1
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Fotiou D, Theodorakakou F, Spiliopoulou S, Gavriatopoulou M, Migkou M, Kanellias N, Eleutherakis-Papaiakovou E, Malandrakis P, Dialoupi I, Roussou M, Ntanasis-Stathopoulos I, Terpos E, Dimopoulos MA, Kastritis E. Thrombotic and bleeding complications in patients with AL amyloidosis. Br J Haematol 2024; 204:1816-1824. [PMID: 38321638 DOI: 10.1111/bjh.19331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/08/2024] [Accepted: 01/25/2024] [Indexed: 02/08/2024]
Abstract
Haemostatic abnormalities and deregulated coagulation are common complications in AL amyloidosis. The relevant risks of thromboembolic and haemorrhagic events have not been thoroughly evaluated. To describe clinically significant thrombotic/haemorrhagic events in 450 consecutive patients with AL amyloidosis. Venous thromboembolic events (VTEs) were reported in 6% and arterial embolic events (AEEs) in 5% of patients, respectively, during a 55-month median follow-up. Lower albumin, lower eGFR, higher BM infiltration, soft tissue involvement, IMiD-based therapy and prior thrombosis were associated with VTE risk. Prior thrombosis was the only independent prognostic variable (HR 9.3, p = 0.001). Coronary arterial disease, prior AEE, 24-h proteinuria and higher platelet counts were associated with AEE risk. Significant bleeding events were reported in 9%, and associated mortality was 19%. Liver involvement, higher serum creatinine and higher baseline VWF:Ag levels were linked to bleeding risk. Using competing risk analysis, the cumulative probability of thrombosis/bleeding was higher during the first year following diagnosis, but a stable lower risk for both events remained for the duration of follow-up. In AL amyloidosis patients, the risk of thrombotic/arterial embolic events is significant, but the bleeding risk is also high. A multiparametric assessment is required to initiate anti-thrombotic or anti-platelet therapy appropriately.
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Affiliation(s)
- Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Sotiria Spiliopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Dialoupi
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Roussou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
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2
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Jarchowsky O, Avnery O, Ellis MH. Thrombosis in multiple myeloma: mechanisms, risk assessment and management. Leuk Lymphoma 2023; 64:1905-1913. [PMID: 37584485 DOI: 10.1080/10428194.2023.2247513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/08/2023] [Indexed: 08/17/2023]
Abstract
Multiple myeloma (MM) is associated with an increased risk of venous and arterial thrombosis. Pathophysiologic mechanisms include patient, disease and treatment related factors. Risk assessment models have been developed to determine whichpatients are at highest thrombotic risk and pursuant to this, risk adapted thrombosis prophylaxis has been suggested. Areas in which further basic and clinical research is imperative include the molecular and cellular mechanisms of thrombosis in myeloma, the inclusion of relevant biomarkers in risk assessment scores and controlled clinical trials of VTE prophylaxis and treatment using direct oral anticoagulants.
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Affiliation(s)
- Osnat Jarchowsky
- Hematology Institute, Meir Medical Center, Kfar SabaIsrael
- Tel Aviv University, Israel
| | - Orly Avnery
- Hematology Institute, Meir Medical Center, Kfar SabaIsrael
- Tel Aviv University, Israel
| | - Martin H Ellis
- Hematology Institute, Meir Medical Center, Kfar SabaIsrael
- Tel Aviv University, Israel
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3
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Falanga A, Ay C, Di Nisio M, Gerotziafas G, Jara-Palomares L, Langer F, Lecumberri R, Mandala M, Maraveyas A, Pabinger I, Sinn M, Syrigos K, Young A, Jordan K. Venous thromboembolism in cancer patients: ESMO Clinical Practice Guideline. Ann Oncol 2023; 34:452-467. [PMID: 36638869 DOI: 10.1016/j.annonc.2022.12.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 12/09/2022] [Accepted: 12/11/2022] [Indexed: 01/11/2023] Open
Affiliation(s)
- A Falanga
- Division of Immunohaematology and Transfusion Medicine, Haemostasis and Thrombosis Center, Department of Oncology and Haematology, Hospital Papa Giovanni XXIII, Bergamo, Italy; University of Milan Bicocca, Department of Medicine and Surgery, Monza, Italy
| | - C Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - M Di Nisio
- Department of Medicine and Ageing Sciences, G. d'Annunzio University, Chieti, Italy
| | - G Gerotziafas
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics", Group "Cancer-Hemostasis-Angiogenesis", Institut Universitaire de Cancérologie, Consultation Thrombosis in Oncology (COTHON), Tenon-Saint Antoine Hospital, AP-HP, Paris, France
| | - L Jara-Palomares
- Respiratory Department, Medical Surgical Unit of Respiratory Diseases, Hospital Virgen del Rocio, Sevilla; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - F Langer
- Centre for Oncology, University Cancer Centre Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Centre Eppendorf, Hamburg, Germany
| | - R Lecumberri
- Servicio de Hematología, Clínica Universidad de Navarra, Pamplona (Navarra); CIBER-CV, Instituto de Salud Carlos III, Madrid, Spain
| | - M Mandala
- University of Perugia, Unit of Medical Oncology, Santa Maria Misericordia Hospital, Perugia, Italy
| | - A Maraveyas
- Queen's Centre for Oncology and Haematology, Faculty of Health Sciences, Hull York Medical School and Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - I Pabinger
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria
| | - M Sinn
- Centre for Oncology, University Cancer Centre Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Centre Eppendorf, Hamburg, Germany
| | - K Syrigos
- Oncology Unit, 3rd Department of Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - A Young
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - K Jordan
- Department of Hematology, Oncology and Palliative Medicine, Ernst von Bergmann Hospital, Potsdam, Germany; Department of Rheumatology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
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4
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Gkalea V, Fotiou D, Dimopoulos MA, Kastritis E. Monoclonal Gammopathy of Thrombotic Significance. Cancers (Basel) 2023; 15:cancers15020480. [PMID: 36672429 PMCID: PMC9856365 DOI: 10.3390/cancers15020480] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/04/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023] Open
Abstract
The current review provides an overview of the thrombotic risk observed in patients with MG who do not otherwise require treatment. We discuss clinical and biomarker studies that highlight the heterogenous hemostatic profile observed in these patients and how knowledge has evolved over the past 20 years. Biomarker studies suggest shared biologic features between multiple myeloma and monoclonal gammopathy of undetermined significance (MGUS), which involves both hypercoagulability and platelet activation. Hemostatic abnormalities identified in MGUS patients cannot be translated into clinical practice as they lack correlation to clinical events. The prothrombotic phenotype of MGUS patients has not been ascertained yet, but novel data on coagulation markers are promising. We also review rare conditions associated with the thrombogenic properties of the monoclonal protein that predispose to arterial, venous or microthrombotic events and demonstrate that the M-protein can be linked to clinically significant thrombotic events. Cryoglobulinemia, cryofibrinogenemia, cryo-crystaloglobulinemia and MG-related antiphospholipid syndrome are reviewed. We propose the new umbrella term "monoclonal gammopathy of thrombotic significance" (MGTS) to refer to significant, recurrent thrombotic events in patients with MGUS that provide a rationale for targeting the underlying plasma cell clone. Identifying MGUS patients at high risk for thrombotic events is currently a challenge.
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5
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Fotiou D, Dimopoulos MA, Kastritis E. Approach to Contemporary Risk Assessment, Prevention and Management of Thrombotic Complications in Multiple Myeloma. Cancers (Basel) 2022; 14:cancers14246216. [PMID: 36551701 PMCID: PMC9777181 DOI: 10.3390/cancers14246216] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/09/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Multiple myeloma (MM) is associated with an increased risk of thrombotic complications, which remains substantial despite the implementation of thromboprophylaxis. The procoagulant state that characterizes the disease is multifactorial, and a greater understanding of the underlying pathophysiology is required to inform appropriate thrombosis prevention. Currently, there is a shift towards using direct oral anticoagulants (DOACs) in this setting; head-to-head comparisons in the context of controlled clinical trials between class agents are still missing. MM-specific VTE risk assessment scores have been developed to optimize management and minimize the associated mortality/morbidity. Their clinical utility remains to be evaluated. The value of adding biomarkers to clinical scores to optimize their performance and increase their discriminatory power is also under assessment.
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Incidence of Venous Thromboembolism in Multiple Myeloma Patients across Different Regimens: Role of Procoagulant Microparticles and Cytokine Release. J Clin Med 2022; 11:jcm11102720. [PMID: 35628848 PMCID: PMC9143530 DOI: 10.3390/jcm11102720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/25/2022] [Accepted: 05/09/2022] [Indexed: 12/10/2022] Open
Abstract
Introduction: Multiple myeloma (MM) is characterized by a high prevalence of thrombotic complications. Microvesicles (MVs) are small membrane vesicles released from activated cells, and they may potentially contribute to thrombosis. Methods: We have evaluated the plasma levels of MVs and cytokines (IL-10, IL-17, and TGF-β in MM and Watch and Wait Smoldering MM (WWSMM) from patients and related them to thrombotic complications. The secondary aim was to assess the impact of ongoing therapy on MV and on cytokine levels. Result: 92 MM and 31 WWSMM were enrolled, and 14 (12%) experienced a thrombotic episode. Using univariate analysis, TGF-β and MV were significantly higher in patients with thrombotic events (p = 0.012; p = 0.008, respectively). Utilizing a Cox proportional hazard model, we confirmed this difference (TGF-β p = 0.003; Odds ratio 0.001, 95% CI 0−0.003 and MV p = 0.001; Odds ratio 0.003, 95% CI 0.001−0.005). Active treatment management displayed higher levels of MV (p < 0.001) and lower levels of glomerular filtration-rate (p < 0.001), IL-17 (p < 0.001) as compared to the WWSMM group. The TGF-β values of immunomodulatory derivatives patients were lower in the WWSMM (p < 0.001) and Dexamethasone/Bortezomib subgroup (p < 0.001). Conclusion: The increased levels of MVs in active regimens add insight into the mechanisms of hypercoagulation in MM. In addition, a role for cytokine-related thrombosis is also suggested.
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Gozzetti A, Pacelli P, Raspadori D, Bestoso E, Tocci D, Sicuranza A, Bocchia M. Long-term CR Multiple Myeloma Patients Show Cured or MGUS-like Minimal Residual Disease Pattern by Next Generation Flow. Rev Recent Clin Trials 2022; 17:92-96. [PMID: 35578845 DOI: 10.2174/1574887117666220516145628] [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: 10/22/2022] [Revised: 02/20/2022] [Accepted: 03/18/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In the era of novel agents, many multiple myeloma patients can achieve a complete remission, but most of them relapse, and minimal residual disease detection can play a crucial role. Next-generation flow (NGF) can detect monoclonal plasma cells with a sensitivity of 10-6. Little is known about long-term remission patients (> 2 years) and in particular, if more sensitive techniques such as NGF can still detect minimal disease in those patients. OBJECTIVE Aim of the study was to analyze patients with MM in response to NGF at > 2 years of sustained remission after several treatments. METHODS MRD was studied by NGF in bone marrow aspirates according to Euroflow Consortium indications. RESULTS 62 patients with sustained CR at >2 years were studied, MRD+ status was detected at a threshold cut-off of 10-6 in 32/62 (52%); 4/15 (27%) patients were MRD positive at >5 years of remission and they displayed a prevalence of normal vs abnormal monoclonal plasma cell immune-phenotype (MGUS-like). CONCLUSION NGF is a powerful technique to detect MRD. Myeloma patients in prolonged sustained complete remission can show in high percentage an MRD negative status or MGUS like.
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Affiliation(s)
- Alessandro Gozzetti
- Hematology, University of Siena, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - Paola Pacelli
- Hematology, University of Siena, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - Donatella Raspadori
- Hematology, University of Siena, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - Elena Bestoso
- Hematology, University of Siena, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - Dania Tocci
- Hematology, University of Siena, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - Anna Sicuranza
- Hematology, University of Siena, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
| | - Monica Bocchia
- Hematology, University of Siena, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria alle Scotte", Siena, Italy
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8
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Gozzetti A, Bacchiarri F, Sammartano V, Defina M, Sicuranza A, Mecacci B, Zappone E, Cencini E, Fabbri A, Raspadori D, Bocchia M. Long-Term Safety of Rapid Daratumumab Infusions in Multiple Myeloma Patients. Front Oncol 2021; 10:570187. [PMID: 33415072 PMCID: PMC7783633 DOI: 10.3389/fonc.2020.570187] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 11/13/2020] [Indexed: 11/22/2022] Open
Abstract
Multiple myeloma survival has significantly improved in recent years, due to novel agents that are available for treatment. The anti-CD38 monoclonal antibody Daratumumab is particularly efficient for patients with relapse/refractory disease, and many studies have shown its unprecedented efficacy also as a first treatment. However, to avoid the incidence of infusion reactions, long infusion schedules of 8 h at first dose and 4 h in the following doses are required, which can reduce the compliance of patients and health care professionals. A reduced infusion time of 90 min has been reported previously, but data are missing on the prolonged safety of this over time as well as the efficacy of this approach. In this work, we investigate the safety of 484 rapid Daratumumab infusions given early after the second dose over a 22 months period in 39 myeloma patients.
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Affiliation(s)
- Alessandro Gozzetti
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Francesca Bacchiarri
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Vincenzo Sammartano
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Marzia Defina
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Anna Sicuranza
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Bianca Mecacci
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Elisabetta Zappone
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Emanuele Cencini
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Alberto Fabbri
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Donatella Raspadori
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Monica Bocchia
- Hematology Unit, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
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9
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Gozzetti A, Raspadori D, Bacchiarri F, Sicuranza A, Pacelli P, Ferrigno I, Tocci D, Bocchia M. Minimal Residual Disease in Multiple Myeloma: State of the Art and Applications in Clinical Practice. J Pers Med 2020; 10:jpm10030120. [PMID: 32927719 PMCID: PMC7565263 DOI: 10.3390/jpm10030120] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/03/2020] [Accepted: 09/08/2020] [Indexed: 12/14/2022] Open
Abstract
Novel drugs have revolutionized multiple myeloma therapy in the last 20 years, with median survival that has doubled to up to 8–10 years. The introduction of therapeutic strategies, such as consolidation and maintenance after autologous stem cell transplants, has also ameliorated clinical results. The goal of modern therapies is becoming not only complete remission, but also the deepest possible remission. In this context, the evaluation of minimal residual disease by techniques such as next-generation sequencing (NGS) and next-generation flow (NGF) is becoming part of all new clinical trials that test drug efficacy. This review focuses on minimal residual disease approaches in clinical trials, with particular attention to real-world practices.
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10
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Chan TSY, Hwang YY, Tse E. Risk assessment of venous thromboembolism in hematological cancer patients: a review. Expert Rev Hematol 2020; 13:471-480. [DOI: 10.1080/17474086.2020.1751608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
| | - Yu Yan Hwang
- Department of Medicine, Queen Mary Hospital, Hong Kong
| | - Eric Tse
- Department of Medicine, Queen Mary Hospital, Hong Kong
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11
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Multiple Myeloma and Thrombosis: Prophylaxis and Risk Prediction Tools. Cancers (Basel) 2020; 12:cancers12010191. [PMID: 31940972 PMCID: PMC7016665 DOI: 10.3390/cancers12010191] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 12/19/2022] Open
Abstract
Thromboembolism in multiple myeloma (MM) patients remains a common complication that renders the optimization of our thromboprophylaxis practice necessary. This review aims to make clear the need for the development of more accurate risk assessment tools and means of thrombosis prevention. Current clinical practice is guided by available guidelines published by the IMWG in 2014, but the extent to which these are implemented is unclear. Recently, several groups developed clinical scores for thrombosis risk in MM in an attempt to improve risk stratification, but these have not been validated or used in clinical practice so far. Research in this field is increasingly focusing on understanding the unique coagulation profile of the MM patient, and data on potential biomarkers that accurately reflect hypercoagulability is emerging. Finally, promising evidence on the effectiveness of direct oral anticoagulants (DOACs) in the context of thrombosis prevention in MM patients is increasingly becoming available. The critical appraisal of the above research areas will establish the necessity of combining disease-specific clinical risk factors with coagulation biomarkers to allow more effective risk stratification that will eventually lead to the reduction of this significant complication. Results from ongoing clinical trials on the role of DOACs are much anticipated.
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12
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Fotiou D, Gavriatopoulou M, Ntanasis-Stathopoulos I, Migkou M, Dimopoulos MA, Terpos E. Updates on thrombotic events associated with multiple myeloma. Expert Rev Hematol 2019; 12:355-365. [DOI: 10.1080/17474086.2019.1604214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Despina Fotiou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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13
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Yin QS, Chen L, Mi RH, Ai H, Yin JJ, Liu XJ, Wei XD. Efficacy and Safety of Danshen Compound Tablets in Preventing Thalidomide-Associated Thromboembolism in Patients with Multiple Myeloma: A Multicenter Retrospective Study. Med Sci Monit 2016; 22:3835-3842. [PMID: 27760978 PMCID: PMC5077292 DOI: 10.12659/msm.900575] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Currently available antithrombotic prophylaxis is not perfectly reliable in elderly patients. The aim of this retrospective study was to evaluate the efficacy and safety of Compound Danshen Tablet (CDT) in preventing thromboembolism in multiple myeloma (MM) patients treated with thalidomide-based regimens. MATERIAL AND METHODS MM patients treated with thalidomide-based regimens were retrospectively reviewed between January 2008 and March 2015. Patients were categorized into 3 cohorts based on thromboembolic prophylaxis used: CDT, Warfarin Tablet, and no prophylaxis. Venous thromboembolism (VTE), other adverse effects (AEs), and the changes of D-dimer and fibrinogen levels were monitored. RESULTS Seven out of 313 MM patients (2.24%) developed venous thrombosis events (VTE) in this retrospective study, all clustering in the no prophylaxis cohort. Three patients of the Warfarin cohort (3.19%) experienced hemorrhage. Neither VTE events nor serious AEs were observed in the CDT cohort. Following Compound Danshen or Warfarin treatment for 3 months, the D-dimer and fibrinogen levels (in particular the D-dimer level) (all P<0.05), were obviously decreased relative to their respective baselines and the no prophylaxis cohort. In contrast, the 2 blotting parameters were significantly increased in the no prophylaxis cohort relative to the baseline level (All P<0.05), and were even higher in the patients experiencing VTE compared to the no VTE patients (P<0.0001 and P=0.016, respectively). CONCLUSIONS Our findings indicate CDT is an effective therapy for preventing VTE in MM patients treated with thalidomide-based regimens, and is well tolerated in long-term use.
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Affiliation(s)
- Qing-Song Yin
- Department of Leukemia, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China (mainland)
| | - Lin Chen
- Department of Leukemia, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China (mainland)
| | - Rui-Hua Mi
- Department of Leukemia, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China (mainland)
| | - Hao Ai
- Department of Leukemia, Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China (mainland)
| | - Jun-Jie Yin
- Department of Leukemia, The Central Hospital of Xinxiang, Xinxiang, Henan, China (mainland)
| | - Xiao-Juan Liu
- Department of Leukemia , The Second People's Hospital of Jiaozuo, Jiaozuo, Henan, China (mainland)
| | - Xu-Dong Wei
- Department of Leukemia , Affiliated Cancer Hospital of Zhengzhou University, Henan Cancer Hospital, Zhengzhou, Henan, China (mainland)
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14
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Fotiou D, Gerotziafas G, Kastritis E, Dimopoulos MA, Terpos E. A review of the venous thrombotic issues associated with multiple myeloma. Expert Rev Hematol 2016; 9:695-706. [DOI: 10.1080/17474086.2016.1194750] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Grigoris Gerotziafas
- INSERM U938, Faculté de Médecine Pierre et Marie Curie, Université Paris VI, Paris, France
- Thrombosis Center, Service d’Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l’Est Parisien, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Dede RJ, Pruemer JM. Comparing venous thromboembolism prophylactic strategies for ambulatory multiple myeloma patients on immunomodulatory drug therapy. J Oncol Pharm Pract 2015; 22:248-55. [DOI: 10.1177/1078155215569555] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Purpose Patients with multiple myeloma have an increased incidence of venous thromboembolism. The risk for venous thromboembolism further increases when these patients are placed on immunomodulatory drug therapy. This study aims to determine the incidence of venous thromboembolism in patients with multiple myeloma receiving immunomodulatory drug therapy in the ambulatory setting at UC Health and to investigate adherence with guidelines developed by The National Comprehensive Cancer Network for venous thromboembolism prevention in this patient population. Methods A retrospective chart review of patients with multiple myeloma initiated on immunomodulatory drug therapy between January 2000 and January 2014 was conducted. Results Sixty-two cases met inclusion criteria and were included for analysis. The National Comprehensive Cancer Network guidelines were followed in 33.9% of cases. The rate of venous thromboembolism was 4.8% in guideline adherent cases and 12.2% in guideline nonadherent cases (p = 0.65). The overall incidence of venous thromboembolism was 9.7%. No patients on a low-molecular-weight-heparin agent or warfarin developed a venous thromboembolism, 7.9% patients on aspirin therapy developed a venous thromboembolism, and 23.1% patients on no pharmacologic thromboprophylaxis developed a venous thromboembolism (p = 0.26). Conclusion Ambulatory patients with multiple myeloma who are considered for immunomodulatory drug therapy should be placed on pharmacologic thromboprophylaxis based on individual venous thromboembolism and bleeding risk factors. This study identified the need for increased adherence to national guidelines for venous thromboembolism prevention in patients with multiple myeloma receiving immunomodulatory drug therapy so as to increase the quality of care provided at UC Health.
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Affiliation(s)
- Ruth J Dede
- Department of Pharmacy Services, UC Health—University of Cincinnati Medical Center, Cincinnati, USA
| | - Jane M Pruemer
- James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, USA
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Boyle EM, Fouquet G, Manier S, Gauthier J, Noel MP, Borie C, Facon T, Elalamy I, Leleu X. Immunomodulator drug-based therapy in myeloma and the occurrence of thrombosis. Expert Rev Hematol 2014; 5:617-26; quiz 627. [DOI: 10.1586/ehm.12.52] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Aikens GB, Rivey MP, Hansen CJ. Primary venous thromboembolism prophylaxis in ambulatory cancer patients. Ann Pharmacother 2013; 47:198-209. [PMID: 23386067 DOI: 10.1345/aph.1r335] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To summarize and review current medical literature regarding the efficacy and safety of antithrombotic therapy for primary venous thromboembolism (VTE) prophylaxis in various ambulatory cancer populations. DATA SOURCES A literature search was conducted in PubMed (1966-September 2012) and International Pharmaceutical Abstracts (1970-September 2012) using the terms venous thromboembolism, primary prophylaxis, anticoagulation, antithrombotic agents, cancer, and ambulatory. The bibliographies of pertinent studies and topic articles were reviewed for additional references. STUDY SELECTION AND DATA EXTRACTION All English-language articles were evaluated for inclusion. All randomized trials were included in the review. DATA SYNTHESIS Malignancy has been identified as a major independent risk factor for the development of VTE in the surgical, medically ill, and ambulatory populations. Primary VTE prophylaxis has been identified as an area of great impact in cancer patients because of the difficulties associated with the treatment of VTE and the greater risk for its recurrence in this population. Although primary VTE prophylaxis is recommended in all surgical and hospitalized cancer patients without contraindications to anticoagulants, its role in ambulatory cancer patients is less certain because of varying patient, cancer, and treatment-related factors. Fourteen randomized studies have investigated the use of antithrombotic agents for primary VTE prophylaxis in ambulatory cancer patients. Strong evidence for primary prophylaxis exists for several populations with advanced or metastatic cancer considered to be at high risk, including those with pancreatic cancer, lung cancer, or multiple myeloma. Evidence is inconsistent or lacking for lower risk cancer populations, such as those with breast cancer, or for those with malignant glioma, which carries a high risk for VTE and bleeding relative to the general ambulatory cancer population. CONCLUSIONS Use of antithrombotic agents has reduced the rate of primary VTE, with minimal increases in bleeding risk in specific ambulatory cancer populations. Further investigation is needed to guide and narrow recommendations for primary VTE prophylaxis in ambulatory cancer patients.
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Affiliation(s)
- Garrett B Aikens
- Department of Pharmacy Practice and Community Medical Center, The University of Montana, Missoula, MT, USA.
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19
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Deep vein thrombosis induced by thalidomide to control epistaxis secondary to hereditary haemorrhagic telangiectasia. Blood Coagul Fibrinolysis 2012; 22:616-8. [PMID: 21885956 DOI: 10.1097/mbc.0b013e32834a040c] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thalidomide was recently reported to reduce the severity and frequency of epistaxes in patients with hereditary haemorrhagic telangiectasia (HHT). We here describe the case of a patient with HHT and severe epistaxes refractory to medical and local surgical treatments who developed an extensive deep vein thrombosis shortly after initiation of treatment with thalidomide. This is the first report of venous thromboembolic complication induced by thalidomide prescribed in this setting. Although thalidomide was recently found to provide an alternative therapeutic strategy in patients with HHT and refractory epistaxes, this agent should be used with great caution in this indication, given its thrombogenicity and difficulties to manage systemic anticoagulation in patients with HHT.
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Zangari M, Fink L, Zhan F, Tricot G. Low venous thromboembolic risk with bortezomib in multiple myeloma and potential protective effect with thalidomide/lenalidomide-based therapy: review of data from phase 3 trials and studies of novel combination regimens. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2011; 11:228-36. [PMID: 21575928 DOI: 10.1016/j.clml.2011.03.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 01/19/2011] [Accepted: 01/20/2011] [Indexed: 12/21/2022]
Abstract
Patients with multiple myeloma (MM) are at elevated risk of venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE). VTE risk in MM is increased by various patient- and disease-related factors. The type of anti-MM therapy represents a key factor, with a substantially elevated VTE risk in patients treated with the immunomodulatory drugs (IMiDs) thalidomide or lenalidomide in combination with dexamethasone and/or chemotherapy; VTE risk with lenalidomide-dexamethasone is further increased with concomitant erythropoietin. By contrast, treatment with the proteasome inhibitor bortezomib, alone or in combination, does not increase VTE risk; rates of DVT/PE do not appear affected by the use of erythropoiesis-stimulating agents. Bortezomib has shown antihemostatic effects in patients with relapsed or refractory MM, which supports that it exerts antithrombotic actions and thus potentially provides a protective effect in combination with regimens with an elevated VTE risk. Herein, we review data from phase 3 trials of bortezomib- and/or IMiD-based therapy in frontline MM, together with other studies of novel combination regimens. Despite the confounding effect of variable VTE prophylaxis, bortezomib-based regimens were typically associated with DVT/PE rates of ≤5%, similar to those seen with melphalan-prednisone and dexamethasone, whereas IMiD-based bortezomib-free regimens were generally associated with higher rates. Direct comparisons of regimens of thrombogenic potential with or without bortezomib demonstrated lower VTE risk with bortezomib. Between-study comparisons of VTE risk support these findings. Taken together, these data confirm the low VTE risk associated with bortezomib and support a potential protective effect of bortezomib in combination with IMiD-based regimens associated with elevated VTE risk.
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Affiliation(s)
- Maurizio Zangari
- Blood/Marrow Transplant and Myeloma Program, Division of Hematology, University of Utah, Salt Lake City, UT 84132, USA.
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Carrier M, Le Gal G, Tay J, Wu C, Lee AY. Rates of venous thromboembolism in multiple myeloma patients undergoing immunomodulatory therapy with thalidomide or lenalidomide: a systematic review and meta-analysis. J Thromb Haemost 2011; 9:653-63. [PMID: 21255254 DOI: 10.1111/j.1538-7836.2011.04215.x] [Citation(s) in RCA: 135] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The incidence of venous thromboembolism (VTE) in patients with multiple myeloma (MM) treated with thalidomide- and lenalidomide-based regimens is high. Recent observational studies have suggested that thromboprophylaxis might be efficacious in decreasing the risk of VTE in this population. PURPOSE To determine the absolute rates of VTE with and without different thromboprophylactic agents in patients with newly diagnosed or previously treated MM receiving thalidomide- or lenalidomide-based regimens. RESULTS Patients with newly diagnosed MM treated with thalidomide in combination with dexamethasone have a VTE risk of 4.1 (95% CI, 2.8-5.9) per 100 patient-cycles. Therapeutic doses of anticoagulants seem to provide the largest absolute risk reduction of VTE. The rate of VTE in patients with previously treated MM receiving thalidomide in combination with dexamethasone is 0.8 (95% CI, 0.1-2.1) per 100 patient-months. A combination of lenalidomide and dexamethasone is associated with of risk of VTE of 0.8 (95% CI, 0.07-2.0) per 100 patient-cycles and 0.7 (95% CI, 0.4-0.9) per 100 patient-cycles in patients with newly diagnosed and previously treated MM, respectively. Similarly, the rates of VTE in patients also receiving thromboprophylaxis with aspirin were 0.9 (95% CI, 0.5-1.5) and 0.6 (95% CI, 0.01-2.1), respectively. CONCLUSION Patients with newly diagnosed or previously treated MM receiving thalidomide- or lenalidomide-based regimens in combination with dexamethasone are at high risk of VTE. The benefit of various types of thromboprophylaxis is difficult to quantify in patients with MM receiving immunomodulatory therapy, especially in those receiving lenalidomide-based therapy or who have previously treated MM. Randomized controlled trials are needed to address this important clinical need.
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Affiliation(s)
- M Carrier
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Lyman GH. Venous thromboembolism in the patient with cancer: focus on burden of disease and benefits of thromboprophylaxis. Cancer 2010; 117:1334-49. [PMID: 21425133 DOI: 10.1002/cncr.25714] [Citation(s) in RCA: 132] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2010] [Revised: 08/29/2010] [Accepted: 09/09/2010] [Indexed: 12/25/2022]
Abstract
Venous thromboembolism (VTE) is a significant cause of morbidity and mortality in patients with cancer. The risk of VTE varies over the natural history of cancer, with the highest risk occurring during hospitalization and after disease recurrence. Patient and disease characteristics are associated with further increased risk of VTE in this setting. Specific factors include cancer type (eg, pancreatic cancer, brain cancer, lymphoma) and the presence of metastatic disease at the time of diagnosis. VTE is a significant predictor of increased mortality during the first year among all types and stages of cancer, with metastatic disease reported to be the strongest predictor of mortality. VTE is also associated with early death in ambulatory patients with cancer. These data highlight the need for close monitoring, prompt treatment, and appropriate preventive strategies for VTE in patients with cancer. The American Society of Clinical Oncology and the National Comprehensive Cancer Network have issued guidelines regarding the prophylaxis and treatment of patients with cancer. This review summarizes the impact of VTE on patients with cancer, the effects of VTE on clinical outcomes, the importance of thromboprophylaxis in this population, relevant ongoing clinical trials examining the prevention of VTE, and new pharmacologic treatment options.
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Affiliation(s)
- Gary H Lyman
- Comparative Effectiveness and Outcomes Research Program, Duke University and the Duke Comprehensive Cancer Center, Durham, North Carolina 27705, USA.
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