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Frisk G, Szilcz M, Hedman C, Björkhem-Bergman L. Treatment with Antithrombotics in the Last Year of Life-Incidence of Bleeding and Side Effects After Deprescribing. J Palliat Med 2024. [PMID: 38973710 DOI: 10.1089/jpm.2024.0108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Background: Patients in palliative care are often treated with antithrombotics, even in the late stages of disease. Clear guidelines regarding deprescribing are lacking. Objective: The aims of this study were to investigate bleeding as a side effect of antithrombotic treatments the last year in life and map the timing of deprescribing. Methods: A retrospective cohort study was performed. All medical records were screened for deceased patients admitted to a palliative care unit in Stockholm, Sweden, over a 3-year period. Patients with antithrombotics were identified; data on bleeding, and on side effects due to deprescribing, were extracted from the medical records. Log-binomial models were used to explore factors associated with bleeding. Results: Of 1501 patients, 897 were treated with antithrombotics during the last year of life (mean age 75 years, 41% women). Of these, 56% continued treatment up until the last 3 days of life. Of the 897 patients, 144 (16%) had at least one bleeding during the treatment. The risk for bleeding was significantly higher for men with prostate cancer compared to other cancer forms, adjusted relative risk 1.9 (95% CI 1.1-3.2). No difference in risk for bleeding was found between sex, age groups, type of antithrombotics, or indication. Two patients (0.2%) developed strokes after antithrombotics were deprescribed. Conclusions: Treatment with antithrombotics during the last year of life is associated with a high risk of bleeding. In this cohort, men with prostate cancer seemed to have more side effects of bleeding than other groups. Few experienced side effects from deprescribing.
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Affiliation(s)
- Gabriella Frisk
- ASIH Stockholm Södra, Specialized home care and Specialized palliative ward, Älvsjö, Sweden
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Huddinge, Sweden
| | - Máté Szilcz
- Department of Medical Epidemiology and Biostatistics, C8 Medicinsk epidemiologi och biostatistik, MEB Jonell, Karolinska Institutet, Stockholm, Sweden
| | - Christel Hedman
- Stockholms Sjukhems R&D Department, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Clinician Sciences Lund, Lund University, Lund, Sweden
| | - Linda Björkhem-Bergman
- ASIH Stockholm Södra, Specialized home care and Specialized palliative ward, Älvsjö, Sweden
- Stockholms Sjukhems R&D Department, Stockholm, Sweden
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Madsen SF, Christensen DM, Strange JE, Nouhravesh N, Kümler T, Gislason G, Lamberts M, Sindet‐Pedersen C. Short- and Long-Term Mortality for Patients With and Without a Cancer Diagnosis Following Pulmonary Embolism in Denmark, 2000 to 2020: A Nationwide Study. J Am Heart Assoc 2023; 12:e030191. [PMID: 38014671 PMCID: PMC10727333 DOI: 10.1161/jaha.123.030191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/19/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND New treatment regimens have been introduced in the past 20 years, which may influence the short- and long-term prognosis for patients with and without a cancer diagnosis following pulmonary embolism. However, newer studies investigating these trends are lacking. Therefore, we aimed to investigate the 30- and 31- to 365-day mortality following pulmonary embolism. METHODS AND RESULTS Using the Danish nationwide registries, patients with a diagnosis of pulmonary embolism between 2000 and 2020 were included. Age- and sex-standardized 30- and 31- to 365-day mortality was calculated and stratified by cancer status. In total, 60 614 patients (29.6% with recent cancer; mean age, 68.2 years) were included. The 30-day mortality for patients with no recent cancer decreased from 19.1% (95% CI, 17.9%-20.4%) in 2000 to 7.3% (95% CI, 6.7%-8.0%) in 2018 to 2020 (hazard ratio [HR], 0.36 [95% CI, 0.32-0.40]; P<0.001). The 30-day mortality for patients with recent cancer decreased from 32.2% (95% CI, 28.8%-36.6%) to 14.1% (95% CI, 12.7%-15.5%) (HR, 0.38 [95% CI, 0.33-0.44]; P<0.001). The 31- to 365-day mortality for patients with no recent cancer decreased from 12.5% (95% CI, 11.4%-13.6%) to 9.4% (95% CI, 8.6%-10.2%) (HR, 0.73 [95% CI, 0.64-0.83]; P<0.001).The 31- to 365-day mortality for patients with recent cancer remained stable: 39.4% (95% CI, 35.1%-43.7%) to 38.3% (95% CI, 35.9%-40.6%) (HR, 0.97 [95% CI, 0.84-1.12]; P=0.69). CONCLUSIONS From 2000 to 2020, improvements were observed in 30-day mortality following pulmonary embolism regardless of cancer status. For patients with recent cancer, 31- to 365-day mortality did not improve, whereas a minor improvement was observed for patients without recent cancer.
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Affiliation(s)
- Sophie Fredslund Madsen
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
| | | | - Jarl Emanuel Strange
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
- Department of Cardiology, The Heart CenterCopenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Nina Nouhravesh
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Thomas Kümler
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Gunnar Gislason
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
- Danish Heart FoundationCopenhagenDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Morten Lamberts
- Department of Cardiology, Herlev and Gentofte HospitalUniversity of CopenhagenHellerupDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
| | - Caroline Sindet‐Pedersen
- Danish Heart FoundationCopenhagenDenmark
- Department of Clinical Medicine, Faculty of Health and Medical SciencesUniversity of CopenhagenCopenhagenDenmark
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Efficacy and safety of direct oral anticoagulants for the treatment of cancer-associated venous thromboembolism: A systematic review and Bayesian network meta-analysis. Med Clin (Barc) 2023; 160:245-252. [PMID: 36031454 DOI: 10.1016/j.medcli.2022.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/30/2022] [Accepted: 06/30/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) could effectively prevent the occurrence of cancer-associated venous thromboembolism (CAVTE), which incidence rate was estimated to be 4-20%. But the efficacy and safety remain controversial between DOACs and low molecular weight heparin (LMWH). MATERIALS AND METHODS PubMed, Cochrane Library, Embase, ClinicalTrials.gov databases for randomized controlled trials (RCTs) were systematically searched from inception to March 15, 2022. A random-effects model was used to report the odds ratio (OR) and 95% confidence interval (CI) for both direct and network meta-analyses. RESULTS Seven studies were included totaling 3242 patients. A lower rate of recurrence VTE was noted in the DOACs compared with LMWH (OR 0.62, 95% CI 0.47-0.82, I2=0.0%). The aspect of major bleeding (MB) was similar (OR 1.30, 95% CI 0.77-2.18, I2=34.9%). When assessing clinically relevant nonmajor bleeding (CRNMB) (OR 1.61, 95% CI 1.17-2.22, I2=20.7%) and clinically relevant bleeding (CRB) (OR 1.39, 95% CI 1.11-1.74, I2=0.0%), a higher risk of events was observed in DOACs. In subgroup analyses, the MB of gastrointestinal and genitourinary malignancies had a higher rate in the DOACs. For ranking, apixaban ranked the first in prevention of VTE and reducing MB events. Edoxaban had the highest risk drug in MB. In terms of CRNMB and CRB, LMWH showed the lowest risk. CONCLUSIONS Compared with LMWH, DOACs seemed to have a decreased risk of recurrence VTE while increasing CRNMB and CRB. DOACs and LMWH were equivalent to the aspect of MB, but DOACs had a higher MB risk in patients with gastrointestinal and genitourinary malignancies. Apixaban may be the lowest risk compared to the other DOACs in precaution of VTE and reducing bleeding events.
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Chiorescu RM, Mocan M, Stoia MA, Barta A, Goidescu CM, Chiorescu S, Farcaş AD. Arguments for Using Direct Oral Anticoagulants in Cancer-Related Venous Thromboembolism. Healthcare (Basel) 2021; 9:1287. [PMID: 34682967 PMCID: PMC8535422 DOI: 10.3390/healthcare9101287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 12/18/2022] Open
Abstract
(1) Background: Patients with cancer with a hypercoagulable state present an increased incidence of venous thromboembolism (VTE). Neoplastic patients with concurrent VTE undergoing anticoagulant treatment face a series of issues. (2) The aim of the present paper is to systematically summarize current VTE management in patients with neoplasia and to review the current clinical evidence from meta-analyses of randomized controlled trials and guidelines regarding the administration of direct oral anticoagulants (DOACs) for cancer-associated VTE. (3) Search Strategy: We performed a review on meta-analyses of randomized controlled trials and guidelines in favor of the administration of DOACs in patients with cancer-associated VTE published in the last 6 years in the Medline (PubMed) and Embase databases. (4) Results: 21 meta-analyses, 14 randomized controlled studies comparing DOACs to VKAs and LMWH, and 7 national and international guidelines were identified. We identified five studies that show the antineoplastic effect of DOAC on experimental models. (5) Conclusions: DOACs can be seen as the first choice for VTE treatment in neoplastic patients who have a low risk of bleeding, who do not have severe renal impairment, and who are not undergoing treatments that could interact with DOAC's mechanism of action.
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Affiliation(s)
- Roxana Mihaela Chiorescu
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.M.C.); (M.A.S.); (A.B.); (C.M.G.); (A.D.F.)
- Department of Internal Medicine, Emergency Clinical County Hospital, 400006 Cluj-Napoca, Romania
| | - Mihaela Mocan
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.M.C.); (M.A.S.); (A.B.); (C.M.G.); (A.D.F.)
- Department of Internal Medicine, Emergency Clinical County Hospital, 400006 Cluj-Napoca, Romania
| | - Mirela Anca Stoia
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.M.C.); (M.A.S.); (A.B.); (C.M.G.); (A.D.F.)
- Department of Cardiology, Emergency Clinical County Hospital, 400006 Cluj-Napoca, Romania
| | - Anamaria Barta
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.M.C.); (M.A.S.); (A.B.); (C.M.G.); (A.D.F.)
- Department of Cardiology, “Nicolae Stăncioiu” Heart Institute, 400001 Cluj-Napoca, Romania
| | - Cerasela Mihaela Goidescu
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.M.C.); (M.A.S.); (A.B.); (C.M.G.); (A.D.F.)
- Department of Cardiology, Military Emergency Hospital “C. Papilian”, 400132 Cluj-Napoca, Romania
| | - Stefan Chiorescu
- Surgery Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
| | - Anca Daniela Farcaş
- Internal Medicine Department, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania; (R.M.C.); (M.A.S.); (A.B.); (C.M.G.); (A.D.F.)
- Department of Cardiology, Emergency Clinical County Hospital, 400006 Cluj-Napoca, Romania
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Kaliel H, Mior M, Quan S, Ghosh S, Wu C, Bungard TJ. Retrospective Review of Prescribing Patterns in Cancer-Associated Thrombosis: A Single Center Experience in Edmonton, Alberta, Canada. Clin Appl Thromb Hemost 2021; 27:1076029620975489. [PMID: 33443455 PMCID: PMC7812402 DOI: 10.1177/1076029620975489] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Low molecular weight heparin (LMWH) is the standard of care for treating cancer-associated thrombosis (CAT), although new evidence for direct oral anticoagulants (DOACs) supports use in specific cancer populations. In this retrospective review at a specialty CAT clinic from 2016 to 2019, we report the use of anticoagulants (LMWH, DOACs, warfarin, anticoagulant class change) in the acute and chronic phases of CAT and compare use before/after publication of the Hokusai-VTE Cancer trial. Death, venous thromboembolism (VTE) recurrence and bleeding was also reported. Of the 221 included, median age was 69 years, with 57.5% having metastatic disease. In the acute phase, 80.1% were prescribed LMWH, 4.1% DOAC, and 14.5% had an anticoagulant class change (LMWH to DOAC; 78.1%). In the chronic phase, 35.8% were prescribed LMWH, 11.3% DOAC, and 42.9% had an anticoagulant class change (LMWH to DOAC; 90.1%). Use of DOACs in the acute and chronic phase prior to the Hokusai-VTE trial was 1.0% and 2.0%, respectively, and following publication was 6.8% and 19.6%. Death occurred for 22.6% patients, recurrent VTE in 7.2%, and bleeding in 5.0%. DOAC use is increasing with time; real-world data may help to guide optimization of the care of complex patients.
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Affiliation(s)
- Hannah Kaliel
- Pharmacy Services, 3146Alberta Health Services, Edmonton, Alberta, Canada
| | - Meghan Mior
- Pharmacy Services, 3146Alberta Health Services, Edmonton, Alberta, Canada
| | - Steven Quan
- Pharmacy Services, 3146Alberta Health Services, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Pharmacy Services, 3146Alberta Health Services, Edmonton, Alberta, Canada
| | - Cynthia Wu
- Division of Hematology, 3158University of Alberta, Edmonton, Alberta, Canada.,Co-senior author
| | - Tammy J Bungard
- Division of Cardiology, 3158University of Alberta, Edmonton, Alberta, Canada.,Co-senior author
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Song X, Liu Z, Zeng R, Shao J, Liu B, Zheng Y, Liu C, Ye W. Treatment of venous thromboembolism in cancer patients: a systematic review and meta-analysis on the efficacy and safety of different direct oral anticoagulants (DOACs). ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:162. [PMID: 33569464 PMCID: PMC7867886 DOI: 10.21037/atm-20-8156] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background To evaluate the efficacy and safety of different direct oral anticoagulants (DOACs) compared with low molecular weight heparins (LMWHs) in the treatment of venous thromboembolism (VTE) in cancer patients. Methods Literature was searched in databases including Cochrane Library, EMBASE (Ovid), and MEDLINE (PubMed). Eligible studies were included, and data were collected independently by 2 reviewers. We conducted a systematic review of the efficacy and safety of DOACs in the treatment of VTE in cancer patients. The odds ratios (ORs) of different DOACs compared with LMWHs for VTE, deep vein thrombosis (DVT), pulmonary embolism (PE) recurrence, major bleeding, and clinically relevant non-major bleeding (CRNMB), were calculated in meta-analyses and subgroup analyses. Results A total of 18 articles were eligible for analyses, including 4 randomized controlled trials (RCTs) and 14 retrospective studies. Both RCTs and retrospective studies confirmed that DOACs decreased the risk of VTE recurrence [RCTs: OR, 0.60; 95% confidence interval (CI), 0.45–0.80; retrospective studies: OR, 0.73; 95% CI, 0.59–0.90] and DVT recurrence (RCTs: OR, 0.54; 95% CI, 0.36–0.80; retrospective studies: OR, 0.20; 95% CI, 0.06–0.63), but not PE recurrence or fatal PE in cancer patients. Subgroup analyses revealed an important role of rivaroxaban in decreasing recurrent VTE. Meanwhile, major bleeding events were not increased in the DOAC group, but the risks of CRNMBs were significantly elevated. Subgroup analyses confirmed the role of rivaroxaban in increasing the risk of major bleeding events and CRNMBs. Conclusions Compared with LMWHs, DOACs (especially rivaroxaban) significantly reduce the risk of VTE and DVT, but not PE recurrence, in patients with cancer. Although DOACs did not increase the major bleeding events in pooled analysis, rivaroxaban showed an elevated risk of this adverse effect in subgroup analysis. In addition, the risk of CRNMB events was increased after the application of DOACs including rivaroxaban.
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Affiliation(s)
- Xiaojun Song
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Zhili Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Rong Zeng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Jiang Shao
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Bao Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Yuehong Zheng
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Changwei Liu
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
| | - Wei Ye
- Department of Vascular Surgery, Peking Union Medical College Hospital, Beijing, China
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Perrone F, Biagi A, Facchinetti F, Bozzetti F, Ramelli A, Vezzani A, Manca T, Gnetti L, Majori M, Alfieri V, Tiseo M. Systemic thromboembolism from a misdiagnosed non-bacterial thrombotic endocarditis in a patient with lung cancer: A case report. Oncol Lett 2020; 20:194. [PMID: 32952663 PMCID: PMC7479525 DOI: 10.3892/ol.2020.12056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 03/05/2020] [Indexed: 12/03/2022] Open
Abstract
Thromboembolic events are frequent in patients with cancer, commonly involving the venous and pulmonary circulation. The arterial system is rarely implicated in embolism and, when involved, a cardiogenic origin should always be excluded. In the present study, a case of a patient who developed multiple embolic events concomitantly with the diagnosis of locally-advanced non-small cell lung cancer with high expression levels of programmed death-ligand 1 (PD-L1) in >50% of tumor cells is reported. A cardiac defect interpreted as a patent foramen ovale required low molecular weight heparin administration. Despite the anti-coagulant therapy, before first-line anticancer treatment with pembrolizumab immunotherapy could be administered due to high PD-L1 expression levels, a new hospitalization was required due to the onset of novel ischemic manifestation. New transthoracic and transesophageal echocardiography revealed a previously misdiagnosed vegetation of the mitral valve that caused systemic embolization. The lack of any sign of infection led to the diagnosis of a non-bacterial thrombotic endocarditis (NBTE), whose embolic sprouting gave rise to the widespread ischemic events. No active anticancer treatment was feasible due to the rapid progression of the disease. NBTE can evolve quickly, eventually preventing any chance of treatment targeting the primary cause, which in the present study was lung cancer. If NBTE can be correctly diagnosed sooner then there may be the potential for anticancer therapy that does not worsen the hypercoagulability state, thus improving cancer-associated survival.
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Affiliation(s)
- Fabiana Perrone
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy
| | - Andrea Biagi
- Cardiology Department, University Hospital of Parma, I-43126 Parma, Italy
| | - Francesco Facchinetti
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy.,National Institute of Health and Medical Research, Gustave Roussy Cancer Campus, University of Paris-Saclay, 94800 Villejuif, France
| | | | - Andrea Ramelli
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Antonella Vezzani
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Tullio Manca
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Letizia Gnetti
- Unit of Pathology, University of Parma, I-43126 Parma, Italy
| | - Maria Majori
- Unit of Pulmonology and Thoracic Endoscopy, University of Parma, I-43126 Parma, Italy
| | - Veronica Alfieri
- Unit of Respiratory Disease and Lung Function, University of Parma, I-43126 Parma, Italy
| | - Marcello Tiseo
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy.,Department of Medicine and Surgery, University of Parma, I-43126 Parma, Italy
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Direct oral anticoagulant versus low-molecular-weight heparin for treatment of venous thromboembolism in cancer patients: An updated meta-analysis of randomized controlled trials. Thromb Res 2020; 194:57-65. [PMID: 32788122 DOI: 10.1016/j.thromres.2020.06.025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cancer associated venous thromboembolism (VTE) results in significant morbidity and mortality. Low molecular weight heparin (LMWH) has been standard of care for treatment of cancer-associated VTE, however direct oral anticoagulants (DOACs) are emerging as alternative treatment options. OBJECTIVE To compare the benefits and harms of DOACs versus LMWH for treatment of VTE in cancer. DATA SOURCES MEDLINE, Embase, and the Cochrane Collaboration Central Register of Controlled Trials from inception to April 2020. STUDY SELECTION Randomized controlled trials (RCT) comparing DOACs with LMWH for treatment of VTE in cancer patients. DATA SYNTHESIS Four good-quality RCTs, met inclusion criteria. Compared with LMWH, DOACs were associated with lower rates of VTE recurrence (RR 0.62; 95% CI: 0.44-0.87; P = 0.006), and DVT recurrence (RR 0.61; 95% CI: 0.4-0.94; P = 0.02) but not PE recurrence (RR 0.73; 95% CI: 0.51-1.04; P = 0.08), in cancer patients. However, the risk of clinically relevant non-major bleeding (CRNMB) (RR 1.58; 95% CI: 1.11-2.24; P = 0.01), and major bleeding in gastrointestinal cancer (RR 2.55; 95% CI 1.24-5.27, P = 0.01), were higher with DOACs. The risk of overall major bleeding (RR 1.33; 95% CI: 0.84-2.1; P = 0.22), all-cause mortality (RR 0.99; 95% CI: 0.84-1.17; P = 0.92), VTE-related mortality (RR: 1; 95% CI: 0.29-3.44; P = 1) and bleeding-related mortality (RR: 0.71; 95% CI: 0.17-2.91; P = 0.63), were similar in both treatment groups. CONCLUSION Among cancer patients with VTE, treatment with DOACs is associated with a significant reduction of VTE and DVT recurrence, compared to LMWH. These benefits were offset by an increased risk of CRNMB, and major bleeding in gastrointestinal cancer.
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