Test for the Detection of Direct Oral Anticoagulants (Rivaroxaban and Apixaban) in the Emergency Room Setting. Crit Care Explor 2019; 1:e0024. [PMID: 32166266 PMCID: PMC7063952 DOI: 10.1097/cce.0000000000000024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Determining whether a patient has taken a direct oral anticoagulant (DOAC) is critical during the periprocedural and preoperative period in the emergency department. However, the inaccessibility of complete medical records, along with the generally inconsistent sensitivity of conventional coagulation tests to these drugs, complicates clinical decision making and puts patients at risk of uncontrollable bleeding. In this study, we evaluate the utility of inhibitor-II-X (i-II-X), a novel, microfluidics-based diagnostic assay for the detection and identification of Factor Xa inhibitors (FXa-Is) in an acute care setting. DESIGN First-in-human, 91-patient, single-center retrospective pilot study. SETTING Emergency room. PATIENTS Adult patients admitted into the emergency department, which received any clinician-ordered coagulation test requiring a 3.2% buffered sodium citrate blood collection tube. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma samples from patients admitted to the emergency department were screened for the use of FXa-Is, including apixaban and rivaroxaban, within the past 24 hours using our new i-II-X microfluidic test. i-II-X results were then compared with results from conventional coagulation tests, including prothrombin time (PT) and international normalized ratio (INR), which were ordered by treating clinicians, and an anti-Xa assay for rivaroxaban. The i-II-X test detected DOACs in samples collected from the emergency department with 95.20% sensitivity and 100.00% specificity. Unlike PT and INR, i-II-X reliably identified patients who had prolonged clotting times secondary to the presence of a FXa-I. CONCLUSIONS The i-II-X test overcomes the limitations of currently available coagulation tests and could be a useful tool by which to routinely screen patients for DOACs in emergency and critical care settings. Our new diagnostic approach is particularly relevant in clinical situations where medical records may be unavailable, or where precautions need to be taken prior to invasive interventions, such as specific reversal agent administration.
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Affiliation(s)
- Galit H Frydman
- Division of Comparative Medicine, Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Felix Ellett
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | | | - Douglas Hayden
- Department of Biostatistics, Massachusetts General Hospital, Boston, MA
| | - Maulik Majmudar
- Department of Cardiology, Massachusetts General Hospital, Boston, MA
| | | | - Haley Dalzell
- Department of Cardiology, Massachusetts General Hospital, Boston, MA
| | | | - Nick Davis
- Division of Comparative Medicine, Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
| | - Julianne Jorgensen
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - Mehmet Toner
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
| | - James G Fox
- Division of Comparative Medicine, Department of Biological Engineering, Massachusetts Institute of Technology, Cambridge, MA
| | - Ronald G Tompkins
- BioMEMS Resource Center, Department of Surgery, Massachusetts General Hospital, Boston, MA
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38
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Farge D, Frere C. Recent advances in the treatment and prevention of venous thromboembolism in cancer patients: role of the direct oral anticoagulants and their unique challenges. F1000Res 2019; 8. [PMID: 31297188 PMCID: PMC6600867 DOI: 10.12688/f1000research.18673.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2019] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer and is associated with poor prognosis. Low-molecular-weight heparins (LMWHs) are the standard of care for the treatment of cancer-associated thrombosis. Primary VTE prophylaxis with LMWH is recommended after cancer surgery and in hospitalized patients with reduced mobility. However, owing to wide variations in VTE and bleeding risk, based on disease stage, anti-cancer treatments, and individual patient characteristics, routine primary prophylaxis is not recommended in ambulatory cancer patients undergoing chemotherapy. Efforts are under way to validate risk assessment models that will help identify those patients in whom the benefits of primary prophylaxis will outweigh the risks. In recent months, long-awaited dedicated clinical trials assessing the direct oral anticoagulants (DOACs) in patients with cancer have reported promising results. In comparison with the LMWHs, the DOACs were reported to be non-inferior to prevent VTE recurrence. However, there was an increased risk of bleeding, particularly in gastrointestinal cancers. Safe and optimal treatment with the DOACs in the patient with cancer will require vigilant patient selection based on patient characteristics, co-morbidities, and the potential for drug-drug interactions.
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Affiliation(s)
- Dominique Farge
- Université de Paris, IRSL, Paris, France.,Assistance Publique Hôpitaux de Paris, Saint-Louis Hospital, Internal Medicine, Autoimmune and Vascular Disease Unit, Paris, France.,McGill University, Montral, QC, Canada
| | - Corinne Frere
- Sorbonne Université, INSERM UMRS_1166, Institute of Cardiometabolism And Nutrition, Paris, France.,Assistance Publique Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Haematology, Paris, France
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39
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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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40
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Frere C, Benzidia I, Marjanovic Z, Farge D. Recent Advances in the Management of Cancer-Associated Thrombosis: New Hopes but New Challenges. Cancers (Basel) 2019; 11:cancers11010071. [PMID: 30634638 PMCID: PMC6357110 DOI: 10.3390/cancers11010071] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 12/31/2018] [Accepted: 01/08/2019] [Indexed: 12/13/2022] Open
Abstract
Venous thromboembolism (VTE) is a common cause of morbidity and mortality in cancer patients and leads to a significant increase in health care costs. Cancer patients often suffer from multiple co-morbidities and have both a greater risk of VTE recurrence and bleeding compared to non-cancer patients. Anticoagulation is therefore challenging. For many years, long-term therapy with Low-Molecular-Weight Heparin (LMWH) was the standard of care for the management of cancer-associated VTE. Direct oral anticoagulants (DOAC), which offer the convenience of an oral administration and have a rapid onset of action, have recently been proposed as a new option in this setting. Head-to-head comparisons between DOAC and LMWHs for the treatment of established VTE are now available, and data on the efficacy and safety of these drugs for primary prophylaxis of VTE in ambulatory cancer patients receiving systemic anticancer therapy are emerging. This narrative review aims to summarize the main recent advances in the prevention and treatment of cancer-associated VTE, including recent data on the use of individualized factors to stratify the risk of VTE in each individual patient, quality-of-life in patients treated with LMWH, and the place that DOACs will likely take in the cancer-associated VTE management landscape.
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Affiliation(s)
- Corinne Frere
- Institute of Cardiometabolism And Nutrition, INSERM UMRS_1166, Sorbonne Université, F-75013 Paris, France.
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, F-75013 Paris, France.
| | - Ilham Benzidia
- Autoimmune and Vascular Disease Unit, Internal Medicine (UF04), Center of reference for rare systemic autoimmne diseases (FAI2R), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, F-75010 Paris, France.
| | - Zora Marjanovic
- Department of Haematology, Saint-Antoine Hospital, Assistance Publique Hôpitaux de Paris, F-75012 Paris, France.
| | - Dominique Farge
- Autoimmune and Vascular Disease Unit, Internal Medicine (UF04), Center of reference for rare systemic autoimmne diseases (FAI2R), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, F-75010 Paris, France.
- Department of Medicine, McGill University, Montreal, QC H3A 0E7, Canada.
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Scotté F, Leroy P, Chastenet M, Aumont L, Benatar V, Elalamy I. Treatment and Prevention of Cancer-Associated Thrombosis in Frail Patients: Tailored Management. Cancers (Basel) 2019; 11:cancers11010048. [PMID: 30621020 PMCID: PMC6356758 DOI: 10.3390/cancers11010048] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 12/22/2018] [Accepted: 12/28/2018] [Indexed: 01/11/2023] Open
Abstract
Advanced age is one of the major determinants of frailty in patients with cancer-associated thrombosis. However, multiple other factors contribute to frailty in these patients. The identification of frailty in patients with cancer-associated thrombosis is critical as it influences the complexity of the anticoagulant treatment in this population at high risk of venous thromboembolism and bleeding. Factors that contribute to frailty in patients with cancer-associated thrombosis include age, type of cancer, comorbidities such as chronic kidney disease, poly-pharmacotherapy, treatment compliance, cognitive impairment, anemia, thrombocytopenia, mobility, nutritional status, Eastern Cooperative Oncology Group grade, risk of falls, and reduced life expectancy. In the absence of specific clinical studies current anticoagulant treatment guidelines for the management are not fully applicable to frail patients with cancer. The anticoagulant treatment should therefore benefit from a tailored approach based on an algorithm that takes into account the specificities of the malignant disease.
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Affiliation(s)
- Florian Scotté
- Department of Medical Oncology and Supportive Care. Hôpital Foch, 92150 Suresnes, France.
| | - Pauline Leroy
- Department of Medical Oncology and Supportive Care. Hôpital Foch, 92150 Suresnes, France.
| | - Mathilde Chastenet
- Department of Medical Oncology and Supportive Care. Hôpital Foch, 92150 Suresnes, France.
| | - Laure Aumont
- Department of Medical Oncology and Supportive Care. Hôpital Foch, 92150 Suresnes, France.
| | - Vidal Benatar
- Heathics Clinical Consultants. 111 rue des Tennerolles, 92210 Saint-Cloud, France.
| | - Ismaïl Elalamy
- Department of Hematology, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Sorbonne Université, INSERM UMR S938, 75012 Paris, France.
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