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Van Cutsem E, Mahé I, Felip E, Agnelli G, Awada A, Cohen A, Falanga A, Mandala M, Peeters M, Tsoukalas N, Verhamme P, Ay C. Treating cancer-associated venous thromboembolism: A practical approach. Eur J Cancer 2024; 209:114263. [PMID: 39128187 DOI: 10.1016/j.ejca.2024.114263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 07/23/2024] [Accepted: 07/25/2024] [Indexed: 08/13/2024]
Abstract
Venous thromboembolism (VTE) is a common and potentially life-threatening complication in patients with cancer. Both cancer and its treatments increase the risk of developing VTE. Specific cancer types and individual patient comorbidities increase the risk of developing cancer-associated VTE, and the risk of bleeding is increased with anticoagulation therapies. The aims of this article are to summarize the latest evidence for treating cancer-associated VTE, discuss the practical considerations involved, and share best practices for VTE treatment in patients with cancer. The article pays particular attention to challenging contexts including patients with brain, lung, gastrointestinal, and genitourinary tumors and those with hematological malignancies. Furthermore, the article summarizes specific clinical scenarios that require additional treatment considerations, including extremes of body weight, nausea and gastrointestinal disturbances, compromised renal function, and anemia, and touches upon the relevance of drug-drug interactions. Historically, vitamin K antagonists and low-molecular-weight heparins (LMWHs) have been used as therapy for cancer-associated VTE. The development of direct oral anticoagulants has provided additional treatment options, which, in certain instances, offer advantages over LMWHs. There are numerous factors that need to be considered when treating cancer-associated VTE, and although various treatment guidelines are helpful, they do not reflect each unique scenario that may arise in clinical practice. This article provides a summary of the latest evidence and a practical approach for treating cancer-associated VTE.
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Affiliation(s)
- Eric Van Cutsem
- Department of Digestive Oncology, University Hospitals Gasthuisberg Leuven and KU Leuven, Herestraat 49, Leuven 3000, Belgium.
| | - Isabelle Mahé
- Paris Cité University, Assistance-Publique-Hôpitaux de Paris (AP-HP), Service de Médecine Interne, Hôpital Louis-Mourier, 178 Rue des Renouillers, 92700 Colombes, France; Inserm UMR_S1140, Innovative Therapies in Haemostasis Paris, Paris, France
| | - Enriqueta Felip
- Medical Oncology Department, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Oncology, Centro Cellex, Carrer de Natzaret, 115-117, Barcelona 08035, Spain
| | - Giancarlo Agnelli
- Internal, Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Piazza dell'Università, 1, 06123 Perugia, PG, Italy
| | - Ahmad Awada
- Institut Jules Bordet, Université Libre de Bruxelles, Mijlenmeersstraat 90, 1070 Bruxelles, Belgium
| | - Alexander Cohen
- Department of Haematology, Guy's and St Thomas' Hospitals, Kings College, London, UK
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, Piazza OMS, 1, 24127 Bergamo, BG, Italy; School of Medicine and Surgery, University of Milano Bicocca, Via Cadore 48, 20900 Monza, MB, Italy
| | - Mario Mandala
- Unit of Medical Oncology, University of Perugia, Santa Maria della Misericordia Hospital, Piazzale Giorgio Menghini, 3, 06129 Perugia, PG, Italy
| | - Marc Peeters
- Multidisciplinary Oncological Centre Antwerp (MOCA), Antwerp University Hospital, Drie Eikenstraat 655, Edegem 2650, Belgium; Center for Oncological Research (CORE), Integrated Personalized and Precision Oncology Network (IPPON), University of Antwerp and Antwerp University Hospital, Drie Eikenstraat 655, Edegem 2650, Belgium
| | - Nikolaos Tsoukalas
- Department of Oncology, 401 General Military Hospital of Athens, Athens, Greece
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Cihan Ay
- Division of Haematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria.
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Chen W, Wu G, Niu P, Wu S, Lv M, Wu T, Jiang S, Zhang J. The Alfalfa-inpatient-CAT assessment model: a thrombotic risk assessment model for inpatient cancer patients. BMC Cancer 2024; 24:919. [PMID: 39080579 PMCID: PMC11289990 DOI: 10.1186/s12885-024-12678-9] [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: 03/13/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
PURPOSE To construct a venous thromboembolism (VTE) risk assessment model specifically for inpatients with cancer. METHOD Patients were included according to the inclusion criteria. Univariate and multivariate analyses of all variables were included to develop a VTE risk assessment model applicable to the derivation cohort. Hosmer-Lemeshow test and receiver operating characteristic (ROC) curve were used to test the fit degree and identification validity of the model. The patient data from separate validation cohorts verified the external population. RESULT A total of 944 cancer patients were included in this study. Alfalfa-inpatient-CAT model, a risk assessment model for VTE in hospitalized cancer patients, was established, which mainly includes hypertension, surgical history (nearly one month), history of VTE, peripherally inserted central venous catheters (PICC), chemotherapy, PT < 12.85 s, D-dimer ≥ 1.805 μg/mL, hemoglobin ≤ 114.5 g/L, CRP ≥ 7.575 mg/L. Hosmer-Lemeshow test results showed P = 0.353 > 0.05, (χ2 = 8.872, Df = 8). The area under ROC curve was 0.906 [95%CI (0.881-0.930), P < 0.001]. The authenticity evaluation in the model database showed that the risk of thrombosis in the high-risk group (score ≥ 3) was 72.63%, significantly higher than that in the low-risk group (score 0-2) (27.37%) [χ2 = 144.00, Df = 1, P < 0.001]. CONCLUSION This study developed a new VTE risk assessment model - Alfalfa-inpatient-CAT model - for hospitalized cancer patients at high risk of thrombosis. This model has a good fitting degree and discriminant validity. It is expected to provide some reference for the clinical treatment of inpatients with cancer through continuous optimization.
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Affiliation(s)
- Wenjun Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Guilan Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Peiguang Niu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Meina Lv
- Department of Pharmacy, Fujian Medical University Union Hospital, 350001, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Shaojun Jiang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, 350001, Fuzhou, China.
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Zhou H, Jin Y, Chen G, Jin X, Chen J, Wang J. Predictive modeling of lower extreme deep vein thrombosis following radical gastrectomy for gastric cancer: based on multiple machine learning methods. Sci Rep 2024; 14:15711. [PMID: 38977780 PMCID: PMC11231254 DOI: 10.1038/s41598-024-66754-y] [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: 04/14/2024] [Accepted: 07/03/2024] [Indexed: 07/10/2024] Open
Abstract
Postoperative venous thromboembolic events (VTEs), such as lower extremity deep vein thrombosis (DVT), are major risk factors for gastric cancer (GC) patients following radical gastrectomy. Accurately predicting and managing these risks is crucial for optimal patient care. This retrospective case‒control study involved 693 GC patients from our hospital who underwent radical gastrectomy. We collected plentiful and comprehensive clinical indicators including a total of 49 baseline, preoperative, surgical and pathological clinical data. Using univariate logistic regression, we identified potential risk factors, followed by feature selection through the Boruta algorithm. We then constructed the final predictive model using multivariate logistic regression and evaluated it using receiver operating characteristic (ROC) curve analysis, calibration plots, decision curve analysis, and other methods. Additionally, we applied various machine learning techniques, including decision trees and random forests, to assess our model's predictive strength. This retrospective case‒control study involved 693 GC patients from our hospital who underwent radical gastrectomy. We collected plentiful and comprehensive clinical indicators including a total of 49 baseline, preoperative, surgical and pathological clinical data. Using univariate logistic regression, we identified potential risk factors, followed by feature selection through the Boruta algorithm. We then constructed the final predictive model using multivariate logistic regression and evaluated it using receiver operating characteristic (ROC) curve analysis, calibration plots, decision curve analysis, and other methods. Additionally, we applied various machine learning techniques, including decision trees and random forests, to assess our model's predictive strength. Univariate logistic analysis revealed 14 risk factors associated with postoperative lower limb DVT. Based on the Boruta algorithm, six significant clinical factors were selected, namely, age, D-dimer (D-D) level, low-density lipoprotein, CA125, and calcium and chloride ion levels. A nomogram was developed using the outcomes from the multivariate logistic regression analysis. The predictive model showed high accuracy, with an area under the curve of 0.936 in the training set and 0.875 in the validation set. Various machine learning algorithms confirmed its strong predictive capacity. MR analysis revealed meaningful causal relationships between key clinical factors and DVT risk. Based on various machine learning methods, we developed an effective predictive diagnostic model for postoperative lower extremity DVT in GC patients. This model demonstrated excellent predictive value in both the training and validation sets. This novel model is a valuable tool for clinicians to use in identifying and managing thrombotic risks in this patient population.
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Affiliation(s)
- Haiyan Zhou
- Nursing Department, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Yongyan Jin
- Nursing Department, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Guofeng Chen
- Department of Gastroenterology Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Xiaoli Jin
- Department of Gastroenterology Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Jian Chen
- Department of Gastroenterology Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China.
| | - Jun Wang
- Department of Gastroenterology Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China.
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Yang X, Yang B, Li D, Pan W, Tong Q, Wang L, Chen D, Fu C. Thromboembolic Events Associated with Epidermal Growth Factor Receptor Tyrosine Kinase Inhibitors: A Pharmacovigilance Analysis of the US FDA Adverse Event Reporting System (FAERS) Database. Clin Drug Investig 2024; 44:199-207. [PMID: 38376794 DOI: 10.1007/s40261-024-01346-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND OBJECTIVES Although thromboembolic events (TEEs) have been reported with the use of epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), their association remains largely unknown. In this study, we aimed to provide a comprehensive review of TEEs associated with EGFR-TKIs. METHODS We collected EGFR-TKIs (gefitinib, erlotinib, afatinib, and osimertinib) adverse reaction reports from 2015 Q1 to 2023 Q1 from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS) database. Disproportionality analysis was conducted to identify thromboembolic adverse events associated with EGFR-TKIs by comparing them with the overall FAERS database according to the reporting odds ratio (ROR). Associated factors were explored using univariate logistic regression. RESULTS We identified 1068 reports of TEEs associated with EGFR-TKIs (1.24% accounts for all TEEs). Affected patients were females (49.72%) and those older than 65 years (41.20%). The reported TEE case fatality was 30.24%. The median time to onset (TTO) of all cases was 39 days [interquartile range (IQR) 11-161], and the median TTO of fatalities [31 days (IQR 10-116)] was significantly shorter than that of non-fatal cases [46 days (IQR 12-186)]. CONCLUSION This study yielded three key findings. Firstly, EGFR-TKIs seem to exhibit prothrombotic effects, elevating the risk of TEEs. Secondly, the clinical outcomes of TEEs associated with EGFR-TKIs were poor. Thirdly, most TEEs occurred within the initial 3 months, and fatal cases occurred earlier than non-fatal cases.
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Affiliation(s)
- Xiongwen Yang
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Bo Yang
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Dan Li
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Wei Pan
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Qin Tong
- Department of Oncology, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
| | - Lili Wang
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Danjun Chen
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China
| | - Chengxiao Fu
- Department of Pharmacy, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China.
- Institute of Pharmacy and Pharmacology, College of Basic Medical Science, Hengyang Medical School, University of South China, Hengyang, 421200, Hunan, People's Republic of China.
- Clinical Pharmacology Research Center, The First Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, 421001, Hunan, People's Republic of China.
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Weinberg I, Elgendy IY, Dicks AB, Marchena PJ, Malý R, Francisco I, Pedrajas JM, Font C, Hernández-Blasco L, Monreal M. Comparison of Presentation, Treatment, and Outcomes of Venous Thromboembolism in Long-Term Immobile Patients Based on Age. J Gen Intern Med 2023; 38:1877-1886. [PMID: 36750505 PMCID: PMC10271988 DOI: 10.1007/s11606-023-08058-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/26/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Chronic immobility is prevalent, especially as people age. However, little is known about venous thromboembolism (VTE) outcomes in this population. OBJECTIVE To compare the presentation, treatment, and outcomes in chronically immobile (>8 weeks) patients older vs. younger than 75 who presented with VTE. DESIGN An observational international registry of patients with VTE. PARTICIPANTS Patients with acute VTE from the "Registro Informatizado Enfermedad TromboEmbolica" (RIETE) registry who were chronically immobile. MAIN MEASURES Baseline characteristics, presenting signs and symptoms, treatment and outcomes including major bleeding, recurrent VTE, and mortality. KEY RESULTS Among 4612 immobile patients (mean age 75.7 years, 34% male), 2127 (46%) presented with pulmonary embolism (PE). Patients >75 years presented more often with dyspnea (44% vs. 38%) or altered mental status (23% vs. 8.1%) and less often with chest pain (13% vs. 18%). The median duration of anticoagulation was shorter in older compared with younger patients [126 vs. 169 days]. During the first 90 days of anticoagulation, major bleeding (4.0% vs. 2.2%), PE-related death (2.5% vs. 1.1%), and bleeding-related death (0.78% vs. 0.26%) occurred more frequently among older patients. In 3550 patients who received anticoagulation beyond 90 days, older patients had more major bleeding [4.23 vs. 2.21 events per 100 patient years]. After anticoagulation discontinuation, recurrent VTE and major bleeding occurred in 11.8 and 9.25 and 1.49 and 0.69 events per 100 patient years, respectively, both in similar rates in both groups. In multivariable analysis, after stopping anticoagulation, VTE recurrence was inversely associated with long-term facility residence [OR 0.51 (0.28-0.92)], anemia [OR 0.63 (0.42-0.95)], and anticoagulation duration < 90 days [OR 0.38 (0.27-0.54)]. CONCLUSIONS Chronically immobilized patients older than 75 years presenting with VTE experience a high rate of adverse events including major bleeding and recurrent VTE. When considering treatment beyond 90 days, we should account for bleeding, recurrence risk, and associated mortality.
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Affiliation(s)
- Ido Weinberg
- Vascular Medicine, Cardiology Division, Massachusetts General Hospital, 55 Fruit Street, GRB-852G, Boston, MA, 02114, USA.
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Andrew B Dicks
- Department of Vascular Surgery, Prisma Health/USC School of Medicine Greenville, Greenville, SC, USA
| | - Pablo J Marchena
- Department of Internal Medicine and Emergency, Parc Sanitari Sant Joan de Déu-Hospital General, Barcelona, Spain
| | - Radovan Malý
- Department of Cardiovascular Medicine I, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Iria Francisco
- Department of Internal Medicine, Hospital Universitari de Girona Dr. Josep Trueta, Girona, Spain
| | - José M Pedrajas
- Department of Internal Medicine, Hospital Clínico San Carlos, Madrid, Spain
| | - Carme Font
- Department of Medical Oncology, Hospital Clínic, Barcelona, Spain
| | - Luis Hernández-Blasco
- Department of Pneumonology, Hospital General Universitario de Alicante, ISABIAL, UMH, Alicante, Spain
| | - Manuel Monreal
- Faculty of Health Sciences, UCAM - Universidad Católica San Antonio de Murcia, Murcia, Spain
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Cid A, Smetana ME, Hebert C, Coe K, Smith JM. Impact of concomitant fluconazole on direct oral anticoagulant bleeding risk. Pharmacotherapy 2022; 42:880-889. [PMID: 36271717 PMCID: PMC9742296 DOI: 10.1002/phar.2738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
STUDY OBJECTIVE The aim of this study was to evaluate the effect on bleeding risk when fluconazole is administered concomitantly with direct oral anticoagulants (DOACs). DESIGN This was a retrospective cohort study including hospitalized adult patients prescribed a DOAC with or without fluconazole. SETTING The Ohio State University Wexner Medical Center, a tertiary care academic medical center with more than 1800 beds. PATIENTS Hospitalized patients ages 18-89 years who received apixaban or rivaroxaban with or without fluconazole from October 1, 2016, to September 30, 2021, were included. The minimum duration of DOAC or DOAC with fluconazole therapy was 48 h. Patients were excluded if they received fluconazole <400 mg daily or a DOAC at doses outside those recommended for atrial fibrillation or venous thromboembolism treatment or prophylaxis. Patients were matched based on DOAC received. INTERVENTION Patients who received a DOAC with fluconazole were compared with those receiving a DOAC alone. The primary outcome was a composite of major, clinically relevant nonmajor, and minor bleeding events at 30 days. MEASUREMENTS AND MAIN RESULTS There were 216 patients included, 108 in the DOAC with fluconazole group and 108 in the DOAC alone group. More patients in the DOAC with fluconazole group experienced bleeding at 30 days compared with the DOAC alone group [35/108 (32%) vs. 21/108 (19%), respectively; p = 0.03]; however, after adjusting for proven confounding variables (hemoglobin and concomitant carvedilol) this was found not to be statistically significant [adjusted odds ratio 1.71, 95% confidence interval 0.85-3.40]. CONCLUSIONS Patients receiving a DOAC with fluconazole were not at significantly increased risk for bleeding at 30 days compared with those receiving a DOAC alone after controlling for confounding variables. As an increasing number of patients are prescribed DOACs, the results of this study may inform clinical decision-making on the safety of concomitant DOAC and fluconazole use.
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Affiliation(s)
- Allison Cid
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Megan E. Smetana
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Courtney Hebert
- Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kelci Coe
- Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jessica M. Smith
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Safety and Efficacy of Rivaroxaban for Extended-Phase Anticoagulation of Patients with Unprovoked or Recurrent Venous Thromboembolism: Real-Life Data from the MAC Project. Life (Basel) 2022; 12:life12101657. [PMID: 36295091 PMCID: PMC9604582 DOI: 10.3390/life12101657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 09/25/2022] [Accepted: 10/14/2022] [Indexed: 11/29/2022] Open
Abstract
Venous thromboembolism (VTE) is a major cause of death in the world. After the acute-phase treatment, the optimal duration of anticoagulation is still debatable. The latest guidelines suggest maintaining long-term anticoagulation in patients with cancer-associated thrombosis (CAT) or with unprovoked VTE and a low bleeding risk. Methods: The MAC Project is an ongoing prospective-cohort, multi-center, observational study in Italy. The project aims to collect real-life clinical information in unselected patients given oral anticoagulants for VTE over a 5-year follow-up period. There were no exclusion criteria, except for life expectancy <6 months and refusal to sign the informed consent form or to attend the planned follow-up visit. All patients were followed-up prospectively with clinical controls scheduled at 3, 6, and 12 months after the index event, and then annually for up to 5 years. The primary efficacy and safety outcomes were symptomatic recurrent VTE and major bleeding. Results: We analyzed 450 consecutive patients treated with rivaroxaban and referred them to the MAC Project database for unprovoked or recurrent VTE. Of these, 267 (55%) were unprovoked VTE, and 377 (87%) were symptomatic. We followed up with the patients for a mean of 22 months (Q1 10.7; Q3 37.4 months). Recurrent VTE occurred in 12 patients on rivaroxaban treatment (IR 1.7 per 100 person-years). Males had more recurrence than women. During the follow-up period, we recorded 13 (2.9%) major bleeding, 12 (2.7%) clinically relevant non-major bleeding, 8 minor bleeding, and no fatal bleeding events. Overall, bleeding events occurred in 33 (7.3%) patients, most occurring within the first 2 years of treatment. In addition, we observed a statistically significant higher incidence of bleeding in patients with a baseline HAS-BLED score of 3 to 4 compared with those with a score of 0 to 2, with most events occurring during the first 3 months of treatment (RR 5.9). Discussion: Rivaroxaban appears to be safe and effective for the long-term treatment of patients with recurrent or unprovoked VTE. Our results match previously published data, and we are confident that the continuation of the follow-up for up to 5 years will confirm these outcomes.
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Frere C, Font C, Esposito F, Crichi B, Girard P, Janus N. Incidence, risk factors, and management of bleeding in patients receiving anticoagulants for the treatment of cancer-associated thrombosis. Support Care Cancer 2021; 30:2919-2931. [PMID: 34617159 DOI: 10.1007/s00520-021-06598-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/26/2021] [Indexed: 12/19/2022]
Abstract
Updated clinical practice guidelines recommend the long-term use of low-molecular-weight heparins or direct oral anticoagulants as the preferred option for the treatment of cancer-associated thrombosis (CAT), using a personalized approach matching the right drug to the right patient. In most cases, the benefit of anticoagulant therapy outweighs the risk. However, the long-term use of anticoagulants is associated with a non-negligible risk of bleeding, which constitutes a rare but serious adverse effect. Bleeding complications have been reported to be overall 2 to 3 times more frequent in cancer patients with CAT receiving anticoagulation than in non-cancer patients, with a reported incidence of major bleeding ranging from 2.4 to 16.0% in randomized controlled trials (RCT). In the absence of validated risk assessment model to predict the risk of bleeding in these patients, a careful evaluation of each individual profile, with adequate selection of the most appropriate anticoagulant for each individual patient, is warranted for overcoming management challenges, taking in account the numerous factors which may potentiate the overall bleeding risk in these complex patients, such as advanced or metastatic disease, older age, anemia, thrombocytopenia, renal impairment, liver dysfunction, and concomitant anticancer therapies. The purpose of this review is to call for awareness on bleeding complications as a major safety issue of CAT treatment and to summarize data from recent RCT and real-world studies on the incidence and risk factors for bleeding in this unique and challenging population to further help clinicians in decision-making.
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Affiliation(s)
- Corinne Frere
- Institute of Cardiometabolism And Nutrition, GRC 27 GRECO, Sorbonne Université, INSERM UMRS_1166, Paris, France
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Carme Font
- Department of Internal Medicine, Hospital Clinic, Barcelona, Spain
| | | | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 75010, Paris, France
| | - Philippe Girard
- Département Thoracique, Institut Mutualiste Montsouris, Paris, France
- FCRIN INNOVTE, Paris, France
| | - Nicolas Janus
- Global Thrombosis Strategy, Medical Affairs, Leo Pharma, Voisins-le-Bretonneux, France.
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The influence of anemia on clinical outcomes in venous thromboembolism: Results from GARFIELD-VTE. Thromb Res 2021; 203:155-162. [PMID: 34023735 DOI: 10.1016/j.thromres.2021.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 05/10/2021] [Accepted: 05/12/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Clinical characteristics and outcomes of venous thromboembolism (VTE) patients with concomitant anemia are unclear. This study compares baseline characteristics, treatment patterns, and 24-month outcomes in patients with and without anemia within GARFIELD-VTE. MATERIALS AND METHODS GARFIELD-VTE (ClinicalTrials.gov: NCT02155491) is a global, prospective, non-interventional registry of real-world treatment practices. Of the 10,679 patients enrolled in GARFIELD-VTE, 7698 were eligible for analysis. Primary outcomes were all-cause mortality, recurrent VTE, and major bleeding in VTE patients with or without concomitant anemia over 24-months after diagnosis. Event rates and 95% confidence intervals were estimated using Poisson regression. Adjusted hazard ratios were calculated using Cox proportional hazard models. RESULTS Distribution of VTE events in 2771 patients with anemia and 4927 without anemia was similar (deep-vein thrombosis alone: 61·1% vs. 55·9%, pulmonary embolism ± deep vein thrombosis: 38·9% vs. 44·0%, respectively). Patients with anemia were older (62.6 year vs. 58.9 years) than those without. At baseline, VTE risk factors that were more common in patients with anemia included hospitalization (22·0% vs. 6·8%), surgery (19·2% vs. 8·2%), cancer (20·1% vs. 5·6%) and acute medical illness (8·3% vs. 4·2%). Patients with anemia were more likely to receive parenteral anticoagulation therapy alone than those without anemia (26·6% vs. 11·7%) and less likely to receive a direct oral anticoagulant (38·5% vs. 53·5%). During 24-months of follow-up, patients with anemia had a higher risk (adjusted hazard ratio [95% confidence interval]) of all-cause mortality (1·84 [1·56-2·18]), major bleeding (2·83 [2·14-3·75]). Among anemia patients, the risk of all-cause mortality and major bleeding remained higher in patients with severe anemia than in those with mild/moderate anemia, all-cause mortality: HR 1·43 [95% CI: 1·21-1·77]; major bleeding: HR 2·08 [95% CI: 1·52-2·86]). CONCLUSIONS VTE patients with concomitant anemia have a higher risk of adverse clinical outcomes compared with those without anemia. Further optimization of anticoagulation therapy for VTE patients with anemia is warranted.
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Liu Y, Wang W, Wu F, Gao G, Xu J, Li X, Zhao C, Yang S, Mao S, Pan Y, Jia K, Shao C, Chen B, Ren S, Zhou C. High discrepancy in thrombotic events in non-small cell lung cancer patients with different genomic alterations. Transl Lung Cancer Res 2021; 10:1512-1524. [PMID: 33889526 PMCID: PMC8044490 DOI: 10.21037/tlcr-20-1290] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Acute complications, such as venous thromboembolism (VTE), are common in patients with advanced severe lung cancers. However, current VTE risk scores cannot adequately identify high-risk patients with non-small cell lung cancer (NSCLC). The study proposed to elucidated the incidence of thromboembolism (TE) in patients with different oncogenic aberrations and the impact of these aberrations on the efficacy of targeted therapy in patients with NSCLC. Methods A systemic review was conducted in Web of Science, PubMed, Embase and the Cochrane Library to evaluate the incidence of TE in different molecular subtypes of NSCLC. Data from patients diagnosed of advanced NSCLC who harboring anaplastic lymphoma kinase (ALK) or ROS proto-oncogene 1 receptor tyrosine kinase (ROS1) rearrangements since 2016 to 2019 were also retrospectively collected. A meta-analysis with random-effects model, sensitivity analysis and publication bias were performed. The principal summary measure was incidence of thrombotic events in NSCLC patients. And the efficacy of tyrosine kinase inhibitor (TKI) therapy was compared between the two subgroups. Results A total of 5,767 cases from 20 studies were included in the analysis of the incidence of thrombosis in patients with different oncogenic alterations. The pooled analysis showed a higher risk of thrombosis in ROS1-fusion types (41%, 95% CI: 35-47%) and ALK-fusion types (30%, 95% CI: 24-37%) than in EGFR-mutation (12%, 95% CI: 8-17%), KRAS-mutation (25%, 95% CI: 13-50%), and wild-type (14%, 95% CI: 10-20%) cases. A high prevalence of thrombosis (ALK: 24.4%; ROS1: 32.6%) was observed in the Shanghai Pulmonary Hospital (SPH) cohort of 224 patients with ALK or ROS1 fusion. Furthermore, patients with embolism had significantly shorter progression-free survival (PFS) after TKI therapy than those without embolism, both in the ALK+ cohort (5.6 vs. 12.9 months, P<0.0001) and in the ROS1+ cohort (9.6 vs. 17.6 months, P=0.0481). Conclusions NSCLC patients with ALK/ROS1 rearrangements are more likely to develop thrombosis than patients with other oncogenic alterations. Thrombosis may also be associated with an inferior response and PFS after TKI therapy.
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Affiliation(s)
- Yiwei Liu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wanying Wang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Fengying Wu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Guanghui Gao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jian Xu
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xuefei Li
- Department of Lung Cancer and Immunology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chao Zhao
- Department of Lung Cancer and Immunology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shuo Yang
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shiqi Mao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yingying Pan
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Keyi Jia
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chuchu Shao
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Bin Chen
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Shengxiang Ren
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Caicun Zhou
- Department of Medical Oncology, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
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Yamashita Y, Morimoto T, Amano H, Takase T, Hiramori S, Kim K, Oi M, Akao M, Kobayashi Y, Toyofuku M, Izumi T, Tada T, Chen PM, Murata K, Tsuyuki Y, Saga S, Sasa T, Sakamoto J, Kinoshita M, Togi K, Mabuchi H, Takabayashi K, Shiomi H, Kato T, Makiyama T, Ono K, Kimura T. Influence of baseline anemia on long-term clinical outcomes in patients with venous thromboembolism: from the COMMAND VTE registry. J Thromb Thrombolysis 2019; 47:444-453. [PMID: 30673941 DOI: 10.1007/s11239-018-1791-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The influence of anemia on the long-term clinical outcomes has not been fully evaluated in patients with venous thromboembolism (VTE). We evaluated the influence of anemia among 3012 patients in the COMMAND VTE Registry with a median follow-up period of 1219 days. The outcomes measures were ISTH major bleeding, recurrent VTE and all-cause death. There were 1012 patients (34%) with moderate/severe anemia (Hb ≤ 10.9 g/dl), 615 patients (20%) with mild anemia (Hb 11.0-12.9 g/dl for men, and 11.0-11.9 g/dl for women), and 1385 patients (46%) without anemia. The cumulative 5-year incidence of major bleeding was significantly higher in patients with anemia (moderate/severe anemia: 17.6%, mild anemia: 12.1%, and no anemia: 8.7%, P < 0.001). After adjusting the confounders, the excess risk of mild and moderate/severe anemia, respectively, relative to no anemia for major bleeding remained significant (mild: adjusted HR 1.41: [95% CI 1.00-1.98], P = 0.048; moderate/severe: adjusted HR 1.91: [95% CI 1.42-2.58], P < 0.001, respectively). The excess risk of moderate/severe anemia relative to no anemia was also significant for mortality (adjusted HR 2.89: 95% CI 2.45-3.42, P < 0.001), but the risk was neutral for recurrent VTE (adjusted HR 1.05: 95% CI 0.76-1.45, P = 0.77). In conclusions, VTE patients with mild and moderate/severe anemia had higher risk for major bleeding events without significant excess risk for recurrent VTE events, and the risk for major bleeding events increased according to the severity of anemia. We should pay more attention to the optimal intensity and duration of anticoagulation in VTE patients with anemia.
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Affiliation(s)
- Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hidewo Amano
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Mamoru Toyofuku
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Toshiaki Izumi
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Tomohisa Tada
- Department of Cardiology, Shizuoka General Hospital, Shizuoka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada Municipal Hospital, Shimada, Japan
| | - Syunsuke Saga
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tomoki Sasa
- Department of Cardiology, Kishiwada City Hospital, Kishiwada, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | | | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | | | - Hiroki Shiomi
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takao Kato
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeru Makiyama
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
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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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Abstract
Kuperman et al. found that patients with anemia had a higher risk of major bleeding (RR 2.84; 95% CI 2.52-3.39) in RIETE database. Anemia appeared to be an independent predictive factor for major bleeding [hazard ratio (HR) 1.95; 95% CI 1.72-2.20] in this registry. Unfortunately, selection bias due to enrolled patients does not allowed us to use these major results in ambulatory care. The aim of SCORE study was to refine bleeding risk estimation in French vitamin K antagonist (VKA) treated patients and to identifying one or several parameters of prognostic significance. We conducted a prospective, multi-center cohort study of 962 consecutive outpatients from private angiologic offices, clinics and hospitals enrolled in grenoble angiologic network for thromboembolic diseases between May 2009 and December 2010, followed during 1 year by their general practitioner. Main outcome was the occurrence of major bleeding or clinically non major relevant bleeding (CNMRB). Incidence rates major bleeding and CNMRB were 2.86 (95% CI 1.95-4.2) events per 100 patient-years and 12% (95% CI 9.89-14.11) respectively. Cox multivariate analyses showed that only anemia was strongly associated with a risk of major bleeding (HR 6.1; 95% CI 2.7-13.8; p = 0.001). Logistic regression analyses performed in CNMRB showed that anemia, prior gastro-intestinal bleeding and antiplatelet drug use were strongly associated with a risk of CNMRB at 1 year, respectively OR 2.53, 95% CI (1.4-4.56); p = 0.002, OR 3.32, 95% CI (1.51-7.31); p = 0.003 and OR 1.77, 95% CI (1.1-2.83); p = 0.017. These new data were consistent between major and CRNM bleeding in VKA treated patients. The key role of anemia should be confirmed in other prospective cohort studies, with different anticoagulants use such as direct oral anticoagulant in ambulatory care settings.
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