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Laporte S, Benhamou Y, Bertoletti L, Frère C, Hanon O, Couturaud F, Moustafa F, Mismetti P, Sanchez O, Mahé I. [Translation into French and republication of: "Management of cancer-associated thromboembolism in vulnerable population"]. Rev Med Interne 2024:S0248-8663(24)00581-2. [PMID: 38789323 DOI: 10.1016/j.revmed.2024.05.019] [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: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 05/26/2024]
Abstract
Although all patients with cancer-associated thrombosis (CAT) have a high morbidity and mortality risk, certain groups of patients are particularly vulnerable. This may expose the patient to an increased risk of thrombotic recurrence or bleeding (or both), as the benefit-risk ratio of anticoagulant treatment may be modified. Treatment thus needs to be chosen with care. Such vulnerable groups include older patients, patients with renal impairment or thrombocytopenia, and underweight and obese patients. However, these patient groups are poorly represented in clinical trials, limiting the available data on which treatment decisions can be based. Meta-analysis of data from randomised clinical trials suggests that the relative treatment effect of direct oral factor Xa inhibitors (DXIs) and low molecular weight heparin (LMWH) with respect to major bleeding could be affected by advanced age. No evidence was obtained for a change in the relative risk-benefit profile of DXIs compared to LMWH in patients with renal impairment or of low body weight. The available, albeit limited, data do not support restricting the use of DXIs in patients with TAC on the basis of renal impairment or low body weight. In older patients, age is not itself a critical factor for choice of treatment, but frailty is such a factor. Patients over 70 years of age with CAT should undergo a systematic frailty evaluation before choosing treatment and modifiable bleeding risk factors should be addressed. In patients with renal impairment, creatine clearance should be assessed and monitored regularly thereafter. In patients with an eGFR less than 30mL/min/1.72m2, the anticoagulant treatment may need to be adapted. Similarly, platelet count should be assessed prior to treatment and monitored regularly. In patients with grade 3-4, thrombocytopenia (less than 50,000platelets/μL) treatment with a LMWH at a reduced dose should be considered. For patients with CAT and low body weight, standard anticoagulant treatment recommendations are appropriate, whereas in obese patients, apixaban may be preferred.
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Affiliation(s)
- S Laporte
- Unité de recherche clinique, innovation et pharmacologie, hôpital Nord, CHU de Saint-Étienne, Sainbiose Inserm, université Jean-Monnet, 42000 Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Y Benhamou
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine interne, CHU Charles-Nicolle, université de Rouen Normandie, Inserm U1096, Normandie université, Rouen, France
| | - L Bertoletti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, équipe dysfonction vasculaire et hémostase, CHU de Saint-Étienne, Inserm UMR1059, université Jean-Monnet, Inserm CIC-1408, Saint-Étienne, France
| | - C Frère
- Inserm UMRS 1166, GRC 27 Greco, DMU BioGeMH, hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, Sorbonne université, Paris, France
| | - O Hanon
- Service de gérontologie, hôpital Broca, AP-HP, EA 4468, université de Paris Cité, Paris, France
| | - F Couturaud
- F-CRIN INNOVTE network, Saint-Étienne, France; Département de médecine interne, médecine vasculaire et pneumologie, CHU de Brest, Inserm U1304-Getbo, université de Brest, Brest, France
| | - F Moustafa
- F-CRIN INNOVTE network, Saint-Étienne, France; Département urgence, Inrae, UNH, hôpital de Clermont-Ferrand, université Clermont-Auvergne, Clermont-Ferrand, 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
- F-CRIN INNOVTE network, Saint-Étienne, France; Innovations thérapeutiques en hémostase, université Paris Cité, Inserm UMR S1140, Paris, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France
| | - I Mahé
- F-CRIN INNOVTE network, Saint-Étienne, France; Innovations thérapeutiques en hémostase, université Paris Cité, Inserm UMR S1140, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France
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2
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Ma S, Fan G, Xu F, Zhang X, Chen Y, Tao Y, Li Y, Lyu Y, Yang P, Wang D, Zhai Z, Wang C. Efficacy and safety of anticoagulant for treatment and prophylaxis of VTE patients with renal insufficiency: a systemic review and meta-analysis. Thromb J 2024; 22:17. [PMID: 38317247 PMCID: PMC10840151 DOI: 10.1186/s12959-023-00576-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/25/2023] [Indexed: 02/07/2024] Open
Abstract
Patients with venous thromboembolism (VTE) comorbid renal insufficiency (RI) are at higher risk of bleeding and thrombosis. Recommendations in guidelines on anticoagulation therapy for those patients remain ambiguous. The goal of this study is to compare the efficacy and safety between different anticoagulant regimens in VTE patients comorbid RI at different stages of treatment and prophylaxis. We performed English-language searches of Pubmed, EMBASE, and Web of Science (inception to Nov 2022). RCTs evaluated anticoagulants for VTE treatment at the acute phase, extension phase, and prophylaxis in patients with RI and reported efficacy and safety outcomes were selected. The methodological quality of the studies was assessed at the outcome level using the risk-of-bias assessment tool developed by the Cochrane Bias Methods Group. A meta-analysis of twenty-five RCTs was conducted, comprising data from twenty-three articles, encompassing a total of 9,680 participants with RI. In the acute phase, the risk of bleeding was increased with novel oral anticoagulants (NOACs) compared to LMWH (RR 1.29, 95% CI 1.04-1.60). For the prophylaxis of VTE, NOACs were associated with an elevated risk of bleeding compared with placebo (RR 1.31, 95%CI 1.02-1.68). In comparison to non-RI patients, both NOACs and vitamin K antagonists (VKA) could increase the risk of bleeding among RI patients (RR 1.45, 95%CI 1.14-1.84 and RR 1.53, 95%CI 1.25-1.88, respectively) during acute phase, while NOACs may increase the incidence of VTE in RI population (RR 1.74, 95%CI 1.29-2.34). RI patients who are under routine anticoagulation have a significantly higher risk of adverse outcomes. LMWH is the most effective and safe option for VTE treatment or prophylaxis in patients with RI.
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Affiliation(s)
- Shuangshuang Ma
- Beijing University of Chinese Medicine. National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Guohui Fan
- School of Population Medicine and Public Health, Chinese Academy of Medical Sciences & Peking Union Medical College; State Key Laboratory of Respiratory Health and Multimorbidity; Key Laboratory of Pathogen Infection Prevention and Control (Peking Union Medical College), Ministry of Education, Beijing, China
- National Center for Respiratory Medicine; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Clinical Research and Data Management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Feiya Xu
- Graduate School of Capital Medical University, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Xiaomeng Zhang
- Peking University China‑Japan Friendship School of Clinical Medicine, Beijing, P.R. China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yinong Chen
- Peking University China‑Japan Friendship School of Clinical Medicine, Beijing, P.R. China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yuzhi Tao
- The First Bethune Hospital of Jilin University, Beijing, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yishan Li
- The First Clinical Medical College, Shanxi Medical University, Taiyuan, China
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China
| | - Yanshuang Lyu
- Changping Laboratory, Beijing, China
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Peiran Yang
- Department of Physiology, Institute of Basic Medical Sciences, State Key Laboratory of Respiratory Health and Multimorbidity, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Dingyi Wang
- National Center for Respiratory Medicine; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; Department of Clinical Research and Data Management, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.
| | - Zhenguo Zhai
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, 100029, China.
| | - Chen Wang
- National Center for Respiratory Medicine; State Key Laboratory of Respiratory Health and Multimorbidity; National Clinical Research Center for Respiratory Diseases, Beijing, 100029, China.
- Chinese Academy of Medical Sciences, Peking Union Medical College, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
- Department of Respiratory Medicine, Capital Medical University, No 2, East Yinghua Road, Chaoyang District, Beijing, 100029, China.
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Laporte S, Benhamou Y, Bertoletti L, Frère C, Hanon O, Couturaud F, Moustafa F, Mismetti P, Sanchez O, Mahé I. Management of cancer-associated thromboembolism in vulnerable population. Arch Cardiovasc Dis 2024; 117:45-59. [PMID: 38065754 DOI: 10.1016/j.acvd.2023.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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
Although all patients with cancer-associated thrombosis (CAT) have a high morbidity and mortality risk, certain groups of patients are particularly vulnerable. This may expose the patient to an increased risk of thrombotic recurrence or bleeding (or both), as the benefit-risk ratio of anticoagulant treatment may be modified. Treatment thus needs to be chosen with care. Such vulnerable groups include older patients, patients with renal impairment or thrombocytopenia, and underweight and obese patients. However, these patient groups are poorly represented in clinical trials, limiting the available data, on which treatment decisions can be based. Meta-analysis of data from randomised clinical trials suggests that the relative treatment effect of direct oral factor Xa inhibitors (DXIs) and low molecular weight heparin (LMWH) with respect to major bleeding could be affected by advanced age. No evidence was obtained for a change in the relative risk-benefit profile of DXIs compared to LMWH in patients with renal impairment or of low body weight. The available, albeit limited, data do not support restricting the use of DXIs in patients with CAT on the basis of renal impairment or low body weight. In older patients, age is not itself a critical factor for choice of treatment, but frailty is such a factor. Patients over 70 years of age with CAT should undergo a systematic frailty evaluation before choosing treatment and modifiable bleeding risk factors should be addressed. In patients with renal impairment, creatine clearance should be assessed and monitored regularly thereafter. In patients with an eGFR<30mL/min/1.72m2, the anticoagulant treatment may need to be adapted. Similarly, platelet count should be assessed prior to treatment and monitored regularly. In patients with grade 3-4, thrombocytopenia (<50,000 platelets/μL) treatment with a LMWH at a reduced dose should be considered. For patients with CAT and low body weight, standard anticoagulant treatment recommendations are appropriate, whereas in obese patients, apixaban may be preferred.
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Affiliation(s)
- Silvy Laporte
- SAINBIOSE Inserm, unité de recherche clinique, innovation et pharmacologie, hôpital Nord, université Jean-Monnet, CHU de Saint-Étienne, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Ygal Benhamou
- UNI Rouen U1096, service de médecine interne, Normandie université, CHU Charles-Nicolle, Rouen, France; F-CRIN INNOVTE network, Saint-Étienne, 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, CHU Saint-Étienne, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Corinne Frère
- Inserm UMRS 1166, GRC 27 GRECO, DMU BioGeMH, hôpital de la Pitié-Salpêtrière, Sorbonne université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Olivier Hanon
- Service de Gérontologie, hôpital Broca, AP-HP, EA 4468, Université de Paris Cité, Paris, France
| | - Francis Couturaud
- Inserm U1304 - GETBO, département de médecine interne, médecine vasculaire et pneumologie, université de Brest, CHU de Brest, Brest, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Farès Moustafa
- Inrae, UNH, département urgence, hôpital de Clermont-Ferrand, université Clermont Auvergne, Clermont-Ferrand, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU Saint-Etienne, Hôpital Nord, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Olivier Sanchez
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-CRIN INNOVTE network, Saint-Étienne, France
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Yannoutsos A, Cacciatore C, Jaouen S, Farge D, Frere C. Treatment of cancer-associated venous thromboembolism: A focus on special populations. JOURNAL DE MEDECINE VASCULAIRE 2023; 48:124-135. [PMID: 37914457 DOI: 10.1016/j.jdmv.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/02/2023] [Indexed: 11/03/2023]
Abstract
Current evidence-based clinical practice guidelines recommend the use of both low-molecular-weight heparin (LMWH) and direct factor Xa inhibitors (apixapan, edoxaban and rivaroxaban) as first-line options for the treatment of venous thromboembolism (VTE) in patients with cancer. However, most of these guidelines refer to the general cancer patient population and provide limited guidance for specific subgroups of patients at particularly high risk of bleeding, such as those with gastrointestinal cancers, primary or metastatic brain tumors, thrombocytopenia, or renal impairment. In these complex populations, the management of cancer-associated thrombosis (CAT) poses unique challenges and requires a nuanced approach based on the primum non nocere principle. This comprehensive review critically examines the relevant literature and discusses the therapeutic options currently available for the management of CAT in these special situations.
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Affiliation(s)
- Alexandra Yannoutsos
- Department of Vascular Medicine, Groupe Hospitalier Paris Saint-Joseph, Paris, France
| | - Carlotta Cacciatore
- Department of Internal Medicine (UF 04), CRMR MATHEC, Maladies Auto-Immunes et Thérapie Cellulaire, Saint-Louis Hospital, AP-HP Nord, Université de Paris, Paris, France
| | - Simon Jaouen
- Department of Hematology, CHRU de Brest, Brest, France
| | - Dominique Farge
- Department of Internal Medicine (UF 04), CRMR MATHEC, Maladies Auto-Immunes et Thérapie Cellulaire, Saint-Louis Hospital, AP-HP Nord, Université de Paris, Paris, France
| | - Corinne Frere
- Sorbonne Université, INSERM UMRS 1166, GRC 27 GRECO, Paris, France; DMU BioGeMH, AP-HP, Sorbonne Université, Paris, France.
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A systematic review of the efficacy and safety of anticoagulants in advanced chronic kidney disease. J Nephrol 2022; 35:2015-2033. [PMID: 36006608 PMCID: PMC9584987 DOI: 10.1007/s40620-022-01413-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis. METHODS We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included. RESULTS Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile. CONCLUSION Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
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Fan G, Wang D, Zhang M, Luo X, Zhai Z, Wu S. Anticoagulant for treatment and prophylaxis of venous thromboembolism patients with renal dysfunction: A systematic review and network meta-analysis. Front Med (Lausanne) 2022; 9:979911. [PMID: 36226154 PMCID: PMC9548609 DOI: 10.3389/fmed.2022.979911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objective The aim of this study was to compare the efficacy and safety for particular regimen and dosage in venous thromboembolism (VTE) patients with renal insufficiency. Methods English language searches of PubMed, Embase, and Web of Science (inception to May 2021). RCTs evaluating anticoagulants for VTE treatment at acute phase, extension phase, and VTE prophylaxis in patients with renal insufficiency and reporting efficacy (death, recurrence, or occurrence of VTE) and safety (bleeding) outcomes were selected. The methodological quality of each study included was assessed at the outcome level using the risk-of-bias assessment tool developed by the Cochrane Bias Methods Group. Results Twenty-one trials that involved 76,574 participants and 8,972 (11.7%) patients with renal insufficiency were enrolled, including 10 trials on VTE treatment in acute phase (3–12 months), four trials on VTE treatment in extension phase (6–36 months), and seven trials for VTE prophylaxis. For acute VTE treatment, compared with dabigatran etexilate, apixaban (RR 5.90, 95%CI 1.00–34.60) and rivaroxaban (RR 6.18, 95%CI 1.17–32.75) were significantly associated with increased risk of death or recurrence. For extension treatment of VTE, aspirin had the highest probability of the most effective and safest treatment, followed by apixaban. For VTE prophylaxis, compared with enoxaparin, desirudin was associated with lower risk of VTE occurrence (RR 0.56, 95% CI 0.34–0.91), but had higher risk of bleeding than dabigatran etexilate. Conclusion The network meta-analysis informs the optimal choice of anticoagulants and their particular dosage for treatment and prophylaxis of VTE patients comorbid renal insufficiency. Systematic review registration www.crd.york.ac.uk/prospero/, identifier: CRD42021254086.
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Affiliation(s)
- Guohui Fan
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
| | - Dingyi Wang
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
| | - Meng Zhang
- Department of Respiratory and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xufei Luo
- School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhenguo Zhai
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Sinan Wu
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Disease, Beijing, China
- National Clinical Research Center for Respiratory Disease, Beijing, China
- Institute of Respiratory Medicine, Chinses Academy of Medical Sciences, Beijing, China
- *Correspondence: Sinan Wu
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Jiménez-Fonseca P, Gallardo E, Arranz Arija F, Blanco JM, Callejo A, Lavin DC, Costa Rivas M, Mosquera J, Rodrigo A, Sánchez Morillas R, Vares Gonzaléz M, Muñoz A, Carmona-Bayonas A. Consensus on prevention and treatment of cancer-associated thrombosis (CAT) in controversial clinical situations with low levels of evidence. Eur J Intern Med 2022; 100:33-45. [PMID: 35227541 DOI: 10.1016/j.ejim.2022.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/23/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cancer patients suffer high risk of venous thromboembolism (VTE). Cancer-associated VTE (CAT) causes hospitalization, morbidity, delayed cancer treatment, and mortality; therefore, exceptional CAT prevention and management are imperative. METHODS This review offers practical recommendations and treatment algorithms for eight complex, clinically relevant situations posing great uncertainty regarding management and requiring an urgent decision: VTE prophylaxis in ambulatory cancer patients with pancreatic pancreas (1) or lung cancer with molecular alterations (2); optimal management of VTE during antineoplastic treatment with antiangiogenics (3) or chemotherapy (4); protracted VTE treatment, determinants; (5) drugs used (6), and optimal VTE management in situations of high bleeding risk (7) or recurrent VTE (8). RESULTS With the evidence available, primary thromboprophylaxis in patients with lung cancer harbouring ALK/ROS1 translocations or pancreatic cancer receiving ambulatory chemotherapy must be appraised. If antiangiogenic therapy can yield a clear benefit and the patient recovers from a grade 3 thrombotic event, it can be cautiously re-introduced in selected cases, provided that the person agrees to assume the risk after being duly informed. Anticoagulation maintenance beyond 6 months is recommended in individuals with metastatic tumours, on active treatment, or at high risk for recurrent VTE without bleeding risk. In such cases, LMWH and DOACs are safe, being mindful that the latter could entail a higher risk of bleeding; consequently, they should be used judiciously in more haemorrhagic tumours, such as gastrointestinal cancers. In cases of recurrent VTE, the presence of active cancer, infra-therapeutic dose, and anticoagulant treatment failure must be ruled out. In individuals with platelet counts of 25,000-50,000 and VTE liable to recur who need anticoagulation, full-dose LMWH and transfusion support can be contemplated to reach values of > 50,000. In CAT unlikely to recur, decreasing the LMWH dose by 25-50% is recommended. Renal impairment associated with thrombosis must be treated with LMWHs; there is no need to adjust the dose in patients with CrCl > 30; with CrCl = 15-30, dose adjustment is advised, and suspended when CrCl is < 15. CONCLUSION We provide useful advice for complex, clinically relevant situations that clinicians treating CAT must face devoid of any unequivocal, strong, evidence-based recommendations.
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Affiliation(s)
- Paula Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Avenida Roma, Oviedo 33011, Spain.
| | - Enrique Gallardo
- Medical Oncology Department, Hospital Universitario Parc Tauli, Sabadell, Spain
| | - Fernando Arranz Arija
- Medical Oncology Department, Complejo Asistencial Universitario de Palencia, Palencia, Spain
| | - Jesús Manuel Blanco
- Medical Oncology Department, Hospital Universitario de Donosti, Donosti-San Sebastián, Spain
| | - Ana Callejo
- Medical Oncology Department, Hospital Universitario Vall d'Hebron, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Diego Cacho Lavin
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Joaquín Mosquera
- Medical Oncology Department, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Alberto Rodrigo
- Medical Oncology Department, Hospital Arnau de Vilanova, Lleida, Spain
| | | | - María Vares Gonzaléz
- Internal Medicine Department, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Andrés Muñoz
- Medical Oncology Department, Hospital Universitario Gregorio Marañon, Madrid, Spain
| | - Alberto Carmona-Bayonas
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, UMU, IMIB, Murcia, Spain
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Frere C, Crichi B, Rueda-Camino JA, Cajfinger F, Spiess N, Janus N, Le Maignan C, Marjanovic Z, Farge D. Long-term use of tinzaparin for the treatment of cancer-associated thrombosis in clinical practice: Insights from the prospective TROPIQUE study. JOURNAL DE MEDECINE VASCULAIRE 2022; 47:56-64. [PMID: 35691664 DOI: 10.1016/j.jdmv.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 03/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Real word data on the efficacy and safety of long-term use of tinzaparin for the treatment of cancer-associated thrombosis (CAT) are scarce. METHODS We performed a post-hoc analysis of all cancer patients included in the prospective multicenter observational TROPIQUE study who received long-term treatment with tinzaparin for a first venous thromboembolism (VTE) event. We evaluated the patterns of anticoagulant prescription, the adherence to clinical practice guidelines (CPGs) for the treatment of CAT, and the clinical outcomes within a 6-month follow-up. RESULTS In total, 301 patients were included in this post-hoc analysis. At study entry, their mean age was 64.6±11.9years and 143 (47.5%) patients were men. The most frequent cancer type was gastrointestinal (23.9%), followed by breast (17.9%) and lung (15.3%) cancer. At time of VTE diagnosis, 164 (57.8%) patients had metastatic disease and 245 (81.42%) were receiving chemotherapy. Based on the aggregation of all study pre-defined criteria, tinzaparin prescription was fully compliant with CPGs in 219 (72.8%) patients. The mean effective treatment duration with tinzaparin was 6.07±0.17months. At 6-month follow-up, the cumulative incidence of recurrent VTE was 5.4% (95% CI: 3.2-9.2%) and the cumulative incidence of major bleeding was 5.8% (95% CI: 3.6-9.6%). Clinical outcomes tended to differ across different types of cancer. Death from any cause occurred in 102 (33.9%) patients, mainly related to cancer progression. CONCLUSIONS This post-hoc analysis of TROPIQUE confirms the favorable benefit-risk ratio of tinzaparin for the long-term treatment of CAT.
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Affiliation(s)
- C Frere
- INSERM UMRS-1166, Institute of Cardiometabolism and Nutrition, GRC 27 GRECO, Sorbonne Université, DMU BioGem, Pitié-Salpêtrière Hospital, Assistance publique-Hôpitaux de Paris, 75013 Paris, France; Groupe Francophone Thrombose et Cancer, 75015 Paris, France.
| | - B Crichi
- Groupe Francophone Thrombose et Cancer, 75015 Paris, France; Internal Medicine Unit (UF 04): CRMR MATHEC, Maladies Auto-immunes et Thérapie Cellulaire, Saint-Louis Hospital, Assistance publique-Hôpitaux de Paris, 75010 Paris, France
| | - J A Rueda-Camino
- Groupe Francophone Thrombose et Cancer, 75015 Paris, France; Department of Internal Medicine, Hospital Rey Juan Carlos, Madrid, Spain
| | - F Cajfinger
- Groupe Francophone Thrombose et Cancer, 75015 Paris, France; Department of Medical Oncology, Pitié-Salpêtrière Hospital, Assistance publique-Hôpitaux de Paris, 75013 Paris, France
| | - N Spiess
- LEO Pharma, 78960 Voisin-le-Bretonneux, France
| | - N Janus
- LEO Pharma, 78960 Voisin-le-Bretonneux, France
| | - C Le Maignan
- Groupe Francophone Thrombose et Cancer, 75015 Paris, France; Department of Internal Medicine, Hospital Rey Juan Carlos, Madrid, Spain
| | - Z Marjanovic
- Groupe Francophone Thrombose et Cancer, 75015 Paris, France; Department of Hematology, Saint-Antoine Hospital, Assistance publique-Hôpitaux de Paris, 75010 Paris, France
| | - D Farge
- Groupe Francophone Thrombose et Cancer, 75015 Paris, France; Internal Medicine Unit (UF 04): CRMR MATHEC, Maladies Auto-immunes et Thérapie Cellulaire, Saint-Louis Hospital, Assistance publique-Hôpitaux de Paris, 75010 Paris, France; Université de Paris, Institut Universitaire d'Hématologie, EA 3518, 75010 Paris, France
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9
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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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10
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Salgado M, Brozos-Vázquez E, Campos B, González-Villarroel P, Pérez ME, Vázquez-Tuñas ML, Arias D. Venous Thromboembolism In Cancer Patients: "From Evidence to Care". Clin Appl Thromb Hemost 2022; 28:10760296221098717. [PMID: 35538861 PMCID: PMC9102132 DOI: 10.1177/10760296221098717] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This article seeks to review the current status of treatment and prevention of venous thromboembolic disease (VTE) in cancer patients after the addition of direct oral anticoagulants (DOAC) to the therapeutic arsenal available. The suitability of DOAC use in complex clinical situations, poorly represented in clinical trials, is controversial and difficult for care activity, making the recommendations in clinical practice guidelines the focus of special attention in this area. Recently, several randomized trials have compared low molecular weight heparin (LMWH) to DOAC for the management of CAT. Potential drug interactions with DOACs or the increased risk of bleeding in intraluminal tumors require special precautions, as do metastatic or primary brain disease and comorbid conditions, such as renal or liver failure, which are not suitably represented in pivotal studies. Furthermore, few data are available for situations involving elevated bleeding risk, with thrombocytopenia levels below the inclusion criterion of clinical trials, or recurrence during active anticoagulant therapy. Similarly, it is less clear that patients and physicians accept the presumption that oral DOAC administration is more convenient than subcutaneous LMWH, particularly when drug absorption may be compromised. The non-inclusion or under-representation of patients at higher risk for complications with anticoagulation in randomized clinical trials, makes their use complex in certain situations in health care. This paper provides a practical review of current clinical guideline recommendations regarding LMWH and/ or DOAC to treat and prevent CAT, as well as the most controversial clinical conditions for their use.
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Affiliation(s)
- Mercedes Salgado
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Elena Brozos-Vázquez
- Medical Oncology Department, 59535Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Begoña Campos
- Medical Oncology Department, 309716Hospital Universitario Lucus Augusti, Lugo, Spain
| | | | - María Eva Pérez
- Medical Oncology Department, 16811Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | | | - David Arias
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
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11
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Fioretti AM, Leopizzi T, Puzzovivo A, Giotta F, Lorusso V, Luzzi G, Oliva S. Cancer-Associated Thrombosis: Not All Low-Molecular-Weight Heparins Are the Same, Focus on Tinzaparin, A Narrative Review. Int J Clin Pract 2022; 2022:2582923. [PMID: 35936060 PMCID: PMC9325617 DOI: 10.1155/2022/2582923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 05/13/2022] [Accepted: 05/25/2022] [Indexed: 12/21/2022] Open
Abstract
Cancer-associated thrombosis (CAT) is the second main cause of cancer death with high related mortality and morbidity, leading to anticancer agent delays and interruptions. The recommended therapy, low-molecular-weight heparin (LMWH), however, is burdensome for patients and costly for society, as treatment should last until cancer is no longer active, even indefinitely. Tinzaparin is a manageable, efficient, safe, and cost-effective option. Compared to the other LMWHs, advantages are single-daily dose and safety in the elderly and those with renal impairment (RI). The purpose of this review is to critically discuss recent data on its efficacy and safety in CAT.
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Affiliation(s)
- Agnese Maria Fioretti
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Tiziana Leopizzi
- Cardiology-Intensive Care Unit, Ospedale SS. Annunziata, Via Francesco Bruno 1, 74121 Taranto, Italy
| | - Agata Puzzovivo
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Francesco Giotta
- Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Vito Lorusso
- Medical Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
| | - Giovanni Luzzi
- Cardiology-Intensive Care Unit, Ospedale SS. Annunziata, Via Francesco Bruno 1, 74121 Taranto, Italy
| | - Stefano Oliva
- Cardio-Oncology Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale Orazio Flacco 65, 70124 Bari, Italy
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12
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Safety and efficacy of apixaban thromboprophylaxis in ambulatory cancer patients according to renal function: A subgroup analysis of the AVERT trial. Thromb Res 2022; 211:85-87. [DOI: 10.1016/j.thromres.2022.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/20/2022] [Accepted: 01/24/2022] [Indexed: 02/02/2023]
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13
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Englisch C, Moik F, Ay C. Risk assessment for recurrent venous thromboembolism in patients with cancer. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023] Open
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14
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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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15
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Xiong W. Current status of treatment of cancer-associated venous thromboembolism. Thromb J 2021; 19:21. [PMID: 33789658 PMCID: PMC8010277 DOI: 10.1186/s12959-021-00274-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 03/18/2021] [Indexed: 12/20/2022] Open
Abstract
Patients with cancer are prone to develop venous thromboembolism (VTE) that is the second leading cause of mortality among them. Cancer patients with VTE may encounter higher rates of VTE recurrence and bleeding complications than patients without cancer. Treatment of established VTE is often complex in patients with cancer. Treatment of cancer-associated VTE basically comprises initial treatment, long-term treatment, treatment within 6 months, treatment beyond 6 months, treatment of recurrent VTE, and treatment in special situations. Decision of antithrombotic therapy, selection of anticoagulants, duration of anticoagulation, decision of adjuvant therapy, and adjustment of regimen in special situations are the major problems in the treatment of cancer-associated VTE. Therapeutic anticoagulation is the key of the key in the treatment of cancer-associated VTE. In addition to the efficacy and safety of low-molecular-weight heparin (LMWH) that has been fully demonstrated, direct oral anticoagulants (DOACs) are increasingly showing its advantages along with the accompanying concern in the treatment of cancer-associated VTE. The latest ASCO, ITAC and NCCN guidelines agree with each other on most aspects with respect to the treatment of cancer-associated VTE, whereas differ on a few issues. Encompassing recent randomized controlled trials, clinical trials, and meta-analyses, as well as the comparison of the latest authoritative guidelines including the NCCN, ASCO, and ITAC guidelines in this field, the objective of this review is to present current overview and recommendations for the treatment of cancer-associated VTE.
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Affiliation(s)
- Wei Xiong
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Affiliated to Shanghai Jiaotong University School of Medicine, No. 1665, Kongjiang Road, Yangpu District, Shanghai, 200092, China.
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16
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Treatment of venous thromboembolism in cancer patients: The dark side of the moon. Cancer Treat Rev 2021; 96:102190. [PMID: 33812338 DOI: 10.1016/j.ctrv.2021.102190] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. The risk of emergent VTE is four- to seven-fold higher in cancer patients compared to non-cancer patients. Although the therapeutic armamentarium for cancer-associated VTE has been recently implemented, anticoagulant treatment remains challenging because of the increased risk of recurrent VTE and bleeding. Several international societies and expert panels released clinical practice guidelines on VTE treatment which are mostly focused on the general cancer population. Nevertheless, recommendations for the management of VTE in patients with peculiar clinical presentations are inconsistent and remain elusive due to the lack of pertinent evidence. The challenging clinical scenarios include, among others, patients with thrombocytopenia, renal impairment, gastrointestinal cancer, primary or metastatic brain cancer, distal thrombosis of the lower extremities, catheter-related VTE, splanchnic thrombosis, incidental VTE, extreme body weight, recurrent VTE during treatment, as well as the optimal duration of anticoagulant treatment in patients with active disease who have received 3 to 6 months of anticoagulation. Herein, we present a critical overview on VTE management in these challenging clinical settings, discuss potential approaches, and include some calls to action for future clinical research.
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17
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Vathiotis IA, Syrigos NK, Dimakakos EP. Tinzaparin Safety in Patients With Cancer and Renal Impairment: A Systematic Review. Clin Appl Thromb Hemost 2021; 27:1076029620979592. [PMID: 33464938 PMCID: PMC7818003 DOI: 10.1177/1076029620979592] [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] [Indexed: 01/04/2023] Open
Abstract
Low-molecular-weight heparins are approved for primary and secondary venous
thromboembolism prevention. Tinzaparin is the low-molecular-weight heparin with
the highest average molecular weight. The purpose of this systematic review is
to provide an update regarding the safety profile of tinzaparin, prescribed
either as a prophylactic or as a therapeutic regimen for venous thromboembolism
in special populations, including cancer patients and patients with renal
impairment. We identified prospective studies up to August 2020 reporting safety
outcomes for cancer patients and patients with renal impairment on tinzaparin
regimens. In patients with cancer major bleeding rates fluctuated between 0.8%
and 7%. Patients on tinzaparin exhibited significantly lower rates of clinically
relevant nonmajor bleeding events in comparison with those on vitamin K
antagonists. Bioaccumulation of tinzaparin was not correlated with age, body
weight or creatinine clearance. Periodic administration of either prophylactic
or therapeutic doses of tinzaparin did not result in bioaccumulation, even in
patients with severe renal impairment and creatinine clearance < 20 ml/min.
Major bleeding rates for non-cancer patients with renal impairment on
prophylactic tinzaparin regimens were 0%. Non-cancer patients with renal
impairment on therapeutic tinzaparin regimens exhibited major bleeding in 0 to
3.4% of cases; major bleeding rates were higher for cancer patients with renal
impairment on therapeutic tinzaparin regimens (4.3 to 10%). Tinzaparin can be
used without dose adjustment in patients with severe renal impairment and
creatinine clearance > 20 ml/min. Tinzaparin represents a safe choice for
special populations at increased risk for thrombosis and bleeding.
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Affiliation(s)
- I A Vathiotis
- 68989National and Kapodistrian University of Athens School of Medicine, Athens, Greece.,Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - N K Syrigos
- 68989National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - E P Dimakakos
- 68989National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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18
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Alhousani M, Malik SU, Abu-Hashyeh A, Poznanski NJ, Al-Hasan S, Roth DF, Alsharedi M, Mustafa B. Using oral anticoagulants among chronic kidney disease patients to prevent recurrent venous thromboembolism: A systematic review and meta-analysis. Thromb Res 2020; 198:103-114. [PMID: 33310644 DOI: 10.1016/j.thromres.2020.11.036] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Chronic kidney disease (CKD) increases the risk of venous thromboembolism (VTE) among affected patients. Vitamin K antagonists (VKA) and warfarin remains the main stay of its treatment. Due to novelty and unclear risk-to-benefit ratio of direct oral anti-coagulants (DOAC), they remain underutilized in preventing VTE among CKD patients. We aim to assess the efficacy and safety of DOACs and other oral anticoagulants in preventing recurrent VTE among high-risk population. MATERIAL METHODS We conducted a literature search using PubMed, Embase, Cochrane, Web of Science and Clinicaltrials.gov for randomized controlled trials (RCTs) comparing anti-coagulants like DOAC, LMWH or VKA or any oral anti-coagulant (OAC) (This includes VKAs and DOACs) with either placebo or another anti-coagulant. Two independent reviewers screened the retrieved articles and extracted data using a piloted data extraction sheet. The primary outcome of interest was number of recurrent VTE and other side effects among CKD patients receiving respective treatment. Secondary outcomes were risk of major, non-major and intra-cranial bleed. RESULTS We retrieved 7244 titles on initial search, reviewed full text of 818 articles, and selected 10 phase III RCTS for quantitative meta-analysis. Out of 36,326 patients in these trials, only 10,840 (29.8%) were evaluable. We stratified patients into four categories based on severity of renal impairment using serum creatinine clearance (SCr) as the marker e.g. mild (>50 - <80) moderate (>30 - ≤50) severe (<30) and any level (from <30 to <80). There was no difference between DOACs vs VKA in decreasing the risk of recurrent VTE among patients with mild (RR:0.86, 95% CI:0.61-1.22, I2 = 25%) moderate/severe (RR:0.72, 95% CI:0.44-1.17, I2 = 0%) or any level of renal impairment (RR:0.83, 95% CI:0.60-1.14, I2 = 34%). No difference in efficacy between LMWH vs VKA among patients with moderate (RR:2.40, 95% CI:0.44-12.96, I2 = 76%) and any level (RR:2.59, 95% CI:0.66-10.16, I2 = 71%) of renal impairment respectively. Similarly, no difference in efficacy between LMWH vs any OAC (This includes VKAs and edoxaban) among patients with (RR:2.16, 95% CI:0.66-7.-06, I2 = 51%) and any level (RR:1.48, 95% CI:0.79-2.78, I2 = 78%) of renal impairment. DOACs compared to VKAs had significantly lower risk of combined major and non-major bleeding (RR: 0.74, 95% CI:0.65-0.84, I2 = 26%), major bleeding (RR: 0.51, 95% CI:0.38-0.69, I2 = 7%) and non-major clinically relevant bleeding (RR: 0.73, 95% CI:0.57-0.94, I2 = 45%) respectively. Risk of intracranial bleeding was comparable (RR: 0.68, 95% CI:0.19-2.44, I2 = 0%). There was no difference in the risk of major bleeding between LMWH vs any OAC (RR: 0.83, 95% CI:0.46-1.51, I2 = 0%). CONCLUSION DOACS and other anticoagulants (VKA and LMWH) showed no statistical difference in preventing recurrent VTEs among CKD patients but DOACs had significantly lower risk of major and non-major clinically relevant bleeding irrespective of the level of renal impairment compared to VKAs. There was no difference in risk of intra-cranial bleeding between DOACs and VKAs.
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Affiliation(s)
- Mohammad Alhousani
- Department of Internal Medicine, Marshall University, Huntington, WV, United States of America.
| | - Saad Ullah Malik
- Department of Internal Medicine, Marshall University, Huntington, WV, United States of America
| | - Ahmad Abu-Hashyeh
- Department of Internal Medicine, Marshall University, Huntington, WV, United States of America
| | - Noah John Poznanski
- Department of Internal Medicine, Marshall University, Huntington, WV, United States of America
| | - Sara Al-Hasan
- Department of Pharmacy, The University of Jordan, Amman, Jordan
| | - Danielle Frances Roth
- Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States of America
| | - Mohamed Alsharedi
- Department of Hematology and Oncology, Marshall University, Huntington, WV, United States of America
| | - Bisher Mustafa
- Department of Internal Medicine, Marshall University, Huntington, WV, United States of America
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19
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Li J, Qiang WM, Wang Y, Wang XY. Development and validation of a risk assessment nomogram for venous thromboembolism associated with hospitalized postoperative Chinese breast cancer patients. J Adv Nurs 2020; 77:473-483. [PMID: 33159325 DOI: 10.1111/jan.14571] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/22/2020] [Accepted: 08/07/2020] [Indexed: 12/26/2022]
Abstract
AIM The purpose of this study was to develop and validate an individualized nomogram to predict venous thromboembolism (VTE) risk in hospitalized postoperative breast cancer patients. DESIGN A single-central retrospective and non-interventional trial. METHODS For model development, we used data from 4,755 breast cancer patients between 1 November 2016-30 June 2018 (3,310 patients in the development group and 1,445 in the validation group). Overall, 216 patients developed VTE (150 in development group and 66 in validation group). The model was validated by receiver operating characteristic curves and the calibration plot. The clinical utility of the model was determined through decision curve analysis. RESULTS The individualized nomogram consisted of six clinical factors: age, body mass index, number of cardiovascular comorbidities, neoadjuvant chemotherapy, surgical treatment, hospital length of stay and two pre-operative biomarkers of Homocysteine and D-dimer. The model at the 3.9% optimal cut-off had the area under the curve of 0.854 (95% CI, 0.824-0.884) and 0.805 (95% CI, 0.740-0.870) in the development and validation groups. A p = 0.570 of the calibration test showed that the model was well-calibrated. The net benefit of the model was better between threshold probabilities of 5%-30% in decision curve analysis. CONCLUSION The nomogram of VTE risk assessment, is applicable to hospitalized postoperative breast cancer patients. However, multi-central prospective studies are needed to improve and validate the model. Effectiveness and safety of thromboprophylaxis in high-risk patients are needed to demonstrate in interventional trials. IMPACT This nomogram can be used in clinical to inform practice of physicians and nurses to predict the VTE probability and maybe direct personalized decision making for thromboprophylaxis in hospitalized postoperative breast cancer patients.
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Affiliation(s)
- Jing Li
- Tianjin Medical University Cancer Institute & Hospital, Tianjin, P.R. China
| | - Wan-Min Qiang
- Tianjin Medical University Cancer Institute & Hospital, Tianjin, P.R. China
| | - Yan Wang
- Tianjin Medical University Cancer Institute & Hospital, Tianjin, P.R. China
| | - Xiao-Yuan Wang
- Tianjin Medical University Cancer Institute & Hospital, Tianjin, P.R. China
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20
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Helfer H, Siguret V, Mahé I. Tinzaparin Sodium Pharmacokinetics in Patients with Chronic Kidney Disease: Practical Implications. Am J Cardiovasc Drugs 2020; 20:223-228. [PMID: 31721053 PMCID: PMC7266849 DOI: 10.1007/s40256-019-00382-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Low-molecular-weight heparins (LMWHs) are the mainstay of the prophylaxis and treatment of venous thromboembolism (VTE). Due to their renal elimination, the risk of accumulation with the related bleeding risk may represent a limitation for the use of LMWHs in patients with chronic kidney disease (CKD) as the risk of major bleeding is increased in patients with creatinine clearance (CrCl) < 30 mL/min, especially in patients with cancer. LMWH structure and molecular weight (MW) are heterogeneous among available agents. The elimination of tinzaparin, which has the highest mean MW among LMWHs, is less dependent on renal function as it is also metabolized through the reticuloendothelial system. A subcutaneous therapeutic dose of tinzaparin (175 IU/kg) once daily has been shown to cause no accumulation of anti-factor Xa activity in patients with CrCl ≥ 20 mL/min. Clinical experience from randomized controlled studies has shown no significant impact of CKD on bleeding risk in cancer patients receiving treatment doses of tinzaparin. This suggests that in these patients the use of treatment doses of tinzaparin does not require anticoagulation monitoring or dose adjustment.
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Affiliation(s)
- Hélène Helfer
- Hôpital Louis-Mourier, Service de Médecine Interne (APHP), Université Paris Diderot, Université de Paris, Colombes, France
- INSERM, UMR S1140 Therapeutic innovations in Haemostasis, Université de Paris, Paris, France
| | - Virginie Siguret
- Service d'Hématologie biologique, Hôpital Lariboisière (APHP), Paris, France
- INSERM, UMR S1140 Therapeutic innovations in Haemostasis, Université de Paris, Paris, France
| | - Isabelle Mahé
- Hôpital Louis-Mourier, Service de Médecine Interne (APHP), Université Paris Diderot, Université de Paris, Colombes, France.
- INSERM, UMR S1140 Therapeutic innovations in Haemostasis, Université de Paris, Paris, France.
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Chen Y, Yang Y, Xu WJ, Xin YJ, Wang YN, Zhou X, Li X. Clinical application of interventional embolization in tumor-associated hemorrhage. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:394. [PMID: 32355838 PMCID: PMC7186755 DOI: 10.21037/atm.2020.03.69] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Recently, the main clinical treatment methods for tumor-associated hemorrhage include systemic therapy, the application of hemostatic drugs, blood transfusion, symptomatic support therapy and endoscopic interventional hemostasis. Endoscopic hemostasis is performed mainly for patients with gastrointestinal bleeding, and the procedures include hardening of the blood vessels and the injection of hemostatic drugs. Surgical hemostasis methods mainly include the surgical ligation of bleeding blood vessels or tumor resection for hemostasis. Interventional hemostasis is a new hemostasis method. With the development of interventional radiology in recent years, transcatheter arterial embolization (TAE) can quickly detect and accurately embolize arterial blood vessels. It is the preferred treatment for present tumor-associated hemorrhages.
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Affiliation(s)
- Yi Chen
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China.,Department of Interventional Radiology, First Hospital of Shanxi Medical University, Taiyuan 030001, China
| | - Yi Yang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Wen-Ji Xu
- Department of CT and MRI, The Hospital of Shanxi University of Chinese Medicine, Taiyuan 030001, China
| | - Yu-Jing Xin
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Ya-Nan Wang
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiang Zhou
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiao Li
- Department of Interventional Therapy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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22
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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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23
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Otašević V, Antić D, Mihaljević B. Venous thromboembolic complications in lymphoma patients. MEDICINSKI PODMLADAK 2020. [DOI: 10.5937/mp71-29196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Lymphomas represent a heterogeneous group of malignant hematological diseases with high risk for development of venous thromboembolic complications (VTE). Consequently, VTE significantly impacts morbidity and mortality in these patients. Another concern is the financial burden of the healthcare system caused by diagnostic and therapeutic procedures of cancer-associated thrombosis (CAT). The complex biology of lymphoma, in conjunction with patient and treatment related risk factors for the development of VTE, results in a procoagulant hemostatic dysregulation. Considering the incidence of VTE in patients with lymphoma, there is an emerging demand for both reliable risks assessment model (RAM) for prediction of VTE, as well as for effective VTE prophylaxis and treatment. The clinical course of patients with malignant diseases is accompanied by a wide range of potential treatment complications, making the task of prevention and treatment of VTE even more challenging. In recent years, great progress has been achieved in understanding the pathophysiological mechanisms of thrombotic complications, while the significant number of randomized controlled trials (RCT) have provided standards of prophylaxis and treatment of VTE complications in patients with malignancy. In comparison to previous recommendations and guidelines for CAT, the use of direct oral anticoagulants (DOAC) has been gradually approaching low molecular weight heparins (LMWH) in terms of efficacy and safety profile in these indications. This systematic review is focused on the latest pathophysiological advances, risk factors assessment, prophylactic and therapeutic recommendations and guidelines concerning VTE in patients with lymphoma.
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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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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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26
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Kim SY, Lee EH, Park SY, Choi H, Koh JT, Park EK, Kim IS, Kim JE. Ablation of Stabilin-1 Enhances Bone-Resorbing Activity in Osteoclasts In Vitro. Calcif Tissue Int 2019; 105:205-214. [PMID: 31025051 DOI: 10.1007/s00223-019-00552-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/11/2019] [Indexed: 02/07/2023]
Abstract
Stabilin-1 is a transmembrane receptor that regulates molecule recycling and cell homeostasis by controlling the intracellular trafficking and participates in cell-cell adhesion and transmigration. Stabilin-1 expression is observed in various organs, including bones; however, its function and regulatory mechanisms in the bone remain unclear. In this study, we evaluated the physiological function of stabilin-1 in bone cells and tissue using a stabilin-1 knockout (Stab1 KO) mouse model. In wild-type (WT) mice, stabilin-1 was expressed in osteoblasts and osteoclasts, and its expression was maintained during osteoblast differentiation but significantly decreased after osteoclast differentiation. There was no difference in osteoblast differentiation and function, or the expression of osteoblast differentiation markers between mesenchymal stem cells isolated from Stab1 KO and WT mice. However, osteoclast differentiation marker levels demonstrated a non-significant increase and bone-resorbing activity was significantly increased in vitro in RANKL-induced osteoclasts from Stab1-deficient bone marrow macrophages (BMMs) compared with those of WT BMMs. Microcomputed tomography showed a negligible difference between WT and Stab1 KO mice in bone volume and trabecular thickness and number. Moreover, no in vivo functional defect in bone formation by osteoblasts was observed in the Stab1 KO mice. The osteoclast surface and number showed an increased tendency in Stab1 KO mice compared to WT mice in vivo, but this difference was not statistically significant. Overall, these results indicate that Stab1 does not play an essential role in in vivo bone development and bone cell function, but it does affect in vitro osteoclast maturation and function for bone resorption.
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Affiliation(s)
- Soon-Young Kim
- Department of Molecular Medicine, CMRI, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 41944, Republic of Korea
- BK21 Plus KNU Biomedical Convergence Program, Department of Biomedical Science, Kyungpook National University, Daegu, Republic of Korea
| | - Eun-Hye Lee
- Department of Molecular Medicine, CMRI, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 41944, Republic of Korea
- BK21 Plus KNU Biomedical Convergence Program, Department of Biomedical Science, Kyungpook National University, Daegu, Republic of Korea
| | - Seung-Yoon Park
- Department of Biochemistry, School of Medicine, Dongguk University, Gyeongju, Republic of Korea
| | - Hyuck Choi
- Department of Pharmacology and Dental Therapeutics, School of Dentistry, Chonnam National University, Gwangju, Republic of Korea
| | - Jeong-Tae Koh
- Department of Pharmacology and Dental Therapeutics, School of Dentistry, Chonnam National University, Gwangju, Republic of Korea
| | - Eui Kyun Park
- Department of Oral Pathology and Regenerative Medicine, School of Dentistry, IHBR, Kyungpook National University, Daegu, Republic of Korea
| | - In-San Kim
- Center for Theragnosis, Biomedical Research Institute, Korea Institute of Science and Technology, Seoul, Republic of Korea
- KU-KIST Graduate School of Converging Science and Technology, Korea University, Seoul, Republic of Korea
| | - Jung-Eun Kim
- Department of Molecular Medicine, CMRI, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 41944, Republic of Korea.
- BK21 Plus KNU Biomedical Convergence Program, Department of Biomedical Science, Kyungpook National University, Daegu, Republic of Korea.
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Ageno W, Barni S, Di Nisio M, Falanga A, Imberti D, Labianca RF, Mantovani L. Treatment of venous thromboembolism with tinzaparin in oncological patients. Minerva Med 2019; 110:251-258. [PMID: 30990000 DOI: 10.23736/s0026-4806.19.06026-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Venous thromboembolism (VTE) is a major cause of morbidity and mortality in patients with cancer. For over a decade, the gold standard of treatment and secondary prevention of cancer-associated thrombosis (CAT) has been represented by low-molecular-weight heparins (LMWHs), which are currently recommended as the first-line treatment for CAT. Among the LMWHs that were more extensively tested in patients with CAT, tinzaparin is a LMWH produced by the enzymatic degradation of porcine-derived unfractionated heparin. The efficacy of tinzaparin in this setting is supported by well-grounded evidence. However, there is a need to discuss the positioning of tinzaparin in the continuously evolving treatment scenario of VTE therapy in cancer patients. In this paper, which was developed by a group of clinicians with wide experience in the treatment of VTE in cancer patients, we discuss the current therapeutic options and the role of tinzaparin for the treatment of CAT.
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Affiliation(s)
- Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy -
| | - Sandro Barni
- Department of Oncology, ASST Bergamo Ovest, Treviglio Hospital, Treviglio, Bergamo, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Davide Imberti
- Service of Internal Medicine, Thrombosis and Hemostasis Center, Piacenza Civil Hospital, Piacenza, Italy
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Chu G, Versteeg HH, Verschoor AJ, Trines SA, Hemels MEW, Ay C, Huisman MV, Klok FA. Atrial fibrillation and cancer - An unexplored field in cardiovascular oncology. Blood Rev 2019; 35:59-67. [PMID: 30928168 DOI: 10.1016/j.blre.2019.03.005] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 03/15/2019] [Accepted: 03/22/2019] [Indexed: 12/28/2022]
Abstract
An increasing body of evidence suggests an association between cancer and atrial fibrillation (AF). The exact magnitude and underlying mechanism of this association are however unclear. Cancer-related inflammation, anti-cancer treatment and other cancer-related comorbidities are proposed to affect atrial remodelling, increasing the susceptibility of cancer patients for developing AF. Moreover, cancer is assumed to modify the risk of thromboembolisms and bleeding. A thorough and adequate understanding of these risks is however lacking, as current literature is scarce and show ambiguous results in AF patients. The standardized risk-models that normally aid the clinician in the decision of initiating anticoagulant therapy do not take the presence of malignancy into account. Other factors that complicate risk assessment in AF patients with cancer include drug-drug interactions and other cancer-related comorbidities such as renal impairment. In this review, we highlight the available literature regarding epidemiological association, risk assessment and anticoagulation therapy in AF patients with cancer.
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Affiliation(s)
- Gordon Chu
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands.
| | - Henri H Versteeg
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands
| | - Arie J Verschoor
- Department of Medical Oncology, Leiden University Medical Centre, the Netherlands
| | - Serge A Trines
- Department of Cardiology, Heart-Lung Centre, Leiden University Medical Centre, the Netherlands
| | - Martin E W Hemels
- Department of Cardiology, Rijnstate, Arnhem, the Netherlands; Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Comprehensive Cancer Center Vienna, Medical University of Vienna, Austria
| | - Menno V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Centre, the Netherlands
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29
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Kim SA, Yhim HY, Bang SM. Current Management of Cancer-associated Venous Thromboembolism: Focus on Direct Oral Anticoagulants. J Korean Med Sci 2019; 34:e52. [PMID: 30787683 PMCID: PMC6374546 DOI: 10.3346/jkms.2019.34.e52] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 11/26/2018] [Indexed: 01/19/2023] Open
Abstract
Cancer-associated venous thromboembolism (CAT) is a common complication associated with high morbidity and mortality. In accordance with major clinical trials comparing low-molecular-weight heparin (LMWH) with a vitamin K antagonist (VKA), LMWH is currently the standard treatment for CAT, owing to its efficacy for thrombosis recurrence and improved safety profile compared to VKA. Over the past few years, direct oral anticoagulants (DOACs) have emerged as potential alternative therapies to LMWH due to their convenient route of administration and predictable pharmacokinetics, but evidence for their use in CAT is inconclusive, as only a small fraction of the study populations in these trials had CAT. Recently, two large head-to-head trials comparing DOACs to LMWH in CAT patients reported comparable efficacies of DOACs with increased bleeding risk. Occasionally, CAT treatment can be challenging due to the heterogeneity of underlying malignancies and comorbidities. Renal insufficiency and gastrointestinal defects are the main obstacles in anticoagulant selection. Careful choice of treatment candidates and proper anticoagulant strategies are critical for the treatment of CAT; hence, more studies are required to address these challenges.
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Affiliation(s)
- Sang-A Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ho-Young Yhim
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju, Korea
| | - Soo-Mee Bang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Abstract
PURPOSE OF REVIEW Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients, and its management is often associated with complications including risk of recurrent VTE and bleeding. Here, we review the current data on pitfalls during anticoagulation in cancer patients and measures necessary to avoid them. RECENT FINDINGS Although low-molecular-weight heparin monotherapy has been the standard of treatment for several years, emerging data for direct oral anticoagulants (DOACs) are leading to new paradigms in treatment. Reports of recent randomized trials suggest a lower risk of recurrent thrombosis but higher risk of bleeding, particularly in gastrointestinal cancer patients, with DOACs. Careful patient selection and individualization of therapy based on risk of bleeding as well as recurrent VTE are keys. Problems like bleeding, recurrence, thrombocytopenia, drug-drug interactions, renal impairment, nausea-vomiting along with concerns about adherence arise during anticoagulation in cancer patients. However, with adequate pre-treatment assessment, correct anticoagulant selection and proper monitoring during anticoagulation, these issues can be addressed safely and effectively.
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Affiliation(s)
- Harsh K Patel
- Kansas City VA Medical Center, 4801 Linwood Blvd, Kansas City, MO, 64128, USA
| | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave./CA60, Cleveland, OH, 44195, USA.
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31
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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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32
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Carrier M, Blais N, Crowther M, Kavan P, Le Gal G, Moodley O, Shivakumar S, Tagalakis V, Wu C, Lee AYY. Treatment algorithm in cancer-associated thrombosis: Canadian expert consensus. ACTA ACUST UNITED AC 2018; 25:329-337. [PMID: 30464682 DOI: 10.3747/co.25.4266] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Management of anticoagulant therapy for the treatment of venous thromboembolism (vte) in cancer patients is complex because of an increased risk of recurrent vte and major bleeding complications in those patients relative to the general population. Subgroups of patients with cancer also show variation in their risk for recurrent vte and adverse bleeding events. Accordingly, a committee of 10 Canadian clinical experts developed the consensus risk- stratification treatment algorithm presented here to provide guidance on tailoring anticoagulant treatment choices for the acute and extended treatment of symptomatic and incidental vte, to prevent recurrent vte, and to minimize the bleeding risk in patients with cancer. During a 1-day live meeting, a systematic review of the literature was performed, and a draft treatment algorithm was developed. The treatment algorithm was refined through the use of a Web-based platform and a series of online teleconferences. Clinicians using this treatment algorithm should consider the bleeding risk, the type of cancer, and the potential for drug-drug interactions in addition to informed patient preference in determining the most appropriate treatment for patients with cancer-associated thrombosis. Anticoagulant therapy should be regularly reassessed as the patient's cancer status and management change over time.
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Affiliation(s)
- M Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - N Blais
- Department of Medicine, Centre hospitalier de l'Université de Montréal, Montreal, QC
| | - M Crowther
- Department of Medicine, McMaster University, Hamilton, ON
| | - P Kavan
- Department of Oncology, Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, QC
| | - G Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON
| | - O Moodley
- Department of Hematology, Royal University Hospital, Saskatoon, SK
| | - S Shivakumar
- Department of Medicine, qeii Health Sciences Centre, Dalhousie University, Halifax, NS
| | - V Tagalakis
- Department of Medicine, Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Montreal, QC
| | - C Wu
- Department of Medicine, University of Alberta, Edmonton, AB
| | - A Y Y Lee
- Department of Medicine, University of British Columbia, BC Cancer, Vancouver, BC
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Kahale LA, Hakoum MB, Tsolakian IG, Matar CF, Terrenato I, Sperati F, Barba M, Yosuico VE, Schünemann H, Akl EA. Anticoagulation for the long-term treatment of venous thromboembolism in people with cancer. Cochrane Database Syst Rev 2018; 6:CD006650. [PMID: 29920657 PMCID: PMC6389342 DOI: 10.1002/14651858.cd006650.pub5] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Cancer increases the risk of thromboembolic events, especially in people receiving anticoagulation treatments. OBJECTIVES To compare the efficacy and safety of low molecular weight heparins (LMWHs), direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) for the long-term treatment of venous thromboembolism (VTE) in people with cancer. SEARCH METHODS We conducted a literature search including a major electronic search of the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 1), MEDLINE (Ovid), and Embase (Ovid); handsearching conference proceedings; checking references of included studies; use of the 'related citation' feature in PubMed and a search for ongoing studies in trial registries. As part of the living systematic review approach, we run searches continually, incorporating new evidence after it is identified. Last search date 14 May 2018. SELECTION CRITERIA Randomized controlled trials (RCTs) assessing the benefits and harms of long-term treatment with LMWHs, DOACs or VKAs in people with cancer and symptomatic VTE. DATA COLLECTION AND ANALYSIS We extracted data in duplicate on study characteristics and risk of bias. Outcomes included: all-cause mortality, recurrent VTE, major bleeding, minor bleeding, thrombocytopenia, and health-related quality of life (QoL). We assessed the certainty of the evidence at the outcome level following the GRADE approach (GRADE handbook). MAIN RESULTS Of 15,785 citations, including 7602 unique citations, 16 RCTs fulfilled the eligibility criteria. These trials enrolled 5167 people with cancer and VTE.Low molecular weight heparins versus vitamin K antagonistsEight studies enrolling 2327 participants compared LMWHs with VKAs. Meta-analysis of five studies probably did not rule out a beneficial or harmful effect of LMWHs compared to VKAs on mortality up to 12 months of follow-up (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.88 to 1.13; risk difference (RD) 0 fewer per 1000, 95% CI 45 fewer to 48 more; moderate-certainty evidence). Meta-analysis of four studies did not rule out a beneficial or harmful effect of LMWHs compared to VKAs on major bleeding (RR 1.09, 95% CI 0.55 to 2.12; RD 4 more per 1000, 95% CI 19 fewer to 48 more, moderate-certainty evidence) or minor bleeding (RR 0.78, 95% CI 0.47 to 1.27; RD 38 fewer per 1000, 95% CI 92 fewer to 47 more; low-certainty evidence), or thrombocytopenia (RR 0.94, 95% CI 0.52 to 1.69). Meta-analysis of five studies showed that LMWHs probably reduced the recurrence of VTE compared to VKAs (RR 0.58, 95% CI 0.43 to 0.77; RD 53 fewer per 1000, 95% CI 29 fewer to 72 fewer, moderate-certainty evidence).Direct oral anticoagulants versus vitamin K antagonistsFive studies enrolling 982 participants compared DOACs with VKAs. Meta-analysis of four studies may not rule out a beneficial or harmful effect of DOACs compared to VKAs on mortality (RR 0.93, 95% CI 0.71 to 1.21; RD 12 fewer per 1000, 95% CI 51 fewer to 37 more; low-certainty evidence), recurrent VTE (RR 0.66, 95% CI 0.33 to 1.31; RD 14 fewer per 1000, 95% CI 27 fewer to 12 more; low-certainty evidence), major bleeding (RR 0.77, 95% CI 0.38 to 1.57, RD 8 fewer per 1000, 95% CI 22 fewer to 20 more; low-certainty evidence), or minor bleeding (RR 0.84, 95% CI 0.58 to 1.22; RD 21 fewer per 1000, 95% CI 54 fewer to 28 more; low-certainty evidence). One study reporting on DOAC versus VKA was published as abstract so is not included in the main analysis.Direct oral anticoagulants versus low molecular weight heparinsTwo studies enrolling 1455 participants compared DOAC with LMWH. The study by Raskob did not rule out a beneficial or harmful effect of DOACs compared to LMWH on mortality up to 12 months of follow-up (RR 1.07, 95% CI 0.92 to 1.25; RD 27 more per 1000, 95% CI 30 fewer to 95 more; low-certainty evidence). The data also showed that DOACs may have shown a likely reduction in VTE recurrence up to 12 months of follow-up compared to LMWH (RR 0.69, 95% CI 0.47 to 1.01; RD 36 fewer per 1000, 95% CI 62 fewer to 1 more; low-certainty evidence). DOAC may have increased major bleeding at 12 months of follow-up compared to LMWH (RR 1.71, 95% CI 1.01 to 2.88; RD 29 more per 1000, 95% CI 0 fewer to 78 more; low-certainty evidence) and likely increased minor bleeding up to 12 months of follow-up compared to LMWH (RR 1.31, 95% CI 0.95 to 1.80; RD 35 more per 1000, 95% CI 6 fewer to 92 more; low-certainty evidence). The second study on DOAC versus LMWH was published as an abstract and is not included in the main analysis.Idraparinux versus vitamin K antagonistsOne RCT with 284 participants compared once-weekly subcutaneous injection of idraparinux versus standard treatment (parenteral anticoagulation followed by warfarin or acenocoumarol) for three or six months. The data probably did not rule out a beneficial or harmful effect of idraparinux compared to VKAs on mortality at six months (RR 1.11, 95% CI 0.78 to 1.59; RD 31 more per 1000, 95% CI 62 fewer to 167 more; moderate-certainty evidence), VTE recurrence at six months (RR 0.46, 95% CI 0.16 to 1.32; RD 42 fewer per 1000, 95% CI 65 fewer to 25 more; low-certainty evidence) or major bleeding (RR 1.11, 95% CI 0.35 to 3.56; RD 4 more per 1000, 95% CI 25 fewer to 98 more; low-certainty evidence). AUTHORS' CONCLUSIONS For the long-term treatment of VTE in people with cancer, evidence shows that LMWHs compared to VKAs probably produces an important reduction in VTE and DOACs compared to LMWH, may likely reduce VTE but may increase risk of major bleeding. Decisions for a person with cancer and VTE to start long-term LMWHs versus oral anticoagulation should balance benefits and harms and integrate the person's values and preferences for the important outcomes and alternative management strategies.Editorial note: this is a living systematic review (LSR). LSRs offer new approaches to review updating in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Lara A Kahale
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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