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Chiu J, Lazo-Langner A. Venous thromboembolism in hematopoietic stem cell transplantation: A narrative review. Thromb Res 2023; 226:141-149. [PMID: 37150028 DOI: 10.1016/j.thromres.2023.04.019] [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: 02/07/2023] [Revised: 03/28/2023] [Accepted: 04/21/2023] [Indexed: 05/09/2023]
Abstract
Venous thromboembolism (VTE) is a common complication of hematopoietic stem cell transplantation (HSCT) and its treatment has significant effects on morbidity and non-relapse mortality. There is a complex interplay on balancing the risk for thrombosis and bleeding in these patients, making treatment decisions particularly challenging. Despite this, there are currently no validated risk assessment models or guidelines to aid clinical decision making on thromboprophylaxis and VTE treatment in this population of patients. Herein, we review the many risk factors for VTE in HSCT patients, categorized into patient, disease, catheter, treatment, laboratory, and transplant-related variables. This review also discusses current thromboprophylaxis and VTE management strategies in HSCT patients, with scope into the development of risk assessment models that allow for identification of high-risk subgroups who may benefit from targeted intervention.
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Affiliation(s)
- Jodi Chiu
- Department of Medicine, Division of Hematology, Western University, London, ON, Canada
| | - Alejandro Lazo-Langner
- Department of Medicine, Division of Hematology, Western University, London, ON, Canada; Department of Epidemiology and Biostatistics, Western University, London, ON, Canada.
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Squizzato A, Galliazzo S, Rancan E, Di Pilla M, Micucci G, Podda G, Valeriani E, Campiotti L, Bertù L, Ageno W, Porreca E, Lodigiani C. Current management of cancer-associated venous thromboembolism in patients with thrombocytopenia: a retrospective cohort study. Intern Emerg Med 2022; 17:83-90. [PMID: 34110563 PMCID: PMC8841325 DOI: 10.1007/s11739-021-02771-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 05/21/2021] [Indexed: 11/27/2022]
Abstract
Optimal management of venous thromboembolism (VTE) in cancer patients with thrombocytopenia is uncertain. We described current management and clinical outcomes of these patients. We retrospectively included a cohort of cancer patients with acute VTE and concomitant mild (platelet count 100,000-150,000/mm3), moderate (50,000-99,000/mm3), or severe thrombocytopenia (< 50,000/mm3). Univariate and multivariate logistic regression analyses explored the association between different therapeutic strategies and thrombocytopenia. The incidence of VTE and bleeding complications was collected at a 3-month follow-up. A total of 194 patients of whom 122 (62.89%) had mild, 51 (26.29%) moderate, and 22 (11.34%) severe thrombocytopenia were involved. At VTE diagnosis, a full therapeutic dose of LMWH was administered in 79.3, 62.8 and 4.6% of patients, respectively. Moderate (OR 0.30; 95% CI 0.12-0.75), severe thrombocytopenia (OR 0.01; 95% CI 0.00-0.08), and the presence of cerebral metastasis (OR 0.06; 95% CI 0.01-0.30) were independently associated with the prescription of subtherapeutic LMWH doses. Symptomatic VTE (OR 4.46; 95% CI 1.85-10.80) and pulmonary embolism (OR 2.76; 95% CI 1.09-6.94) were associated with the prescription of full therapeutic LMWH doses. Three-month incidence of VTE was 3.9% (95% CI 1.3-10.1), 8.5% (95% CI 2.8-21.3), 0% (95% CI 0.0-20.0) in patients with mild, moderate, and severe thrombocytopenia, respectively. The corresponding values for major bleeding and mortality were 1.9% (95% CI 0.3-7.4), 6.4% (95% CI 1.7-18.6), 0% (95% CI 0.0-20.0) and 9.6% (95% CI 5.0-17.4), 48.2% (95% CI 16.1-42.9), 20% (95% CI 6.6-44.3). In the absence of sound evidence, anticoagulation strategy of VTE in cancer patients with thrombocytopenia was tailored on an individual basis, taking into account not only the platelet count but also VTE presentation and the presence of cerebral metastasis.
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Affiliation(s)
- Alessandro Squizzato
- Research Center On Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Silvia Galliazzo
- Department of Internal Medicine, San Valentino Hospital, Montebelluna (Treviso), Italy.
- U.O.C. Medicina, ULSS 2, Ospedale San Valentino, via Palmiro Togliatti 1, 31044, Montebelluna (Treviso), Italy.
| | - Elena Rancan
- Research Center On Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Marina Di Pilla
- Thrombosis and Hemorragic Diseases Unit, IRCCS Humanitas Clinical and Research Hospital, Milan, Italy
| | | | - Gianmarco Podda
- U.O. Medicina III, Department of Health Science, ASST Santi Paolo e Carlo-University of Milan, Milan, Italy
| | - Emanuele Valeriani
- Department of Medical, Oral and Biotechnological Sciences "G. D'Annunzio" University, Chieti, Italy
| | - Leonardo Campiotti
- Research Center On Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Lorenza Bertù
- Research Center On Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Walter Ageno
- Research Center On Thromboembolic Disorders and Antithrombotic Therapies, University of Insubria, Varese and Como, Italy
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences "G. D'Annunzio" University, Chieti, Italy
| | - Corrado Lodigiani
- Thrombosis and Hemorragic Diseases Unit, IRCCS Humanitas Clinical and Research Hospital, Milan, Italy
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Platelet cut-off for anticoagulant therapy in thrombocytopenic patients with blood cancer and venous thromboembolism: an expert consensus. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 17:171-180. [PMID: 30418130 DOI: 10.2450/2018.0143-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Management of venous thromboembolism (VTE) in patients with haematologic malignancies and thrombocytopenia is clinically challenging due to the related risks. No prospective studies or clinical trials have been carried out and, therefore, no solid evidence on this compelling issue is available. METHODS Given this, an expert panel endorsed by the Gruppo Italiano Malattie Ematologiche dell'Adulto Working Party on Thrombosis and Haemostasis was set up to produce a formal consensus, according to the RAND method, in order to issue clinical recommendations about the platelet (PLT) cut-off for safe administration of low molecular weight heparin (LMWH) in thrombocytopenic (PLT <100×109/L) adult patients with haematologic malignancies affected by acute (<1 month) or non-acute VTE. RESULTS In acute VTE, the panel suggests safe anticoagulation with LMWH at therapeutic doses for PLT between ≥50<100×109/L and at 50% dose reduction for PLT ≥30<50×109/L. In acute VTE for PLT <30×109/L, the following interventions are recommended: positioning of an inferior vena cava (IVC) filter with prophylactic LMWH administration and platelet transfusion. In non-acute VTE, anticoagulation with LMWH at therapeutic doses for PLT between ≥50<100×109/L or over and at 50% dose reduction for PLT ≥30<50×109/L is considered appropriate. The discontinuation of full or reduced therapeutic dose of LMWH is recommended for PLT <30×109/L, both in acute and non-acute VTE. DISCUSSION We suggest using dose-adjusted LMWH according to PLT to optimise anticoagulant treatment in patients at high bleeding risk.
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Samuelson Bannow BR, Lee AYY, Khorana AA, Zwicker JI, Noble S, Ay C, Carrier M. Management of anticoagulation for cancer-associated thrombosis in patients with thrombocytopenia: A systematic review. Res Pract Thromb Haemost 2018; 2:664-669. [PMID: 30349884 PMCID: PMC6178713 DOI: 10.1002/rth2.12111] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 04/19/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The management of anticoagulation for cancer-associated thrombosis (CAT) in patients with thrombocytopenia is controversial. Whereas some studies suggest that administration of reduced-dose low-molecular-weight heparin (LMWH) or temporary discontinuation for moderate and severe thrombocytopenia may be a safe and effective, others suggest full-dose anticoagulation with transfusion support. We sought to address this important knowledge gap and summarize the literature comparing these two common management strategies. METHODS A systematic review of the literature (PROSPERO CRD42017077127) using MEDLINE (inception to September 2017) was conducted. We included studies that reported recurrent venous thromboembolism (VTE) and major bleeding complications among patients treated with both of the two most common management strategies: therapeutic anticoagulation with platelet transfusion support and dose-modified anticoagulation for periods when the platelet count is <50 × 109/L. RESULTS A total of 134 article records were identified on the initial search and 10 articles underwent full text review. Two observational studies met the inclusions criteria. A total of 121 patients with CAT and thrombocytopenia were included. Forty-two of these patients had pulmonary embolism and 87 had deep vein thrombosis (DVT) including 38 upper extremity DVT. Overall, 27% of patients, regardless of their treatment strategy, experienced recurrent VTE. Thirteen percent of anticoagulated patients (15% of all patients) experienced a major bleeding episode. Meta-analysis could not be conducted. CONCLUSIONS Our findings do not support one management strategy over another to treat CAT patients with thrombocytopenia. However, the data highlights the heightened risk of recurrent VTE in this patient population despite the thrombocytopenia.
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Affiliation(s)
| | - Agnes Y. Y. Lee
- Division of HematologyDepartment of MedicineUniversity of British ColumbiaVancouverBCCanada
| | - Alok A. Khorana
- Department of Hematology and Medical OncologyTaussig Cancer InstituteCleveland Clinic FoundationClevelandOHUSA
| | - Jeffrey I. Zwicker
- Division of Hemostasis and ThrombosisBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMAUSA
| | - Simon Noble
- Cottingham Marie Curie Palliative Care Research CentreCardiff UniversityCardiffWalesUK
| | - Cihan Ay
- Clinical Division of Hematology and HemostaseologyDepartment of MedicineMedical University of ViennaViennaAustria
| | - Marc Carrier
- Department of MedicineOttawa Hospital Research Institute at the University of OttawaOttawaONCanada
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