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Nadeem O, Ailawadhi S, Khouri J, Williams L, Catamero D, Maples K, Berdeja J. Management of Adverse Events Associated with Pomalidomide-Based Combinations in Patients with Relapsed/Refractory Multiple Myeloma. Cancers (Basel) 2024; 16:1023. [PMID: 38473381 DOI: 10.3390/cancers16051023] [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: 01/12/2024] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Multi-agent regimens incorporating immunomodulatory (IMiD®) agents such as thalidomide, lenalidomide, and pomalidomide have become the preferred standard of care for the treatment of patients with multiple myeloma (MM), resulting in improved survival outcomes. Currently, there are three IMiD agents approved for the treatment of MM: thalidomide, lenalidomide, and pomalidomide. Lenalidomide is commonly used to treat patients with newly diagnosed MM and as maintenance therapy following stem cell transplant or after disease relapse. Pomalidomide, the focus of this review, is approved in patients with relapsed/refractory MM (RRMM). Despite survival benefits, IMiD agents each have different safety profiles requiring consideration both prior to starting therapy and during treatment. Adverse event (AE) management is essential, not only to ensure treatment adherence and thus ensure optimal efficacy but also to maintain patient quality of life. Here, we discuss AEs associated with pomalidomide and present five clinically relevant hypothetical case studies in patients with RRMM to provide scenario-driven guidance regarding treatment selection and AE prevention and management in the clinical setting. Lastly, as new treatment approaches continue to be explored in MM, we also discuss novel cereblon E3 ligase modulator (CELMoD™) agents including iberdomide (CC-220) and mezigdomide (CC-92480).
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Affiliation(s)
- Omar Nadeem
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA 02215, USA
| | - Sikander Ailawadhi
- Department of Hematology & Oncology, Mayo Clinic, Jacksonville, FL 32224, USA
| | - Jack Khouri
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Louis Williams
- Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | | | - Kathryn Maples
- Department of Pharmacy, Winship Cancer Institute, Emory University, Atlanta, GA 30322, USA
| | - Jesús Berdeja
- Greco-Hainsworth Centers for Cancer Research, Tennessee Oncology, Nashville, TN 37203, USA
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Carlisi M, Presti RL, Mancuso S, Siragusa S, Caimi G. Thrombotic Risk and Calculated Whole Blood Viscosity in a Cohort of Patients With New Diagnosis of Multiple Myeloma. Clin Appl Thromb Hemost 2024; 30:10760296231222477. [PMID: 38173275 PMCID: PMC10768600 DOI: 10.1177/10760296231222477] [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: 10/03/2023] [Revised: 11/29/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
The pathogenesis of venous thromboembolism in multiple myeloma is still poorly understood because multiple factors are involved. In particular, the increase in whole blood viscosity has a key role and, therefore, we performed an evaluation of some hemorheological determinants in multiple myeloma patients, putting them in relation to the thrombotic risk, with the aim to evaluate if an alteration of the hemorheological pattern was associated with a higher thrombotic risk. We performed an observational retrospective cohort study with data collected from January 2017 to September 2022. In a group of 190 patients with newly diagnosed multiple myeloma, we have examined the trend of calculated blood viscosity according to the Merrill formula, and we stratified the patients for the thrombotic risk in accordance with the IMWG/NCCN guidelines and with IMPEDE VTE score. Using the thrombotic risk stratification proposed by IMWG/NCCN any variation in calculated blood viscosity is evident, while, with the IMPEDE VTE score, we observed an increase in calculated blood viscosity in patients with "intermediate + high" risk. The calculated blood viscosity is higher in subjects presenting an "intermediate + high" thrombotic risk according to the IMPEDE VTE score. This association could therefore lay the groundwork for further research with the aim to confirm the role of hemorheological pattern in MM-related thrombotic risk.
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Affiliation(s)
- Melania Carlisi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Rosalia Lo Presti
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
| | - Salvatrice Mancuso
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Sergio Siragusa
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Gregorio Caimi
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
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Alfredo MDAC, Schmitt JV, Miola AC, Milagres SDP, Lastoria JC. Cardiovascular events associated with thalidomide and prednisone in leprosy type 2 reaction. An Bras Dermatol 2024; 99:53-56. [PMID: 37657956 DOI: 10.1016/j.abd.2023.01.006] [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: 08/29/2022] [Revised: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND Thalidomide is the drug of choice for the treatment of type 2 leprosy reactions and is often associated with corticosteroids. The use of these drugs in multiple myeloma is associated with the risk of cardiovascular events, but there have been few studies assessing this risk in leprosy patients. OBJECTIVE To evaluate the occurrence of cardiovascular events in patients with multibacillary leprosy and their correlation with the use of thalidomide and prednisone. METHODS Analytical cross-sectional study of all patients diagnosed with multibacillary leprosy treated at the Dermatology Service between 2012 and 2022, using electronic medical records. Thromboembolic vascular events, both arterial and venous, including acute myocardial infarction, were considered. The main independent variable was the concomitant use of thalidomide and prednisone during follow-up. RESULTS A total of 89 patients were included, of which 19 used thalidomide and prednisone concomitantly. There were five cardiovascular events (26.3%), three of which of deep venous thrombosis. The combined use of medications was associated with the events (PR=6.46 [3.92 to 10.65]; p<0.01). STUDY LIMITATIONS Small number of events, single-center retrospective study. CONCLUSION The hypothesis of an association between cardiovascular events and the concomitant use of thalidomide and prednisone is supported, but more robust prospective studies are required for a better assessment.
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Affiliation(s)
- Melissa de Almeida Corrêa Alfredo
- Department of Infectology, Dermatology, Diagnostic Imaging and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil.
| | - Juliano Vilaverde Schmitt
- Department of Infectology, Dermatology, Diagnostic Imaging and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
| | - Anna Carolina Miola
- Department of Infectology, Dermatology, Diagnostic Imaging and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
| | - Simone de Pádua Milagres
- Department of Infectology, Dermatology, Diagnostic Imaging and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
| | - Joel Carlos Lastoria
- Department of Infectology, Dermatology, Diagnostic Imaging and Radiotherapy, Faculty of Medicine, Universidade Estadual Paulista, Botucatu, SP, Brazil
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Li P, Xu B, Xu J, Wang Y, Yang Y, Wang W, Maihemaiti A, Li J, Xu T, Ren L, Lan T, Zhou C, Wang P, Liu P. Thrombosis events in Chinese patients with newly diagnosed multiple myeloma. Clin Exp Med 2023; 23:3809-3820. [PMID: 37103654 DOI: 10.1007/s10238-023-01080-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
A high risk of thrombosis is seen in patients with newly diagnosed multiple myeloma (NDMM), particularly those treated with immunomodulatory drugs (IMiDs). Large cohorts addressing the thrombosis issue of NDMM patients in Asia are lacking. We retrospectively analyzed the clinical information of NDMM patients diagnosed in Zhongshan Hospital Fudan University, a national medical center, from January 2013 to June 2021. Death and thrombotic events (TEs) were the endpoints. To investigate risk factors for TEs, the Fine and Gray competing risk regression models were created, in which unrelated deaths were labeled as competing risk events. A total of 931 NDMM patients were recruited in our study. The median follow-up was 23 months [interquartile range (IQR): 9-43 months]. Forty-two patients (4.51%) developed TEs, including 40 cases (4.30%) of venous thrombosis and 2 cases (0.21%) of arterial thrombosis. The median time from taking first-line treatment to TEs occurrence was 2.03 months (IQR: 0.52-5.70 months). The cumulative incidence of TEs was higher in patients treated with IMiDs than in those without IMiDs (8.25 vs. 4.32%, p = 0.038). There was no difference in the incidence of TEs between lenalidomide-based and thalidomide-based groups (7.80 vs. 8.84%, p = 0.886). Besides, TEs occurrence did not adversely affect OS (p = 0.150) or PFS (p = 0.210) in MM patients. Chinese NDMM patients have a lower incidence of thrombosis than those in western countries. The risk of thrombosis was particularly increased in patients treated with IMiDs. TEs were not associated with inferior progression-free survival or overall survival.
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Affiliation(s)
- Panpan Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bei Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Medical Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiadai Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yawen Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yang Yang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenjing Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Aiziguli Maihemaiti
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Li
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianhong Xu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liang Ren
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tianwei Lan
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chi Zhou
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pu Wang
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China.
- Cancer Center, Zhongshan Hospital, Fudan University, Shanghai, China.
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Li X, Sun X, Fang B, Leng Y, Sun F, Wang Y, Wang Q, Jin J, Yang M, Xu B, Fang Z, Chen L, Chen Z, Yang Q, Zhang K, Ye Y, Geng H, Sun Z, Hao D, Huang H, Wang X, Jing H, Ma L, Pan X, Chen W, Li J. Development and validation of a new risk assessment model for immunomodulatory drug-associated venous thrombosis among Chinese patients with multiple myeloma. Thromb J 2023; 21:105. [PMID: 37794471 PMCID: PMC10552366 DOI: 10.1186/s12959-023-00534-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 08/19/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Individuals with multiple myeloma (MM) receiving immunomodulatory drugs (IMiDs) are at risk of developing venous thromboembolism (VTE), a serious complication. There is no established clinical model for predicting VTE in the Chinese population. We develop a new risk assessment model (RAM) for IMiD-associated VTE in Chinese MM patients. METHODS We retrospectively selected 1334 consecutive MM patients receiving IMiDs from 16 medical centers in China and classified them randomly into the derivation and validation cohorts. A multivariate Cox regression model was used for analysis. RESULTS The overall incidence of IMiD-related VTE in Chinese MM patients was 6.1%. Independent predictive factors of VTE (diabetes, ECOG performance status, erythropoietin-stimulating agent use, dexamethasone use, and VTE history or family history of thrombosis) were identified and merged to develop the RAM. The model identified approximately 30% of the patients in each cohort at high risk for VTE. The hazard ratios (HRs) were 6.08 (P < 0.001) and 6.23 (P < 0.001) for the high-risk subcohort and the low-risk subcohort, respectively, within both the derivation and validation cohorts. The RAM achieved satisfactory discrimination with a C statistic of 0.64. The stratification approach of the IMWG guidelines yielded respective HRs of 1.77 (P = 0.053) and 1.81 (P = 0.063). The stratification approach of the SAVED score resulted in HRs of 3.23 (P = 0.248) and 1.65 (P = 0.622), respectively. The IMWG guideline and the SAVED score-based method yielded C statistics of 0.58 and 0.51, respectively. CONCLUSIONS The new RAM outperformed the IMWG guidelines and the SAVED score and could potentially guide the VTE prophylaxis strategy for Chinese MM patients.
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Affiliation(s)
- Xiaozhe Li
- Department of Haematology, First Affiliated Hospital of Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510000, Guangdong, China
| | - Xiuli Sun
- Department of Haematology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Baijun Fang
- Department of Haematology, Henan Cancer Hospital, Zhengzhou, China
| | - Yun Leng
- Department of Haematology, Beijing Chaoyang Hospital, Beijing, China
| | - Fangfang Sun
- Department of Haematology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Yaomei Wang
- Department of Haematology, Henan Cancer Hospital, Zhengzhou, China
| | - Qing Wang
- Department of Haematology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jie Jin
- Department of Haematology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Yang
- Department of Haematology, First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Bing Xu
- Department of Haematology, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Zhihong Fang
- Department of Haematology, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Lijuan Chen
- Department of Haematology, Jiangsu Provincial People's Hospital, Nanjing, China
| | - Zhi Chen
- Department of Haematology, Jiangsu Provincial People's Hospital, Nanjing, China
| | - Qimei Yang
- Department of Haematology, Shantou Central Hospital, Shantou, China
| | - Kejie Zhang
- Department of Haematology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Yinhai Ye
- Department of Haematology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen, China
| | - Hui Geng
- Department of Haematology, Affiliated Hospital of Qinghai University, Xining, China
| | - Zhiqiang Sun
- Department of Haematology, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Dan Hao
- Department of Haematology, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Hongming Huang
- Department of Haematology, Nantong University Hospital, Nantong, China
| | - Xiaotao Wang
- Department of Haematology, Second Affiliated Hospital of Guilin Medical College, Guilin, China
| | - Hongmei Jing
- Department of Haematology, Peking University Third Hospital, Beijing, China
| | - Lan Ma
- Department of Haematology, Peking University Third Hospital, Beijing, China
| | - Xueyi Pan
- Department of Haematology, First Affiliated Hospital of Guangdong Pharmaceutical University, Guangzhou, China
| | - Wenming Chen
- Department of Haematology, Beijing Chaoyang Hospital, Beijing, China.
| | - Juan Li
- Department of Haematology, First Affiliated Hospital of Sun Yat-sen University, No. 58 Zhongshan Er Road, Guangzhou, 510000, Guangdong, China.
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Miller D, Kerkhofs K, Abbas-Aghababazadeh F, Madahar SS, Minden MD, Hébert J, Haibe-Kains B, Bayfield MA, Benchimol S. Heterogeneity in leukemia cells that escape drug-induced senescence-like state. Cell Death Dis 2023; 14:503. [PMID: 37543610 PMCID: PMC10404232 DOI: 10.1038/s41419-023-06015-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 07/06/2023] [Accepted: 07/25/2023] [Indexed: 08/07/2023]
Abstract
Erythropoietin (EPO) suppresses drug-induced apoptosis in EPO-receptor-positive leukemia cells and allows cells to persist after drug treatment by promoting cellular senescence. Importantly a small proportion of senescent cells can re-enter the cell cycle and resume proliferation after drug treatment, resulting in disease recurrence/persistence. Using a single-cell assay to track individual cells that exit a drug-induced senescence-like state, we show that cells exhibit asynchronous exit from a senescent-like state, and display different rates of proliferation. Escaped cells retain sensitivity to drug treatment, but display inter-clonal variability. We also find heterogeneity in gene expression with some of the escaped clones retaining senescence-associated gene expression. Senescent leukemia cells exhibit changes in gene expression that affect metabolism and senescence-associated secretory phenotype (SASP)-related genes. Herein, we generate a senescence gene signature and show that this signature is a prognostic marker of worse overall survival in AML and multiple other cancers. A portion of senescent leukemia cells depend on lysosome activity; chloroquine, an inhibitor of lysosome activity, promotes senolysis of some senescent leukemia cells. Our study indicates that the serious risks associated with the use of erythropoietin-stimulating agents (ESAs) in anemic cancer patients may be attributed to their ability to promote drug-tolerant cancer cells through the senescence program.
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Affiliation(s)
- David Miller
- Department of Biology, York University, Toronto, ON, M3J 1P3, Canada.
| | - Kyra Kerkhofs
- Department of Biology, York University, Toronto, ON, M3J 1P3, Canada
| | | | | | - Mark D Minden
- Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Canada
| | - Josée Hébert
- Division of Hematology-Oncology, Maisonneuve-Rosemont Hospital and Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Benjamin Haibe-Kains
- Princess Margaret Cancer Centre, University Health Network and University of Toronto, Toronto, Canada
- Medical Biophysics, University of Toronto, Toronto, Canada
- Vector Institute for Artificial Intelligence, Toronto, Canada
- Ontario Institute for Cancer Research, Toronto, Canada
- Department of Computer Science, University of Toronto, Toronto, Canada
- Department of Biostatistics, Dalla Lana School of Public Health, Toronto, Canada
| | - Mark A Bayfield
- Department of Biology, York University, Toronto, ON, M3J 1P3, Canada
| | - Samuel Benchimol
- Department of Biology, York University, Toronto, ON, M3J 1P3, Canada.
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Sun MY, Bhaskar SMM. When Two Maladies Meet: Disease Burden and Pathophysiology of Stroke in Cancer. Int J Mol Sci 2022; 23:15769. [PMID: 36555410 PMCID: PMC9779017 DOI: 10.3390/ijms232415769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022] Open
Abstract
Stroke and cancer are disabling diseases with an enormous global burden, disproportionately affecting vulnerable populations and low- and middle-income countries. Both these diseases share common risk factors, which warrant concerted attention toward reshaping population health approaches and the conducting of fundamental studies. In this article, an overview of epidemiological trends in the prevalence and burden of cancer and stroke, underlying biological mechanisms and clinical risk factors, and various tools available for risk prediction and prognosis are provided. Finally, future recommendations for research and existing gaps in our understanding of pathophysiology. Further research must investigate the causes that predispose patients to an increased risk of stroke and/or cancer, as well as biomarkers that can be used to predict growing morbidity and mortality.
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Affiliation(s)
- Ming-Yee Sun
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
- UNSW Medicine and Health, University of New South Wales (UNSW), South Western Sydney Clinical Campuses, Sydney, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital and South West Sydney Local Health District (SWSLHD), Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, Liverpool, NSW 2170, Australia
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8
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Jiang T, Su H, Li Y, Wu Y, Ming Y, Li C, Fu R, Feng L, Li Z, Li L, Ni R, Liu Y. Post-marketing safety of immunomodulatory drugs in multiple myeloma: A pharmacovigilance investigation based on the FDA adverse event reporting system. Front Pharmacol 2022; 13:989032. [DOI: 10.3389/fphar.2022.989032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/18/2022] [Indexed: 12/02/2022] Open
Abstract
Objective: In recent years, the emergence of immunomodulatory drugs (IMiDs) has significantly improved clinical outcomes in patients with multiple myeloma (MM); however, serious adverse events (AEs) have hindered their safe clinical application. This study aimed to characterize the safety profiles and differences in IMiDs through a disproportionality analysis using the U.S. Food and Drug Administration Adverse Event Reporting System (FAERS), a post-marketing surveillance database.Methods: This study filtered reports of thalidomide, lenalidomide, and pomalidomide as primary suspect drugs in FAERS files from January 2013 to December 2021. AEs in the reports were retrieved according to the preferred terms (PTs) of the Medical Dictionary for Regulatory Activities. Furthermore, we detected safety signals using the reporting odds ratio (ROR), proportional reporting ratio (PRR), and Bayesian belief propagation neural network (BCPNN). When all three algorithms showed an association between the target drug and the AE, a positive signal was generated.Results: We extracted 9,968 thalidomide, 231,926 lenalidomide, and 55,066 pomalidomide AE reports. AEs were more common in male patients and in those >44 years old. Important safety signals were detected based on the system organ classes (SOC), including thalidomide (cardiac disorders: ROR, 2.87; PRR, 2.79; IC 1.22), lenalidomide (gastrointestinal disorders: ROR, 2.38; PRR, 2.27; IC 0.75), and pomalidomide (respiratory, thoracic, and mediastinal disorders: ROR, 2.14; PRR, 2.09; IC 0.85). Within the PT level, we identified novel risk signals: the thalidomide-induced second primary malignancy (SPM) signal was significant; lenalidomide reduced the success rate of hematopoietic stem cell collection; and three IMiDs may cause human chorionic gonadotropin increase, but this needs to be proven by clinical data. Pneumonia, sepsis, and renal failure are common risk factors for death due to IMiDs. Compared with thalidomide and lenalidomide, pomalidomide has a lower risk of venous thromboembolism (VTE) and is beneficial to patients with renal insufficiency.Conclusion: Mining data from FAERS resulted in novel AE signals, including adenocarcinoma of colon, harvest failure of blood stem cells, and increased levels of human chorionic gonadotropin. Further investigation is required to verify the significance of these signals. Moreover, IMiDs showed differences in safety reports, which should be emphasized by clinicians.
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9
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Allouchery M, Beuvon C, Pérault-Pochat MC, Roblot P, Puyade M, Martin M. Immune Checkpoint Inhibitors and Venous Thromboembolism: An Analysis of the WHO Pharmacovigilance Database. Clin Pharmacol Ther 2022; 112:164-170. [PMID: 35426120 DOI: 10.1002/cpt.2615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/06/2022] [Indexed: 11/07/2022]
Abstract
Data on venous thromboembolic events (VTEs) in patients receiving immune checkpoint inhibitors (ICIs) are scarce and conflicting. This study investigated the risk of reporting VTEs associated with ICIs in comparison with all other anticancer drugs. The World Health Organization pharmacovigilance database (VigiBase), comprising >30 million individual case safety reports, was queried. All reports on patients with cancer, involving at least one anticancer drug as a suspect or interacting drug and registered from January 1, 2008, to May 31, 2021, were included. The association between ICIs and the risk of reporting VTEs was estimated using the reporting odds ratio (ROR) as a measure of disproportionality with all other anticancer drugs as comparators. RORs were estimated as crude and adjusted RORs for age, sex, and other medications (excluding anticancer drugs) associated with risk of VTEs. Among 1,196 patients experiencing VTEs after ICI treatment, the median age was 65 years and 57.6% were men. Anti-PD-1 agents (62.5%) were the most frequently reported. ICIs were not associated with higher reporting of VTEs when compared with other anticancer drugs (crude ROR 0.63, 95% confidence interval (CI) 0.60 to 0.67 and adjusted ROR 0.70, 95% CI 0.65-0.74). No signal of disproportionate reporting was found when considering each class of ICIs. In conclusion, ICIs were not associated with higher reporting of VTEs, in comparison with all other anticancer drugs in a large-scale pharmacovigilance database. Owing to the limitations inherent to pharmacovigilance studies, prospective studies, including an adequate comparison group, are needed to assess the risk of VTEs in ICI-treated patients.
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Affiliation(s)
- Marion Allouchery
- Pharmacologie Clinique et Vigilances, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
| | - Clément Beuvon
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Médecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Marie-Christine Pérault-Pochat
- Pharmacologie Clinique et Vigilances, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Laboratoire de Neurosciences Expérimentales et Cliniques, INSERM U1084, Université de Poitiers, Poitiers, France
- CIC-1402, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Pascal Roblot
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Médecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Mathieu Puyade
- Médecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- CIC-1402, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Mickaël Martin
- Faculté de Médecine et de Pharmacie, Université de Poitiers, Poitiers, France
- Médecine Interne et Maladies Infectieuses, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- INSERM U1313, Université de Poitiers, Poitiers, France
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10
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Costa BA, Mouhieddine TH, Richter J. What's Old is New: The Past, Present and Future Role of Thalidomide in the Modern-Day Management of Multiple Myeloma. Target Oncol 2022; 17:383-405. [PMID: 35771402 DOI: 10.1007/s11523-022-00897-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2022] [Indexed: 10/17/2022]
Abstract
Immunomodulatory drugs (IMiDs) have become an integral part of therapy for both newly diagnosed and relapsed/refractory multiple myeloma (RRMM). IMiDs bind to cereblon, leading to the degradation of proteins involved in B-cell survival and proliferation. Thalidomide, a first-generation IMiD, has little to no myelosuppressive potential, negligible renal clearance, and long-proven anti-myeloma activity. However, thalidomide's adverse effects (e.g., somnolence, constipation, and peripheral neuropathy) and the advent of more potent therapeutic options has led to the drug being less frequently used in many countries, including the US and Canada. Newer-generation IMiDs, such as lenalidomide and pomalidomide, are utilized far more frequently. In numerous previous trials, salvage therapy with thalidomide (50-200 mg/day) plus corticosteroids (with or without selected cytotoxic or targeted agents) has been shown to be effective and well-tolerated in the RRMM setting. Hence, thalidomide-based regimens remain important alternatives for heavily pretreated patients, especially for those who have no access to novel therapies and/or are not eligible for their use (due to renal failure, high-grade myelosuppression, or significant comorbidities). Ongoing and future trials may provide further insights into the current role of thalidomide, especially by comparing thalidomide-containing regimens with protocols based on newer-generation IMiDs and by investigating thalidomide's association with novel therapies (e.g., antibody-drug conjugates, bispecific antibodies, and chimeric antigen receptor T cells).
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Affiliation(s)
- Bruno Almeida Costa
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tarek H Mouhieddine
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1185, New York, NY, 10029, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1185, New York, NY, 10029, USA.
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11
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Piedra K, Peterson T, Tan C, Orozco J, Hultcrantz M, Hassoun H, Mailankody S, Lesokhin A, Shah U, Lu S, Patel D, Derkach A, Wilkins C, Korde N. Comparison of venous thromboembolism incidence in newly diagnosed multiple myeloma patients receiving bortezomib, lenalidomide, dexamethasone (RVD) or carfilzomib, lenalidomide, dexamethasone (KRD) with aspirin or rivaroxaban thromboprophylaxis. Br J Haematol 2022; 196:105-109. [PMID: 34396516 PMCID: PMC9527668 DOI: 10.1111/bjh.17772] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/22/2021] [Accepted: 07/30/2021] [Indexed: 01/03/2023]
Abstract
Incidence of venous thromboembolism (VTE) varies across different regimens in newly diagnosed multiple myeloma (NDMM) patients. Limited data exist on the use of direct oral anticoagulants as thromboprophylaxis in the setting of haematologic malignancies, specifically multiple myeloma. In this retrospective study of 305 NDMM patients, VTE rates in those treated with carfilzomib, lenalidomide, dexamethasone (KRD) + aspirin (ASA), bortezomib, lenalidomide, dexamethasone (RVD) + ASA, and KRD + rivaroxaban were statistically significant, 16·1%, 4·8%, and 4·8%, respectively. The findings confirm a higher incidence of VTE when using KRD induction compared to RVD induction and reveal that the use of low-dose rivaroxaban thromboprophylaxis can mitigate this risk without an observable increase in bleeding rates.
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Affiliation(s)
- Katrina Piedra
- Department of Pharmacy, Sylvester Comprehensive Cancer Center, University of Miami Hospitals and Clinics, 1475 NW 12th Ave, Miami, FL 33136
| | - Tim Peterson
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, 1250 1st Avenue New York, NY 10065
| | - Carlyn Tan
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Jennifer Orozco
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, 1250 1st Avenue New York, NY 10065
| | - Malin Hultcrantz
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Hani Hassoun
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Sham Mailankody
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Alexander Lesokhin
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Urvi Shah
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Sydney Lu
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Dhwani Patel
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
| | - Andriy Derkach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 1275 York Avenue New York NY 10065
| | - Cy Wilkins
- Hematology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue New York NY 10065
| | - Neha Korde
- Multiple Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 530 East 74th Street, NY, NY 10021,Department of Medicine, Weill Cornell Medical College, 1300 York Ave, New York, NY 10065
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12
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Kahale LA, Matar CF, Tsolakian I, Hakoum MB, Yosuico VE, Terrenato I, Sperati F, Barba M, Hicks LK, Schünemann H, Akl EA. Antithrombotic therapy for ambulatory patients with multiple myeloma receiving immunomodulatory agents. Cochrane Database Syst Rev 2021; 9:CD014739. [PMID: 34582035 PMCID: PMC8477647 DOI: 10.1002/14651858.cd014739] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Multiple myeloma is a malignant plasma cell disorder characterised by clonal plasma cells that cause end-organ damage such as renal failure, lytic bone lesions, hypercalcaemia and/or anaemia. People with multiple myeloma are treated with immunomodulatory agents including lenalidomide, pomalidomide, and thalidomide. Multiple myeloma is associated with an increased risk of thromboembolism, which appears to be further increased in people receiving immunomodulatory agents. OBJECTIVES (1) To systematically review the evidence for the relative efficacy and safety of aspirin, oral anticoagulants, or parenteral anticoagulants in ambulatory patients with multiple myeloma receiving immunomodulatory agents who otherwise have no standard therapeutic or prophylactic indication for anticoagulation. (2) To maintain this review as a living systematic review by continually running the searches and incorporating newly identified studies. SEARCH METHODS We conducted a comprehensive literature search that included (1) a major electronic search (14 June 2021) of the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE via Ovid, and Embase via Ovid; (2) hand-searching of conference proceedings; (3) checking of reference lists of included studies; and (4) a search for ongoing studies in trial registries. As part of the living systematic review approach, we are running continual searches, and we will incorporate new evidence rapidly after it is identified. SELECTION CRITERIA Randomised controlled trials (RCTs) assessing the benefits and harms of oral anticoagulants such as vitamin K antagonist (VKA) and direct oral anticoagulants (DOAC), anti-platelet agents such as aspirin (ASA), and parenteral anticoagulants such as low molecular weight heparin (LMWH)in ambulatory patients with multiple myeloma receiving immunomodulatory agents. DATA COLLECTION AND ANALYSIS Using a standardised form, we extracted data in duplicate on study design, participants, interventions, outcomes of interest, and risk of bias. Outcomes of interest included all-cause mortality, symptomatic deep vein thrombosis (DVT), pulmonary embolism (PE), major bleeding, and minor bleeding. For each outcome we calculated the risk ratio (RR) with its 95% confidence interval (CI) and the risk difference (RD) with its 95% CI. We then assessed the certainty of evidence at the outcome level following the GRADE approach (GRADE Handbook). MAIN RESULTS We identified 1015 identified citations and included 11 articles reporting four RCTs that enrolled 1042 participants. The included studies made the following comparisons: ASA versus VKA (one study); ASA versus LMWH (two studies); VKA versus LMWH (one study); and ASA versus DOAC (two studies, one of which was an abstract). ASA versus VKA One RCT compared ASA to VKA at six months follow-up. The data did not confirm or exclude a beneficial or detrimental effect of ASA relative to VKA on all-cause mortality (RR 3.00, 95% CI 0.12 to 73.24; RD 2 more per 1000, 95% CI 1 fewer to 72 more; very low-certainty evidence); symptomatic DVT (RR 0.57, 95% CI 0.24 to 1.33; RD 27 fewer per 1000, 95% CI 48 fewer to 21 more; very low-certainty evidence); PE (RR 1.00, 95% CI 0.25 to 3.95; RD 0 fewer per 1000, 95% CI 14 fewer to 54 more; very low-certainty evidence); major bleeding (RR 7.00, 95% CI 0.36 to 134.72; RD 6 more per 1000, 95% CI 1 fewer to 134 more; very low-certainty evidence); and minor bleeding (RR 6.00, 95% CI 0.73 to 49.43; RD 23 more per 1000, 95% CI 1 fewer to 220 more; very low-certainty evidence). One RCT compared ASA to VKA at two years follow-up. The data did not confirm or exclude a beneficial or detrimental effect of ASA relative to VKA on all-cause mortality (RR 0.50, 95% CI 0.05 to 5.47; RD 5 fewer per 1000, 95% CI 9 fewer to 41 more; very low-certainty evidence); symptomatic DVT (RR 0.71, 95% CI 0.35 to 1.44; RD 22 fewer per 1000, 95% CI 50 fewer to 34 more; very low-certainty evidence); and PE (RR 1.00, 95% CI 0.25 to 3.95; RD 0 fewer per 1000, 95% CI 14 fewer to 54 more; very low-certainty evidence). ASA versus LMWH Two RCTs compared ASA to LMWH at six months follow-up. The pooled data did not confirm or exclude a beneficial or detrimental effect of ASA relative to LMWH on all-cause mortality (RR 1.00, 95% CI 0.06 to 15.81; RD 0 fewer per 1000, 95% CI 2 fewer to 38 more; very low-certainty evidence); symptomatic DVT (RR 1.23, 95% CI 0.49 to 3.08; RD 5 more per 1000, 95% CI 11 fewer to 43 more; very low-certainty evidence); PE (RR 7.71, 95% CI 0.97 to 61.44; RD 7 more per 1000, 95% CI 0 fewer to 60 more; very low-certainty evidence); major bleeding (RR 6.97, 95% CI 0.36 to 134.11; RD 6 more per 1000, 95% CI 1 fewer to 133 more; very low-certainty evidence); and minor bleeding (RR 1.42, 95% CI 0.35 to 5.78; RD 4 more per 1000, 95% CI 7 fewer to 50 more; very low-certainty evidence). One RCT compared ASA to LMWH at two years follow-up. The pooled data did not confirm or exclude a beneficial or detrimental effect of ASA relative to LMWH on all-cause mortality (RR 1.00, 95% CI 0.06 to 15.89; RD 0 fewer per 1000, 95% CI 4 fewer to 68 more; very low-certainty evidence); symptomatic DVT (RR 1.20, 95% CI 0.53 to 2.72; RD 9 more per 1000, 95% CI 21 fewer to 78 more; very low-certainty evidence); and PE (RR 9.00, 95% CI 0.49 to 166.17; RD 8 more per 1000, 95% CI 1 fewer to 165 more; very low-certainty evidence). VKA versus LMWH One RCT compared VKA to LMWH at six months follow-up. The data did not confirm or exclude a beneficial or detrimental effect of VKA relative to LMWH on all-cause mortality (RR 0.33, 95% CI 0.01 to 8.10; RD 3 fewer per 1000, 95% CI 5 fewer to 32 more; very low-certainty evidence); symptomatic DVT (RR 2.32, 95% CI 0.91 to 5.93; RD 36 more per 1000, 95% CI 2 fewer to 135 more; very low-certainty evidence); PE (RR 8.96, 95% CI 0.49 to 165.42; RD 8 more per 1000, 95% CI 1 fewer to 164 more; very low-certainty evidence); and minor bleeding (RR 0.33, 95% CI 0.03 to 3.17; RD 9 fewer per 1000, 95% CI 13 fewer to 30 more; very low-certainty evidence). The study reported that no major bleeding occurred in either arm. One RCT compared VKA to LMWH at two years follow-up. The data did not confirm or exclude a beneficial or detrimental effect of VKA relative to LMWH on all-cause mortality (RR 2.00, 95% CI 0.18 to 21.90; RD 5 more per 1000, 95% CI 4 fewer to 95 more; very low-certainty evidence); symptomatic DVT (RR 1.70, 95% CI 0.80 to 3.63; RD 32 more per 1000, 95% CI 9 fewer to 120 more; very low-certainty evidence); and PE (RR 9.00, 95% CI 0.49 to 166.17; RD 8 more per 1000, 95% CI 1 fewer to 165 more; very low-certainty evidence). ASA versus DOAC One RCT compared ASA to DOAC at six months follow-up. The data did not confirm or exclude a beneficial or detrimental effect of ASA relative to DOAC on DVT, PE, and major bleeding and minor bleeding (minor bleeding: RR 5.00, 95% CI 0.31 to 79.94; RD 4 more per 1000, 95% CI 1 fewer to 79 more; very low-certainty evidence). The study reported that no DVT, PE, or major bleeding events occurred in either arm. These results did not change in a meta-analysis including the study published as an abstract. AUTHORS' CONCLUSIONS The certainty of the available evidence for the comparative effects of ASA, VKA, LMWH, and DOAC on all-cause mortality, DVT, PE, or bleeding was either low or very low. People with multiple myeloma considering antithrombotic agents should balance the possible benefits of reduced thromboembolic complications with the possible harms and burden of anticoagulants. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach 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
| | - Charbel F Matar
- Department of Internal Medicine, University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Ibrahim Tsolakian
- Department of Obstertrics and Gynaecology, University of Toledo College of Medicine and Life Sciences, Ohio, USA
| | - Maram B Hakoum
- Department of Family Medicine, Cornerstone Care Teaching Health Center, Mount Morris, Pennsylvania, USA
| | | | - Irene Terrenato
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Francesca Sperati
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Maddalena Barba
- Scientific Direction, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Lisa K Hicks
- Medicine, St. Michael's Hospital and the University of Toronto, Toronto, Canada
| | - Holger Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Elie A Akl
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon
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13
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Jones JR, Pawlyn C, Jackson GH. Safety of lenalidomide for maintenance treatment of patients with multiple myeloma following autologous stem cell transplantation. Expert Opin Drug Saf 2021; 20:1137-1145. [PMID: 34184970 DOI: 10.1080/14740338.2021.1945578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Myeloma is the second most common hematological cancer, with 5800 cases per year diagnosed in the UK. Despite improved treatment it is still considered non-curable, although the median survival has increased from 3 to 8 years over the past 20 years. Treatment involves the use of induction therapy and consolidation with autologous stem cell transplant (ASCT) in patients deemed fit enough. Further attempts to improve outcomes include the use of maintenance therapy. AREAS COVERED This review details all trials in which lenalidomide has been used as maintenance following ASCT. PubMed searches included randomized control trials, observational cohort, reviews, and meta-analysis. EXPERT OPINION Lenalidomide is a well-tolerated, oral agent that is associated with increased overall and progression free survival when used as maintenance following ASCT. Its use in this setting is FDA and EMA approved and is standard of care in Europe and North America. The early link between lenalidomide and second hematological cancers appears to be associated with use in combination with melphalan. There is an increase in non-melanoma skin cancers and solid tumors in the elderly but this has minimal impact on mortality. Lenalidomide use as part of combination maintenance is underway and may further improve outcomes.
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Affiliation(s)
- John R Jones
- Brighton and Sussex Medical School, Brighton, UK.,Department of Haematology, Eastbourne District General Hospital, Eastbourne, UK.,Department of Haematology, King's College Hospital, London, UK
| | - Charlotte Pawlyn
- The Institute of Cancer Research, London, UK.,Royal Marsden Hospital, London, UK
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14
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Levi M, Sivapalaratnam S. An overview of thrombotic complications of old and new anticancer drugs. Thromb Res 2021; 191 Suppl 1:S17-S21. [PMID: 32736772 DOI: 10.1016/s0049-3848(20)30391-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/19/2019] [Accepted: 11/19/2019] [Indexed: 10/23/2022]
Abstract
Thrombosis is a common complication of cancer with a mean prevalence of 15%. Most commonly, this presents as venous thromboembolism; however, other manifestations such as arterial thrombosis or thrombotic microangiopathy may occur. Cancer itself is not only associated with risk factors for thrombotic complications, including intrinsic biological effect of malignant cells, accompanying operations, or the presence of indwellingvascular catheters, but there is also an additional risk caused by anticancer agents including chemotherapy and immunotherapy. In most cases the underlying pathogenetic factor that contributes to the thrombotic risk associated with chemotherapy is endothelial cell injury (or loss of protection of endothelial integrity, for example by vascular endothelial growth factor inhibition). In addition, individual anticancer agents may have specific prothrombotic effects. As in recent years more intense anticancer drugs are administered, such as in myeloablative conditioning regimens preceding stem cell transplantation, thrombosis and in particular thrombotic microangiopathy are a more frequent complication in anticancer treatment.
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Affiliation(s)
- Marcel Levi
- Department of Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Cardiometabolic Programme-NIHR UCLH/UCL BRC, London, UK.
| | - Suthesh Sivapalaratnam
- Department of Haemato-Oncology, Barts NHS Trust, London, UK; Department of Haematology, University of Cambridge, Cambridge, UK
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15
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Pathophysiology of Coagulopathy in Hematological Malignancies and in COVID-19. Hemasphere 2021; 5:e571. [PMID: 34095755 PMCID: PMC8171377 DOI: 10.1097/hs9.0000000000000571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 04/07/2021] [Indexed: 01/08/2023] Open
Abstract
Many severe illnesses with a systemic impact may cause activation of coagulation. While systemic activation of coagulation leads to a coagulopathy that follows many common activation pathways and failure of endogenous regulatory anticoagulant systems, underlying conditions may utilize distinctive pathogenetic routes and may vary in clinical manifestations of the coagulopathy. The coagulation derangement associated with hematological malignancies and the coagulopathy of coronavirus disease 2019 (COVID-19) clearly demonstrate such differences. Malignancies are associated with venous thromboembolism due to the biological effect of malignant cells, frequent medical interventions, or the presence of indwelling vascular catheters. The underlying pathogenesis of cancer-associated coagulopathy relies on tissue factor-mediated activation of coagulation, cytokine-controlled defective anticoagulant pathways, fibrinolytic changes, and dysfunctional endothelium. There is an additional risk caused by anti-cancer agents including chemotherapy and immunotherapy. The underlying pathogenetic factor that contributes to the thrombotic risk associated with chemotherapy is endothelial cell injury (or loss of protection of endothelial integrity, for example, by vascular endothelial growth factor inhibition). In addition, individual anti-cancer agents may have specific prothrombotic effects. One of the remarkable features of severe COVID-19 infections is a coagulopathy that mimics but is not identical to the disseminated intravascular coagulation and thrombotic microangiopathy and has been identified as a strong marker for an adverse outcome. Severe COVID-19 infections cause inflammation-induced changes in coagulation in combination with severe endothelial cell injury. This coagulopathy likely contributes to pulmonary microvascular thrombosis, bronchoalveolar fibrin deposition (which is a hallmark of acute respiratory distress syndrome) and venous thromboembolic complications.
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16
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Wang J, Park C, Arroyo-Suarez R. Venous thromboembolism in patients with multiple myeloma receiving daratumumab-based regimens: a post hoc analysis of phase 3 clinical trials. Leuk Lymphoma 2021; 62:2219-2226. [PMID: 33836624 DOI: 10.1080/10428194.2021.1910687] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
It is unknown if daratumumab could affect venous thromboembolism (VTE) risks in patients with multiple myeloma (MM). In this study, individual participant data from three trials comparing daratumumab (DARA) and non-DARA regimens, the CASTOR, PULLOX and MAIA trial, were pooled into two groups. A total of 896 and 899 patients received DARA and non-DARA regimens, respectively. After a median follow-up of 13.9 and 13.5 months, there was no significant difference in VTE incidence between the two groups (hazard ratio 0.80, 95% confidence interval 0.57-1.13, p = 0.17). The two groups shared similar VTE risk factors. The SAVED score and IMPEDE-VTE score are two validated VTE risk-stratification tools in MM. In the DARA group, the SAVED score had better performance than the IMPEDE-VTE score in identifying high risk patients.
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Affiliation(s)
- Jiasheng Wang
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Changsu Park
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Raul Arroyo-Suarez
- Department of Internal Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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17
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Grover SP, Hisada YM, Kasthuri RS, Reeves BN, Mackman N. Cancer Therapy-Associated Thrombosis. Arterioscler Thromb Vasc Biol 2021; 41:1291-1305. [PMID: 33567864 DOI: 10.1161/atvbaha.120.314378] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Steven P Grover
- UNC Blood Research Center, Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Yohei M Hisada
- UNC Blood Research Center, Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Raj S Kasthuri
- UNC Blood Research Center, Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Brandi N Reeves
- UNC Blood Research Center, Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill
| | - Nigel Mackman
- UNC Blood Research Center, Division of Hematology and Oncology, Department of Medicine, University of North Carolina at Chapel Hill
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18
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Moik F, Ay C, Pabinger I. Risk prediction for cancer-associated thrombosis in ambulatory patients with cancer: past, present and future. Thromb Res 2020; 191 Suppl 1:S3-S11. [DOI: 10.1016/s0049-3848(20)30389-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 12/14/2019] [Accepted: 12/23/2019] [Indexed: 01/29/2023]
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19
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Multiple Myeloma Mimicking a Small Vessel Vasculitis Presentation. Case Rep Rheumatol 2020; 2020:9146842. [PMID: 32099712 PMCID: PMC7037530 DOI: 10.1155/2020/9146842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 11/24/2022] Open
Abstract
Multiple myeloma can have different clinical manifestations, and not all patients present with classic CRAB component. We describe a 46-year-old woman admitted to our hospital with a complaint of a bluish-to-black discoloration of the second toe that was rapidly progressive and acute kidney injury. We documented a Kappa light chain monoclonal gammopathy, increased presence of plasmacytes in bone marrow aspiration, and multiple lytic bone lesions, which led to a diagnosis of multiple myeloma. Although multiple myeloma presenting with blue finger syndrome is uncommon, it must always be considered as a differential diagnosis with this clinical finding.
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20
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Bian Y, An GJ, Kim K, Ngo T, Shin S, Bae ON, Lim KM, Chung JH. Ginsenoside Rg3, a component of ginseng, induces pro-thrombotic activity of erythrocytes via hemolysis-associated phosphatidylserine exposure. Food Chem Toxicol 2019; 131:110553. [PMID: 31163221 DOI: 10.1016/j.fct.2019.05.061] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/19/2019] [Accepted: 05/31/2019] [Indexed: 12/19/2022]
Abstract
Ginseng and its active gradient, ginsenoside Rg3 (Rg3), are widely used for a variety of health benefits, but concerns over their misuses are increasing. Previously, it has been reported that Rg3 can cause hemolysis, but its health outcome remains unknown. Here, we demonstrated that Rg3 could promote the procoagulant activity of erythrocytes through the process of hemolysis, ultimately leading to increased thrombosis. In freshly isolated human erythrocytes, Rg3 caused pore formation and fragmentation of the erythrocyte membrane. Confocal microscopy observation and flow cytometric analysis revealed that remnant erythrocyte fragments after the exposure to Rg3 expressed phosphatidylserine (PS), which can promote blood coagulation through providing assembly sites for coagulation complexes. Rat in vivo experiments further confirmed that intravenous administration of Rg3 produced PS-bearing erythrocyte debris and increased thrombosis. Collectively, we demonstrated that Rg3 could induce the procoagulant activity of erythrocytes by generating PS-bearing erythrocyte debris through hemolysis, which might provoke thrombosis.
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Affiliation(s)
- Yiying Bian
- College of Pharmacy, Seoul National University, Seoul, 151-742, South Korea.
| | - Gwang-Jin An
- College of Pharmacy, Seoul National University, Seoul, 151-742, South Korea.
| | - Keunyoung Kim
- College of Pharmacy, Seoul National University, Seoul, 151-742, South Korea.
| | - Thien Ngo
- College of Pharmacy, Seoul National University, Seoul, 151-742, South Korea.
| | - Sue Shin
- Department of Laboratory Medicine, Boramae Hospital, Seoul, 156-707, South Korea.
| | - Ok-Nam Bae
- College of Pharmacy, Hanyang University, Ansan, Gyeonggi-do, 426-791, South Korea.
| | - Kyung-Min Lim
- College of Pharmacy, Ewha Womans University, Seoul, 03760, South Korea.
| | - Jin-Ho Chung
- College of Pharmacy, Seoul National University, Seoul, 151-742, South Korea.
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21
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Nielsen T, Kristensen SR, Gregersen H, Teodorescu EM, Christiansen G, Pedersen S. Extracellular vesicle-associated procoagulant phospholipid and tissue factor activity in multiple myeloma. PLoS One 2019; 14:e0210835. [PMID: 30640949 PMCID: PMC6331130 DOI: 10.1371/journal.pone.0210835] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/02/2019] [Indexed: 11/18/2022] Open
Abstract
Multiple myeloma (MM) patients have increased risk of developing venous thromboembolism, but the underlying mechanisms and the effect on the coagulation system of the disease and the current cancer therapies are not known. It is possible that cancer-associated extracellular vesicles (EV), carrying tissue factor (TF) and procoagulant phospholipids (PPL) may play a role in thrombogenesis. The aim of this study was to perform an in-depth analysis of procoagulant activity of small and large EVs isolated from 20 MM patients at diagnosis and after receiving first-line treatment compared with 20 healthy control subjects. Differential ultracentrifugation at 20,000 × g and 100,000 × g were used to isolate EVs for quantitative and phenotypical analysis through nanoparticle tracking analysis, Western blotting and transmission electron microscopy. The isolated EVs were analyzed for procoagulant activity using the calibrated automated thrombogram technique, a factor Xa-based activity assay, and the STA Procoag-PPL assay. In general, MM patients contained more EVs, and immunoelectron microscopy confirmed the presence of CD9- and CD38-positive EVs. EVs in the 20,000 × g pellets from MM patients exerted procoagulant activity visualized by increased thrombin generation and both TF and PPL activity. This effect diminished during treatment, with the most prominent effect observed in the high-dose chemotherapy eligible patients after induction therapy with bortezomib, cyclophosphamide, and dexamethasone. In conclusion, the EVs in patients with MM carrying TF and PPL are thus capable of exerting procoagulant activity.
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Affiliation(s)
- Thøger Nielsen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Risom Kristensen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Gregersen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Elena Manuela Teodorescu
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Shona Pedersen
- Department of Clinical Biochemistry, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Faculty of Medicine, Aalborg University Hospital, Aalborg, Denmark
- * E-mail:
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22
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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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23
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Abstract
Cancer patients have an increased risk of thrombosis. The development of cancer thrombosis is dependent on a number of factors including cancer type, stage, various biologic markers, and the use of central venous catheters. In addition, cancer treatment itself may increase thrombotic risk. Tamoxifen increases the risk of venous thromboembolism (VTE) by two- to sevenfold, while an impact on risk of arterial thrombosis is uncertain. Immunomodulatory imide drugs (IMiDs) such as thalidomide and lenalidomide increase the risk of VTE in patients with multiple myeloma (MM) by about 10-40% when given in combination with glucocorticoids or other chemotherapy agents; the risk of VTE in MM patients treated with IMiD-containing regimens necessitates that such patients receive thromboprophylaxis with aspirin, low-molecular-weight heparin, or warfarin. Among cytotoxic chemotherapy agents, cisplatin, and to a lesser extent fluorouracil, has been described in association with thrombosis. L-asparaginase in treatment of acute lymphoblastic leukemia is significantly associated with increased thrombosis particularly affecting the CNS, which may be due to acquired antithrombin deficiency; at some centers, plasma infusions or antithrombin replacement is used to mitigate this. Bevacizumab, an inhibitor of vascular endothelial growth factor, increases arterial and possibly venous thrombotic risk, although the literature is conflicting about the latter. Supportive care agents in cancer care, such as erythropoiesis-stimulating agents, granulocyte colony stimulating factor, and steroids, also have some impact on thrombosis. This review summarizes the mechanisms by which these and other therapies modulate thrombotic risks and how such risks may be managed.
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Affiliation(s)
- M D Debbie Jiang
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - M D Alfred Ian Lee
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
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24
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Yang X, Li X, Yuan M, Tian C, Yang Y, Wang X, Zhang X, Sun Y, He T, Han S, Chen G, Liu N, Gao Y, Hu D, Xing Y, Shang H. Anticancer Therapy-Induced Atrial Fibrillation: Electrophysiology and Related Mechanisms. Front Pharmacol 2018; 9:1058. [PMID: 30386232 PMCID: PMC6198283 DOI: 10.3389/fphar.2018.01058] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 09/03/2018] [Indexed: 12/19/2022] Open
Abstract
Some well-established immunotherapy, radiotherapy, postoperation, anticancer drugs such as anthracyclines, antimetabolites, human epidermal growth factor receptor 2 blockers, tyrosine kinase inhibitors, alkylating agents, checkpoint inhibitors, and angiogenesis inhibitors, are significantly linked to cardiotoxicity. Cardiotoxicity is a common complication of several cancer treatments. Some studies observed complications of cardiac arrhythmia associated with the treatment of cancer, including atrial fibrillation (AF), supraventricular arrhythmias, and cardiac repolarization abnormalities. AF increases the risk of cardiovascular morbidity and mortality; it is associated with an almost doubled risk of mortality and a nearly 5-fold increase in the risk of stroke. The occurrence of AF is also usually researched in patients with advanced cancer and those undergoing active cancer treatments. During cancer treatments, the incidence rate of AF affects the prognosis of tumor treatment and challenges the treatment strategy. The present article is mainly focused on the cardiotoxicity of cancer treatments. In our review, we discuss these anticancer therapies and how they induce AF and consequently provide information on the precaution of AF during cancer treatment.
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Affiliation(s)
- Xinyu Yang
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China.,Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xinye Li
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Mengchen Yuan
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Chao Tian
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Yihan Yang
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China.,Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xiaofeng Wang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoyu Zhang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Yang Sun
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Tianmai He
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Songjie Han
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Guang Chen
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Nian Liu
- Department of Cardiology, Beijing An Zhen Hospital of the Capital University of Medical Sciences, Beijing, China
| | - Yonghong Gao
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China
| | - Dan Hu
- Department of Cardiology and Cardiovascular Research Institute, Renmin Hospital of Wuhan University, Wuhan, China.,Hubei Key Laboratory of Cardiology, Wuhan, China
| | - Yanwei Xing
- Guang'an men Hospital, Chinese Academy of Chinese Medical Sciences, Beijing, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of the Ministry of Education, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, China.,Institute of Integration of Traditional and Western Medicine of Guangzhou Medical University, Guangzhou, China
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25
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Abstract
PURPOSE OF REVIEW This review aims to summarize the epidemiology, current pathophysiologic understanding, and state-of-the-art treatment of venous thromboembolism (VTE) in cancer patients. RECENT FINDINGS The risk of VTE varies among cancer patients. Recently introduced prediction models better identify those at high risk of VTE. New mechanisms underlying hypercoagulability in cancer have been uncovered. Initial data on the efficacy of direct oral anticoagulants (DOACs) compared with low-molecular weight heparin to treat VTE in patients with cancer are promising. However, they may be associated with higher risk of gastrointestinal bleeding. VTE causes significant morbidity and mortality in cancer patients. Our understanding of the mechanisms of VTE, including those associated with cancer treatments, has significantly grown. The assessment of the benefit/risk balance of VTE treatment remains challenging in many patients with cancer. The introduction of DOACs has expanded treatment options, but knowledge on their efficacy and safety is incomplete.
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Affiliation(s)
- Alec A Schmaier
- Brigham & Women's Hospital, 75 Francis St. AB378, Boston, MA, 02115, USA
| | - Paurush Ambesh
- Maimonides Medical Center, Department of Internal Medicine, 4802 10th Ave, Brooklyn, NY, 11219, USA
| | - Umberto Campia
- Brigham & Women's Hospital, 75 Francis St. AB378, Boston, MA, 02115, USA.
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26
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Costa PDSS, Fraga LR, Kowalski TW, Daxbacher ELR, Schuler-Faccini L, Vianna FSL. Erythema Nodosum Leprosum: Update and challenges on the treatment of a neglected condition. Acta Trop 2018; 183:134-141. [PMID: 29474830 DOI: 10.1016/j.actatropica.2018.02.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 02/09/2018] [Accepted: 02/11/2018] [Indexed: 01/25/2023]
Abstract
Erythema Nodosum Leprosum (ENL) occurs due to the immunological complication of multibacillary leprosy and is characterized by painful nodules and systemic compromising. It is usually recurrent and/or chronic and has both physical and economic impact on the patient, being a very important cause of disability. In addition, ENL is a major health problem in countries where leprosy is endemic. Therefore, adequate control of this condition is important. The management of ENL aims to control acute inflammation and neuritis and prevent the onset of new episodes. However, all currently available treatment modalities have one or two drawbacks and are not effective for all patients. Corticosteroid is the anti-inflammatory of choice in ENL but may cause dependence, especially for chronic patients. Thalidomide has a rapid action but its use is limited due the teratogenicity and neurotoxicity. Clofazimine and pentoxifylline have slow action and have important adverse effects. Finally, there is no pattern or guidelines for treating these patients, becoming more difficult to evaluate and to control this condition. This review aims to show the main drugs used in the treatment of ENL and the challenges in the management of the reaction.
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27
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Chung JW, Cho YH, Ahn MJ, Lee MJ, Kim GM, Chung CS, Bang OY. Association of Cancer Cell Type and Extracellular Vesicles With Coagulopathy in Patients With Lung Cancer and Stroke. Stroke 2018; 49:1282-1285. [DOI: 10.1161/strokeaha.118.020995] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 02/27/2018] [Accepted: 03/07/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Jong-Won Chung
- From the Departments of Neurology (J.-W.C., M.J.L., G.-M.K., C.-S.C., O.Y.B.)
- Hemato-oncology (M.-J.A.)
| | - Yeon Hee Cho
- Hemato-oncology (M.-J.A.)
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; and Clinical Research Center, Samsung Biomedical Research Institute, Seoul, Korea (Y.H.C.)
| | | | - Mi Ji Lee
- From the Departments of Neurology (J.-W.C., M.J.L., G.-M.K., C.-S.C., O.Y.B.)
| | - Gyeong-Moon Kim
- From the Departments of Neurology (J.-W.C., M.J.L., G.-M.K., C.-S.C., O.Y.B.)
| | - Chin-Sang Chung
- From the Departments of Neurology (J.-W.C., M.J.L., G.-M.K., C.-S.C., O.Y.B.)
| | - Oh Young Bang
- From the Departments of Neurology (J.-W.C., M.J.L., G.-M.K., C.-S.C., O.Y.B.)
- Hemato-oncology (M.-J.A.)
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28
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Tilemann LM, Heckmann MB, Katus HA, Lehmann LH, Müller OJ. Cardio-oncology: conflicting priorities of anticancer treatment and cardiovascular outcome. Clin Res Cardiol 2018; 107:271-280. [PMID: 29453595 PMCID: PMC5869944 DOI: 10.1007/s00392-018-1202-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/11/2018] [Indexed: 12/03/2022]
Abstract
BACKGROUND This article about the emerging field of cardio-oncology highlights typical side effects of oncological therapies in the cardiovascular system, cardiovascular complications of malignancies itself, and potential preventive or therapeutic modalities. METHODS We performed a selective literature search in PubMed until September 2016. RESULTS Cardiovascular events in cancer patients can be frequently attributed to oncological therapies or to the underlying malignancy itself. Furthermore, many patients with cancer have pre-existing cardiovascular diseases that can be aggravated by the malignancy or its therapy. Cardiovascular abnormalities in oncological patients comprise a broad spectrum from alterations in electrophysiological, laboratory or imaging tests to the occurrence of thromboembolic, ischemic or rhythmological events and the impairment of left ventricular function or manifest heart failure. DISCUSSION A close interdisciplinary collaboration between oncologists and cardiologists/angiologists as well as an increased awareness of potential cardiovascular complications could improve clinical care of cancer patients and provides a basis for an improved understanding of underlying mechanisms of cardiovascular morbidity.
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Affiliation(s)
- Lisa M Tilemann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Markus B Heckmann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Hugo A Katus
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany
| | - Lorenz H Lehmann
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany.
| | - Oliver J Müller
- Abteilung für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Heidelberg, Mannheim, Germany.
- Department of Internal Medicine III, University of Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
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29
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Levi M. Clinical characteristics of disseminated intravascular coagulation in patients with solid and hematological cancers. Thromb Res 2018; 164 Suppl 1:S77-S81. [DOI: 10.1016/j.thromres.2018.01.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 01/05/2018] [Accepted: 01/08/2018] [Indexed: 01/15/2023]
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30
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Ay C, Pabinger I. Risk of venous thromboembolism and primary prophylaxis in cancer. Hamostaseologie 2017; 32:132-7. [DOI: 10.5482/ha-1173] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Accepted: 07/21/2011] [Indexed: 01/28/2023] Open
Abstract
SummaryVenous thromboembolism (VTE) is a common complication in patients with cancer that causes significant morbidity and mortality. Several patient-, tumour-and treatment-related risk factors for VTE in cancer patients have been identified. An effective and safe thromboprophylaxis in cancer patients at high risk of VTE is desirable. Recently, the identification of potential biomarkers and the development of risk scoring models for prediction of cancer-associated VTE have been published. Whether primary VTE prophylaxis based on risk assessment through these biomarkers and risk prediction models might be useful, is currently not yet known. However, thromboprophylaxis is clearly indicated in high-risk situations. While VTE prophylaxis is recommended in cancer patients undergoing surgery and in hospitalised patients with acute disease, studies in ambulatory cancer patients are still rare and evidence for primary VTE prophylaxis is currently limited. In this review, risk factors associated with VTE in cancer patients and current approaches of thromboprophylaxis in different settings, specifically in ambulatory cancer patients are subjected to a critical evaluation.
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31
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Abstract
Venous thromboembolism is a condition that includes both deep venous thrombosis and pulmonary embolism. Venous thromboembolism disease can result because of a combination of risk factors, including patient-related, treatment-related, and, more specifically, cancer-related factors. It is not disease-specific or a population-specific disorder, but it is more prevalent in certain specialty populations. This article will cover those specialty populations including cancer, pregnancy, and athletes.
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32
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Abstract
Venous thromboembolism is the formation of a blood clot in the vein. It mainly consists of 2 life-threatening conditions-deep venous thrombosis and pulmonary embolism. Deep venous thrombosis is a potentially dangerous condition with grave sequelae, the worst of which is pulmonary embolism. Venous thromboembolism can also lead to multiple other conditions with significant morbidity and mortality that include extension of thrombi, pulmonary hypertension, recurrence, and postthrombotic syndrome. An update on the epidemiology, etiology, and pathogenesis of venous thromboembolism will be reviewed in this article.
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33
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Abstract
Background: The introduction of monoclonal antibodies, either as native molecules or conjugated to radioisotopes or other toxins, has led to new therapeutic options for patients with hematologic malignancies. In addition, the use of small molecules against specific cell surface receptors, enzymes, and proteins has become an important strategy in the treatment of such disorders. Methods: The author reviewed the published clinical trials of monoclonal antibody and other targeted therapies in hematologic malignancies. Results: Results from several trials demonstrate a therapeutic benefit for the use of monoclonal antibodies (either native or conjugated) and other targeted therapies, used alone or in combination with standard cytotoxic chemotherapy. Conclusions: Targeted therapy of hematologic malignancies seems to be an effective and less toxic approach to the treatment of such disorders. Nevertheless, additional studies are needed to determine where and when such management fits into a therapeutic regimen for any given disorder, whether upfront or as salvage therapy, alone or in combination with chemotherapy (concurrent or sequential).
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MESH Headings
- Antibodies, Monoclonal/therapeutic use
- Antineoplastic Agents/classification
- Antineoplastic Agents/therapeutic use
- Drug Delivery Systems/trends
- Hematologic Neoplasms/drug therapy
- Hematologic Neoplasms/immunology
- Hematologic Neoplasms/therapy
- Humans
- Immunologic Factors/immunology
- Immunologic Factors/therapeutic use
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/immunology
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/drug therapy
- Leukemia, Myelogenous, Chronic, BCR-ABL Positive/immunology
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/immunology
- Multiple Myeloma/drug therapy
- Multiple Myeloma/immunology
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/immunology
- Radioimmunotherapy
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Affiliation(s)
- Philip Kuriakose
- Department of Internal Medicine, Division of Hematology/Oncology, Henry Ford Hospital, Detroit, MI 48202, USA.
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34
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Liebman HA. Current Perspectives on Primary Prophylaxis and Patient Risk Factors for Venous Thromboembolism in the Cancer Patient. Cancer Control 2017; 12 Suppl 1:11-6. [PMID: 16179899 DOI: 10.1177/1073274805012003s03] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Howard A Liebman
- Keck School of Medicine, University of Southern California, Los Angeles 90033, USA.
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35
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Abstract
The increasing complexity of cancer chemotherapy heightens the requirement that pharmacists be familiar with these highly toxic agents. This column will review various issues related to preparation, dispensing, and administration of cancer chemotherapy. It will also serve as a review of various agents, both commercially available and investigational, used to treat malignant diseases.
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Affiliation(s)
- Leonard E. Wryter
- Medical College of Virginia, Virginia Commonwealth University School of Pharmacy, Richmond, VA
| | - Dominic A. Solimando
- Oncology Pharmacy Services, Inc., 4201 Wilson Blvd #110-545, Arlington, VA 22203
| | - J. Aubrey Waddell
- University of Tennessee College of Pharmacy; Oncology Pharmacist, Pharmacy Department, Blount Memorial Hospital, 907 East Lamar Alexander Parkway, Maryville, TN 37804
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36
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Ageno W, Mantovani LG, Haas S, Kreutz R, Monje D, Schneider J, van Eickels M, Gebel M, Turpie AGG. Subgroup Analysis of Patients with Cancer in XALIA: A Noninterventional Study of Rivaroxaban versus Standard Anticoagulation for VTE. TH OPEN 2017; 1:e33-e42. [PMID: 31259294 PMCID: PMC6598195 DOI: 10.1055/s-0037-1603924] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background
The noninterventional XALIA study compared rivaroxaban with standard anticoagulation for deep vein thrombosis treatment. This substudy describes the demographics, clinical characteristics, and outcomes of the patients with cancer.
Methods
Therapy type, dose, and duration were at the physician's discretion. The cohorts identified were rivaroxaban (rivaroxaban alone or after heparin or fondaparinux for ≤48 hours); early switchers (rivaroxaban after heparin or fondaparinux for >48 hours to 14 days and/or a vitamin K antagonist [VKA] for 1–14 days); standard anticoagulation (heparin or fondaparinux and a VKA); low-molecular-weight heparin (LMWH) alone; and miscellaneous (other heparins, fondaparinux alone, VKA alone). Primary outcomes were major bleeding, recurrent venous thromboembolism, and all-cause mortality.
Results
In XALIA, 587 patients (11.4% of the XALIA cohort) were with cancer: 146 (24.9%) rivaroxaban, 30 (5.1%) early switchers, 141 (24.0%) standard anticoagulation, 223 (38.0%) LMWH, and 47 (8.0%) miscellaneous. Patients with gastrointestinal or lung cancer more commonly received LMWH than rivaroxaban; the opposite occurred in patients with breast or genitourinary cancer. Rates of primary outcome in the rivaroxaban group were as follows: major bleeding, 1.4% (
n
= 2); recurrent venous thromboembolism, 3.4% (
n
= 5); and all-cause mortality, 4.8% (
n
= 7).
Conclusion
In XALIA, physicians treated cancer-associated thrombosis with various anticoagulant regimens, most commonly LMWH. In addition, the choice of anticoagulant varied with cancer type. In rivaroxaban-treated patients, rates for the primary outcomes were low, suggesting that patients administered rivaroxaban were a good prognosis group.
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Affiliation(s)
- Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Lorenzo G Mantovani
- CESP-Center for Public Health Research, University of Milan Bicocca, Monza, Italy
| | - Sylvia Haas
- Technical University of Munich, Munich, Germany
| | - Reinhold Kreutz
- Institute of Clinical Pharmacology and Toxicology, Charité Universitätsmedizin, Berlin, Germany
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Giza DE, Boccalandro F, Lopez-Mattei J, Iliescu G, Karimzad K, Kim P, Iliescu C. Ischemic Heart Disease: Special Considerations in Cardio-Oncology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2017; 19:37. [PMID: 28425056 DOI: 10.1007/s11936-017-0535-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OPINION STATEMENT The interplay and balance between the competing morbidity and mortality of cardiovascular diseases and cancer have a significant impact on both short- and long-term health outcomes of patients who survived cancer or are being treated for cancer. Ischemic heart disease in patients with cancer or caused by cancer therapy is a clinical problem of emerging importance. Prompt recognition and optimum management of ischemic heart disease mean that patients with cancer can successfully receive therapies to treat their malignancy and reduce morbidity and mortality due to cardiovascular disease. In this sense, the presence of cancer and cancer-related comorbidities (e.g., thrombocytopenia, propensity to bleed, thrombotic status) substantially complicates the management of cardiovascular diseases in cancer patients. In this review, we will summarize the current state of knowledge on the management strategies for ischemic disease in patients with cancer, focusing on the challenges encountered when addressing these complexities.
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Affiliation(s)
- Dana Elena Giza
- The Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Fernando Boccalandro
- Odessa Heart Institute,Department of Internal Medicine, Permian Research Foundation, Texas-Tech University, Odessa, TX, 79761, USA
| | - Juan Lopez-Mattei
- The Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Gloria Iliescu
- The Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Kaveh Karimzad
- The Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Peter Kim
- The Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA
| | - Cezar Iliescu
- The Department of Cardiology, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street, Houston, TX, 77030, USA.
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Donnellan E, Khorana AA. Cancer and Venous Thromboembolic Disease: A Review. Oncologist 2017; 22:199-207. [PMID: 28174293 DOI: 10.1634/theoncologist.2016-0214] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/02/2016] [Indexed: 02/03/2023] Open
Abstract
Venous thromboembolism (VTE), including deep-vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in cancer patients. Patients with cancer are six times more likely to develop VTE than their noncancer counterparts, and VTE is the second leading cause of death in cancer patients. Despite the publication of major consensus guidelines setting out recommendations for thromboprophylaxis in cancer patients, there remains a gulf between these guidelines and clinical practice. In general, thromboprophylaxis is recommended for most patients hospitalized with active cancer. Furthermore, outpatient thromboprophylaxis may be used in carefully selected high-risk ambulatory patients. Certain areas of controversy still remain. Although low-molecular-weight heparin has been shown to be superior to vitamin K antagonists in cancer patients, the role of direct oral anticoagulants is still uncertain. Moreover, recurrent thromboembolism, bleeding, and thrombocytopenia are frequently seen in cancer patients. Optimal anticoagulation in such instances presents a major challenge to clinicians. Modern computed tomography techniques have resulted in an increase in the detection of "incidental" VTE. Despite a growing body of evidence promulgating standard anticoagulant treatment in such cases, these cases present further challenges for members of the multidisciplinary team. The Oncologist 2017;22:199-207Implications for Practice: This article discusses venous thromboembolism (VTE) in patients with malignancy. Practical guidance is offered on how to prevent, diagnose, and treat VTE in cancer patients. The management of "challenging" cases of VTE is also discussed.
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Affiliation(s)
- Eoin Donnellan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alok A Khorana
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio, USA
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Abstract
Cancer patients have a significantly higher risk of developing venous thromboembolism (VTE) compared to non-cancer patients and several studies suggest that VTE risk among ambulatory cancer patients varies widely. Recently, predictive models capable of risk-stratifying a broad range of ambulatory cancer outpatients have been developed and validated; using the Khorana model a score of 2 is associated with an intermediate-high risk for VTE. However, the use of VTE prophylaxis in ambulatory patients who have cancer remains controversial. Even if important randomized clinical trials showed decreased rates of VTE events among patients who were receiving chemotherapy, the effect of prophylaxis on morbidity, mortality, and costs has not been rigorously studied. Outpatients with active cancer should be assessed for thrombosis risk and although most do not routinely require thromboprophylaxis, it should be considered for high risk patients.
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Affiliation(s)
- Davide Imberti
- Haemostasis and Thrombosis Center, Department of Internal Medicine, Hospital of Piacenza, Piacenza, Italy.
| | - Raffaella Benedetti
- Haemostasis and Thrombosis Center, Department of Internal Medicine, Hospital of Piacenza, Piacenza, Italy
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Brown JD, Adams VR, Moga DC. Impact of Time-Varying Treatment Exposures on the Risk of Venous Thromboembolism in Multiple Myeloma. Healthcare (Basel) 2016; 4:healthcare4040093. [PMID: 27999418 PMCID: PMC5198135 DOI: 10.3390/healthcare4040093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Revised: 12/09/2016] [Accepted: 12/14/2016] [Indexed: 12/22/2022] Open
Abstract
Multiple myeloma (MM) has one of the highest risks of venous thromboembolism (VTE) of all cancers due to pathologic changes and treatment-related exposures. This study assessed the one-year incidence of VTE in newly diagnosed MM and to determine the baseline and time-varying treatment-related factors associated with VTE risk in a U.S.-based cohort. MM patients were identified and age, gender, and baseline comorbidities were determined. Treatment-related exposures included thalidomide derivatives (IMIDs), proteasome inhibitors, cytotoxic chemotherapy, steroids, erythropoietin-stimulating agents (ESAs), stem cell transplants (SCT), hospitalizations, infection, and central venous catheters (CVC). Multiple statistical models were used including a baseline competing risks model, a time-varying exposure Cox proportional hazard (CPH) model, and a case-time-control analysis. The overall incidence of VTE was 107.2 per 1000 person-years with one-half of the VTEs occurring in the first 90 days. The baseline model showed that increasing age, heart failure, and hypertension were associated with one-year incidence of VTE. MM-specific IMID treatment had lower than expected associations with VTE based on prior literature. Instead, exposure to ESAs, SCT, CVC, and infection had higher associations. Based on these results, VTE risk in MM may be less straightforward than considering only chemotherapy exposures, and other treatment-related exposures should be considered to determine patient risk.
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Affiliation(s)
- Joshua D Brown
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40536, USA.
- Department of Pharmaceutical Outcomes & Policy, University of Florida College of Pharmacy, Gainesville, FL 32610, USA.
| | - Val R Adams
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40536, USA.
| | - Daniela C Moga
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY 40536, USA.
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Tiong IS, Rodgers SE, Lee CHS, McRae SJ. Baseline and treatment-related changes in thrombin generation in patients with multiple myeloma. Leuk Lymphoma 2016; 58:941-949. [PMID: 27931131 DOI: 10.1080/10428194.2016.1219900] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The prothrombotic risk in multiple myeloma (MM) could be potentially assessed by thrombin generation (TG) assays. TG was performed using Calibrated Automated Thrombography with 5 and 1 pM tissue factor. We compared baseline TG among 24 MM patients, 19 MGUS, and 50 healthy controls, and assessed change in TG in MM patients during the initial treatment period at 1, 2, and 3 months. MM subjects demonstrated increased FVIII and VWF:Ag levels pretreatment, and a prothrombotic TG phenotype with increased velocity index, reduced lag time and time-to-peak, and increased resistance to thrombomodulin inhibition. There were no significant changes in TG with treatment for the majority of parameters, however, MM subjects exhibited persistent elevation of velocity index throughout treatment. Two subjects developed thrombosis during the study period despite thromboprophylaxis. This study provides information on the optimal conditions for examining TG as a predictor of thrombotic risk in MM patients.
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Affiliation(s)
- Ing S Tiong
- a Haematology Division , SA Pathology , Adelaide , SA , Australia.,b School of Medicine, University of Adelaide , Adelaide , SA , Australia
| | - Susan E Rodgers
- a Haematology Division , SA Pathology , Adelaide , SA , Australia.,c School of Pharmacy and Medical Sciences, University of South Australia , Adelaide , SA , Australia
| | - Cindy H S Lee
- a Haematology Division , SA Pathology , Adelaide , SA , Australia.,b School of Medicine, University of Adelaide , Adelaide , SA , Australia.,d Haematology Department , The Queen Elizabeth Hospital , Adelaide , SA , Australia
| | - Simon J McRae
- a Haematology Division , SA Pathology , Adelaide , SA , Australia.,c School of Pharmacy and Medical Sciences, University of South Australia , Adelaide , SA , Australia.,d Haematology Department , The Queen Elizabeth Hospital , Adelaide , SA , Australia
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Hinduja A, Limaye K, Ravilla R, Sasapu A, Papanikolaou X, Wei L, Torbey M, Waheed S. Spectrum of Cerebrovascular Disease in Patients with Multiple Myeloma Undergoing Chemotherapy-Results of a Case Control Study. PLoS One 2016; 11:e0166627. [PMID: 27902730 PMCID: PMC5130211 DOI: 10.1371/journal.pone.0166627] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 11/01/2016] [Indexed: 12/21/2022] Open
Abstract
Objectives Patients with multiple myeloma (MM) are at increased risk of arterial thrombosis. Our aim was to determine the risk factors, mechanisms and outcome of strokes in these patients. Methods We conducted a retrospective matched case–control study from our database of MM patients enrolled in Total Therapy (TT) 2, TT3a and TT3b protocols who developed a vascular event (transient ischemic attack, ischemic stroke, or intracerebral hemorrhage) from October 1998 to January 2014. Cases were matched for age-matched selected controls. Baseline demographics, risk factors, MM characteristics, laboratory values, and mortality of cases were compared to those of controls. Multivariate logistic regression analysis identified risk factors associated with stroke. Ischemic strokes (IS) were classified with modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Results Of 1,148 patients, 46 developed a vascular event (ischemic stroke, 33; transient ischemic attack, 11; hypertensive intracerebral hemorrhage, 2). Multivariate logistic regression analysis determined renal insufficiency (odds Ratio, 3.528; 95% CI, 1.36–9.14; P = 0.0094) and MM Stages I and II (odds Ratio, 2.770, 95% CI, 1.31–5.81; p = 0.0073) were independent predictors of stroke. In our study, strokes attributable to hypercoagulability, atrial fibrillation and small-vessel occlusion were common mechanisms. After a stroke, 78% of patients were discharged to home or a rehabilitation facility and 4% to a long-term nursing facility; in-hospital mortality was 15%. Despite suffering a stroke no significant differences in survival were observed. Conclusion In our cohort of multiple myeloma patients, renal failure and MM Stages I and II had increased risk of stroke.
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Affiliation(s)
- Archana Hinduja
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
- * E-mail:
| | - Kaustubh Limaye
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Rahul Ravilla
- Department of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Appalnaidu Sasapu
- Department of Hematology and Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Xenofon Papanikolaou
- Multiple Myeloma for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
| | - Lai Wei
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Michel Torbey
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
- Department of Neurosurgery, Ohio State University Wexner Medical Center, Columbus, OH, United States of America
| | - Sarah Waheed
- Multiple Myeloma for Research and Therapy, University of Arkansas for Medical Sciences, Little Rock, AR, United States of America
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Hu Q, Qian C, Sun W, Wang J, Chen Z, Bomba HN, Xin H, Shen Q, Gu Z. Engineered Nanoplatelets for Enhanced Treatment of Multiple Myeloma and Thrombus. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2016; 28:9573-9580. [PMID: 27626769 PMCID: PMC5283718 DOI: 10.1002/adma.201603463] [Citation(s) in RCA: 149] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/07/2016] [Indexed: 05/09/2023]
Abstract
A platelet-membrane-coated biomimetic nanocarrier, which can sequentially target the bone microenvironment and myeloma cells to enhance the drug availability at the myeloma site and decrease off-target effects, is developed for inhibiting multiple myeloma growth and simultaneously eradicating thrombus complication.
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Affiliation(s)
- Quanyin Hu
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Chenggen Qian
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; Department of Polymer Science and Engineering and Key Laboratory of High Performance Polymer Materials and Technology of MOE, School of Chemistry and Chemical Engineering, Nanjing University Nanjing 210023, China
| | - Wujin Sun
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Jinqiang Wang
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Zhaowei Chen
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Hunter N. Bomba
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Hongliang Xin
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC 27695, USA and Division of Molecular Pharmaceutics and Center for Nanotechnology in Drug Delivery, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA; School of Pharmacy, Nanjing Medical University, Nanjing 211166, China
| | - Qundong Shen
- Department of Polymer Science and Engineering and Key Laboratory of High Performance Polymer Materials and Technology of MOE, School of Chemistry and Chemical Engineering, Nanjing University Nanjing 210023, China
| | - Zhen Gu
- Corresponding author. ; Phone: 1-919-515-7944
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Abstract
This paper presents an overview of new information on clinically relevant drug-drug interactions, particular focuses on negative drug interactions in oncology. We have generated a concise table of drug-drug interactions that provides a synopsis of the clinical outcome of the interaction along with a recommendation for management. We have also generated other tables that describe specific interactions with methotrexate and dosing guidelines for cytotoxic drugs in the presence of renal or hepatic dysfunction. Since warfarin is one of the non-anticancer drugs that is commonly used in cancer patients for the treatment and prevention of venous thromboembolism, its interactions with other anticancer drugs that have been reported in literatures were also reviewed in this paper. In general, drug interactions observed in cancer patients may be categorized into pharmacokinetic, pharmacodynamic and pharmaceutic interactions. Pharmacokinetic interactions involve one drug altering the absorption, distribution, metabolism, or excretion of another drug. Interpatient variability in the pharmacokinetic profile of many anticancer agents often complicates the predictability of the antitumor response and toxicities. Among four pharmacokinetic characteristics, drug interactions involving hepatic metabolism is probably the most common and important mechanism responsible for oncologic drug interactions. For example, several anticancer drugs including taxanes, vinca alkaloids, and irinotecan are known to be metabolized by cytochrome CYP3A4. Enzyme-inducing anticonvulsants have been shown to significantly decrease the plasma levels of these anticancer drugs, thereby compromising the anti-tumor effects. N ephrotoxicity or changes in hepatic function caused by some anticancer drugs (e.g., cisplatin, asparaginase) may also have an impact on the pharmacokinetics of the interacting agents. Pharmacodynamic interactions may occur when two or more drugs acting at a common receptor-binding site impact on the pharmacologic action of the object drug, without influencing the pharmacokinetics of each interacting agent. In clinical setting, a decrease of antitumor efficacy was observed in breast cell lines when gemcitabine or vinorelbine were used in combination with paclitaxel. On the other hand, a decreased incidence of thrombocytopenia was seen in patients receiving combination of carboplatin and palcitaxel compared to those receiving carboplatin alone. The third type of drug-drug interaction is known as pharmaceutic interaction. When one drug may alter the physical or chemical compatibility of another drug that utlimately leads to a change in appearance of the solution or a decrease of effectiveness of the drug due to drug inactivation or degradation.
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Affiliation(s)
- Masha S H Lam
- Department of Clinical Pharmacy, Shands at the University of Florida, Gainesville, FL 32610, USA
| | - Robert J Ignoffo
- School of Pharmacy, Department of Clinical Pharmacy, University of California, San Francisco 94901-6022, USA
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Abstract
Background. Multiple myeloma accounts for 10% of all haematologic malignancies worldwide. In Europe, over 10 000 new cases and nearly 8000 deaths were attributed to multiple myeloma in 2000. Unlike other malignancies, in which surgery and radiation are important treatment modalities, myeloma is exclusively treated with stem cell transplantation and drug therapy, requiring pharmacists to stay abreast of new developments. The melphalan-prednisolone and vincristine-doxorubicin-dexamethasone (VAD) regimens, which have been standard treatments for multiple myeloma over the past few decades, have yielded responses without real survival benefits. Transplantation utilizing high-dose chemotherapy has produced the only meaningful survival benefits for patients with multiple myeloma, but many patients are not candidates for this aggressive treatment option. More effective therapies for multiple myeloma are needed. Objective. To address the mechanisms of action, safety, and efficacy of novel approaches to the treatment of myeloma involving bortezomib, thalidomide and its analogues, lenalidomide and CC-4047 (ActimidTM), and arsenic trioxide as single agents or in combination regimens. Data sources. Published preclinical and primary clinical trial results, as well as scientific or clinical meeting abstracts. The author determined the relevance and subsequent inclusion of the data. Conclusions. Bortezomib is approved in the US and Europe as single-agent therapy for the treatment of relapsed or refractory multiple myeloma. Thalidomide, its analogues, and arsenic trioxide have demonstrated activity and are under investigation in this disease. Further clinical trials of the efficacy and toxicity of these novel agents are ongoing and will further define optimal combinations and sequencing with conventional therapies.
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Adess M, Eisner R, Nand S, Godwin J, Messmore HL, Wehrmacher WH. Thromboembolism in Cancer Patients: Pathogenesis and Treatment. Clin Appl Thromb Hemost 2016; 12:254-66. [PMID: 16959679 DOI: 10.1177/1076029606291432] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
In this review we summarize the causes of cancer related thrombosis as well as modern treatment approaches. Malignancy as a risk factor for thromboembolism is becoming increasingly recognized by clinicians caring for these patients. The probability of thrombosis occurring in an individual patient is dependent on several factors, including accompanying medical problems, the type of cancer, the clinical stage, performance status, and the treatment modalities employed. Thrombophilia with a history of thromboembolism is important as well. The overall risk of thrombosis is sevenfold that of noncancer patients. Though much has been learned about the pathogenesis of cancer-related thrombosis, we are in fact just beginning to understand the cross-talk between cancer cells and their related microenvironment, and such investigations are likely to increase our knowledge of cancer-related thrombosis mechanisms. Research in these areas may also suggest new strategies for cancer prevention, metastasis suppression, and new treatments. Drugs used in cancer therapy are increasingly recognized to directly contribute to the thrombotic tendency. Few studies provide data on the optimal management of cancer patients with thrombosis. It has been learned that retreating with the same drug can be very hazardous. In general the approach to prevention of thrombosis is the same as for noncancer patients, recognizing that specific cancer types and stage can place a patient in a high-risk category. Initial coumadin therapy fails in a significant number of patients with cancer. Recognition of the cancer patients at highest risk for coumadin failure is challenging. Low-molecular-weight heparins appear to be more effective in such situations where coumadin is likely to fail or has failed, but these drugs are thought to be costlier. Newer agents such as Factor Xa inhibitors and TF inhibitors are currently under investigation and may be found useful in the management of cancer-related thrombosis.
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Affiliation(s)
- Matthew Adess
- Loyola University Stritch School of Medicine, Maywood, IL 60153, USA
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Disseminated intravascular coagulation at diagnosis is a strong predictor for thrombosis in acute myeloid leukemia. Blood 2016; 128:1854-1861. [PMID: 27354723 DOI: 10.1182/blood-2016-02-701094] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 06/19/2016] [Indexed: 12/21/2022] Open
Abstract
Venous thromboembolism is a common complication in patients with cancer, but only limited data are available in acute myeloid leukemia (AML). In a prospective study in a cohort of 272 adult patients (aged 18-65) and an independent validation cohort of 132 elderly adults (aged >60) with newly diagnosed AML, we assessed markers of disseminated intravascular coagulation (DIC) (fibrinogen, D-dimer, α-2-antiplasmin, antitrombin, prothrombin time, and platelet count) and the DIC score according the International Society of Thrombosis and Haemostasis and their associations with the occurrence of venous and arterial thrombosis during follow-up. The prevalence of thrombosis was 8.7% (4.7% venous, 4.0% arterial) in the younger adults over a median follow-up of 478 days and 10.4% (4.4% venous, 5.9% arterial) in elderly patients. Most thrombotic events (66%) occurred before the start of the second course of chemotherapy. The calculated DIC score significantly predicted venous and arterial thrombosis with a hazard ratio (HR) for a high DIC score (≥5) of 4.79 (1.71-13.45). These results were confirmed in the validation cohort of elderly patients with AML (HR 11.08 [3.23-38.06]). Among all DIC parameters, D-dimer levels are most predictive for thrombosis with an HR of 12.3 (3.39-42.64) in the first cohort and an HR of 7.82 (1.95-31.38) in validation cohort for a D-dimer >4 mg/L vs ≤4 mg/L. It is concluded that venous and arterial thrombosis may develop in ∼10% of AML patients treated with intensive chemotherapy, which to a large extent can be predicted by the presence of DIC at time of AML diagnosis.
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Incidence and Risk Factors of Thromboembolism with Multiple Myeloma in the Presence of Death as a Competing Risk: An Empirical Comparison of Statistical Methodologies. Healthcare (Basel) 2016; 4:healthcare4010016. [PMID: 27417604 PMCID: PMC4934550 DOI: 10.3390/healthcare4010016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/19/2016] [Accepted: 02/23/2016] [Indexed: 02/06/2023] Open
Abstract
Multiple myeloma (MM) has an inherent high risk of thromboembolic events associated with patient as well as disease- and treatment-related factors. Previous studies have assessed the association of MM-related thromboembolism using "traditional" Kaplan-Meier (KM) and/or Cox proportional hazard (PH) regression. In the presence of high incidence of death, as would be the case in cancer patients with advanced age, these statistical models will produce bias estimates. Instead, a competing risk framework should be used. This study assessed the baseline patient demographic and clinical characteristics associated with MM-related thromboembolism and compared the cumulative incidence and the measures of association obtained using each statistical approach. The cumulative incidence of thromboembolism was 9.2% using the competing risk framework and nearly 12% using the KM approach. Bias in the measures of covariate risk associations was highest for factors related to risk of death such as increased age (75% bias) and severe liver disease (50%) for the Cox PH model compared to the competing risk model. These results show that correct specification of statistical techniques can have a large impact on the results obtained.
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