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Desai R, Koipallil GK, Thomas N, Mhaskar R, Visweshwar N, Laber D, Patel A, Jaglal M. Efficacy and safety of direct oral anticoagulants for secondary prevention of cancer associated thrombosis: a meta-analysis of randomized controlled trials. Sci Rep 2020; 10:18945. [PMID: 33144679 PMCID: PMC7642281 DOI: 10.1038/s41598-020-75863-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/13/2020] [Indexed: 12/29/2022] Open
Abstract
Direct oral anticoagulants (DOACs) may be good alternatives to low molecular weight heparin (LMWH) or vitamin K antagonists (VKA) for treatment of cancer associated thrombosis (CAT). We conducted a meta-analysis of ten randomized clinical trials to evaluate the efficacy and safety of DOACs in patients with CAT. All had study populations composed in entirety or in part of patients with CAT. The primary outcome (efficacy) was recurrent VTE and the secondary outcomes (safety outcomes) included major bleeding, clinically relevant non-major bleeding (CRNMB), and all bleeding (major bleeding + CRNMB). Participants treated with DOACs had lower risk of recurrent VTE, overall (RR 0.63; 95% CI 0.51-0.79; p < 0.0001), compared to LMWH (RR 0.57; 95% CI 0.40-0.83; p = 0.003), but not compared to VKA (RR 0.69; 95% CI 0.44-1.06; p = 0.09). Compared to LMWH, DOACs showed no difference in major bleeding risk (RR 1.31; 95% CI 0.78-2.18; p = 0.31), though had higher risk of CRNMB (RR 1.60; 95% CI 1.13-2.26; p = 0.008) and all bleeding (RR 1.49; 95% CI 1.10-2.01; p = 0.010). These results indicate that DOACs are more effective than LMWH for prevention of recurrent VTE with CAT though carry an increased risk for non-major bleeding compared to standard of care, LMWH.
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Affiliation(s)
- Ruchi Desai
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Division of Hematology, The Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Gautam Krishna Koipallil
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Nelson Thomas
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Nathan Visweshwar
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
| | - Damian Laber
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Division of Hematology, The Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Ankita Patel
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA
- Division of Hematology, The Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA
| | - Michael Jaglal
- Department of Hematology, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA.
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, 33612, USA.
- Division of Hematology, The Moffitt Cancer Center and Research Institute, Tampa, FL, 33612, USA.
- Tampa General, 3 Tampa General Circle, Tampa, FL, 33606, USA.
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Platelet cut-off for anticoagulant therapy in thrombocytopenic patients with blood cancer and venous thromboembolism: an expert consensus. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2018; 17:171-180. [PMID: 30418130 DOI: 10.2450/2018.0143-18] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 10/08/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Management of venous thromboembolism (VTE) in patients with haematologic malignancies and thrombocytopenia is clinically challenging due to the related risks. No prospective studies or clinical trials have been carried out and, therefore, no solid evidence on this compelling issue is available. METHODS Given this, an expert panel endorsed by the Gruppo Italiano Malattie Ematologiche dell'Adulto Working Party on Thrombosis and Haemostasis was set up to produce a formal consensus, according to the RAND method, in order to issue clinical recommendations about the platelet (PLT) cut-off for safe administration of low molecular weight heparin (LMWH) in thrombocytopenic (PLT <100×109/L) adult patients with haematologic malignancies affected by acute (<1 month) or non-acute VTE. RESULTS In acute VTE, the panel suggests safe anticoagulation with LMWH at therapeutic doses for PLT between ≥50<100×109/L and at 50% dose reduction for PLT ≥30<50×109/L. In acute VTE for PLT <30×109/L, the following interventions are recommended: positioning of an inferior vena cava (IVC) filter with prophylactic LMWH administration and platelet transfusion. In non-acute VTE, anticoagulation with LMWH at therapeutic doses for PLT between ≥50<100×109/L or over and at 50% dose reduction for PLT ≥30<50×109/L is considered appropriate. The discontinuation of full or reduced therapeutic dose of LMWH is recommended for PLT <30×109/L, both in acute and non-acute VTE. DISCUSSION We suggest using dose-adjusted LMWH according to PLT to optimise anticoagulant treatment in patients at high bleeding risk.
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Fialho A, Fialho A, Schenone A, Thota P, McCullough A, Shen B. Association between small intestinal bacterial overgrowth and deep vein thrombosis. Gastroenterol Rep (Oxf) 2016; 4:299-303. [PMID: 27044499 PMCID: PMC5193062 DOI: 10.1093/gastro/gow004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/13/2016] [Indexed: 01/02/2023] Open
Abstract
Objective: Small intestinal bacterial overgrowth (SIBO) has been associated with several diseases. The association between SIBO and deep vein thrombosis (DVT) has not been investigated. This study was aimed to investigate the frequency and risk factors for the development of DVT in patients tested for SIBO. Methods: All 321 eligible patients were included from the Cleveland Clinic Gastrointestinal Motility Lab databank from January 2008 to January 2014. Patients who were evaluated with glucose hydrogen/methane breath test as well as Doppler ultrasonography for suspected DVT were included. Patients with catheter-related DVT were excluded. The primary outcomes were the frequency and risk factors (including SIBO) for DVT in this patient population. Results: Of the 321-case cohort, 144 patients (44.9%) tested positive for SIBO, and 53 (16.5%) had ultrasonographic findings of DVT. SIBO evaluation before the evaluation of DVT occurred in 201 patients (median time from the breath test to ultrasonography: 27 months; interquartile range [IQR]: 11.0–45.0 months), and SIBO evaluation after evaluation for DVT occurred in 120 patients (median time from ultrasonography to the breath test: 30 months; IQR: 11.8–54.3 months). In the univariate analysis, DVT was associated with family history of thromboembolic events (35.8% vs 16.0%, P=0.001), chronic kidney diseases (CKD; 26.4% vs 13.4%, P=0.019) and the presence of SIBO (69.8% vs 39.9%, P<0.001). In the multivariate analysis, family history of thromboembolic events (odds ratio [OR]: 3.39; 95% confidence interval [CI]: 1.67–6.87; P<0.001), CKD (OR: 2.23; 95%CI: 1.04–4.74; P = 0.037), and the presence of SIBO (OR: 3.27; 95% CI: 1.70–6.32; P < 0.001) remained independently associated with DVT. Conclusion: SIBO was found to be associated with DVT. The nature of this association warrants further investigation.
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Affiliation(s)
- Andre Fialho
- Department of Internal Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA and
| | - Andrea Fialho
- Department of Internal Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA and
| | - Aldo Schenone
- Department of Internal Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA and
| | - Prashanthi Thota
- Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Arthur McCullough
- Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bo Shen
- Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Cleveland, OH, USA
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