1
|
Parmentier S, Koschmieder S, Henze L, Griesshammer M, Matzdorff A, Bakchoul T, Langer F, Alesci RS, Duerschmied D, Thomalla G, Riess H. Antithrombotic Therapy in Cancer Patients with Cardiovascular Diseases: Daily Practice Recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society for Thrombosis and Hemostasis Research (GTH e.V.). Hamostaseologie 2024. [PMID: 39009011 DOI: 10.1055/a-2337-4025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024] Open
Abstract
Active cancer by itself but also chemotherapy is associated with an increased risk of cardiovascular disease (CVD) and especially coronary artery disease (CAD) and atrial fibrillation (AF). The frequency of CVD, CAD, and AF varies depending on comorbidities (particularly in older patients), cancer type, and stage, as well as the anticancer therapeutic being taken. Many reports exist for anticancer drugs being associated with CVD, CAD, and AF, but robust data are often lacking. Because of this, each patient needs an individual structured approach concerning thromboembolic and bleeding risk, drug-drug interactions, as well as patient preferences to evaluate the need for anticoagulation therapy and targeting optimal symptom control. Interruption of specific cancer therapy should be avoided to reduce the potential risk of cancer progression. Nevertheless, additional factors like thrombocytopenia and anticoagulation in the elderly and frail patient with cancer cause additional challenges which need to be addressed in daily clinical management. Therefore, the aim of these recommendations is to summarize the available scientific data on antithrombotic therapy (both antiplatelet and anticoagulant therapy) in cancer patients with CVD and in cases of missing data providing guidance for optimal careful decision-making in daily routine.
Collapse
Affiliation(s)
- Stefani Parmentier
- Tumorzentrum, St. Claraspital Tumorzentrum, St. Claraspital, Basel, Basel-Stadt, Switzerland
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Larissa Henze
- Department of Medicine, Clinic III - Hematology, Oncology, Palliative Medicine, Rostock University Medical Center, Rostock, Germany
- Department of Internal Medicine II, Hematology, Oncology and Palliative Medicine, Asklepios Hospital Harz, Goslar, Germany
| | - Martin Griesshammer
- University Clinic for Hematology, Oncology, Hemostaseology and Palliative Care, Johannes Wesling Medical Center Minden, University of Bochum, Minden, Germany
| | - Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark, Schwedt, Germany
| | - Tamam Bakchoul
- Department of Transfusion Medicine, Medical Faculty of Tübingen, University of Tübingen, Tübingen, Germany
| | - Florian Langer
- Center for Oncology, University Cancer Center Hamburg (UCCH), II Medical Clinic and Polyclinic, University Medical Center Eppendorf, Hamburg, Germany
| | - Rosa Sonja Alesci
- IMD Blood Coagulation Center, Hochtaunus/Frankfurt, Bad Homburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Hemostaseology, Angiology and Medical Intensive Care, Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanno Riess
- Division of Hematology, Oncology and Tumorimmunology, Department of Medical, Campus Charité Mitte, Charité Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
2
|
Xiong W, Chatani R, Yamashita Y. Cancer-Associated Venous Thromboembolism: Changes Over the Past 20 Years. JACC CardioOncol 2023; 5:773-774. [PMID: 38205015 PMCID: PMC10774771 DOI: 10.1016/j.jaccao.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Wei Xiong
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Department of Pulmonary and Critical Care Medicine, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| |
Collapse
|
3
|
Escobar A, Salem AM, Dickson K, Johnson TN, Burk KJ, Bashoura L, Faiz SA. Anticoagulation and bleeding in the cancer patient. Support Care Cancer 2022; 30:8547-8557. [PMID: 35579752 PMCID: PMC9529787 DOI: 10.1007/s00520-022-07136-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.
Collapse
Affiliation(s)
- Andres Escobar
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Ahmed M Salem
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kodwo Dickson
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tami N Johnson
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathyrn J Burk
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA.
| |
Collapse
|
4
|
Outcomes with direct acting oral anticoagulants in patients with a history of bariatric surgery: a retrospective cohort study. Surg Obes Relat Dis 2022. [DOI: 10.1016/j.soard.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
5
|
Jiménez-Fonseca P, Gallardo E, Arranz Arija F, Blanco JM, Callejo A, Lavin DC, Costa Rivas M, Mosquera J, Rodrigo A, Sánchez Morillas R, Vares Gonzaléz M, Muñoz A, Carmona-Bayonas A. Consensus on prevention and treatment of cancer-associated thrombosis (CAT) in controversial clinical situations with low levels of evidence. Eur J Intern Med 2022; 100:33-45. [PMID: 35227541 DOI: 10.1016/j.ejim.2022.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/23/2022] [Accepted: 02/21/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Cancer patients suffer high risk of venous thromboembolism (VTE). Cancer-associated VTE (CAT) causes hospitalization, morbidity, delayed cancer treatment, and mortality; therefore, exceptional CAT prevention and management are imperative. METHODS This review offers practical recommendations and treatment algorithms for eight complex, clinically relevant situations posing great uncertainty regarding management and requiring an urgent decision: VTE prophylaxis in ambulatory cancer patients with pancreatic pancreas (1) or lung cancer with molecular alterations (2); optimal management of VTE during antineoplastic treatment with antiangiogenics (3) or chemotherapy (4); protracted VTE treatment, determinants; (5) drugs used (6), and optimal VTE management in situations of high bleeding risk (7) or recurrent VTE (8). RESULTS With the evidence available, primary thromboprophylaxis in patients with lung cancer harbouring ALK/ROS1 translocations or pancreatic cancer receiving ambulatory chemotherapy must be appraised. If antiangiogenic therapy can yield a clear benefit and the patient recovers from a grade 3 thrombotic event, it can be cautiously re-introduced in selected cases, provided that the person agrees to assume the risk after being duly informed. Anticoagulation maintenance beyond 6 months is recommended in individuals with metastatic tumours, on active treatment, or at high risk for recurrent VTE without bleeding risk. In such cases, LMWH and DOACs are safe, being mindful that the latter could entail a higher risk of bleeding; consequently, they should be used judiciously in more haemorrhagic tumours, such as gastrointestinal cancers. In cases of recurrent VTE, the presence of active cancer, infra-therapeutic dose, and anticoagulant treatment failure must be ruled out. In individuals with platelet counts of 25,000-50,000 and VTE liable to recur who need anticoagulation, full-dose LMWH and transfusion support can be contemplated to reach values of > 50,000. In CAT unlikely to recur, decreasing the LMWH dose by 25-50% is recommended. Renal impairment associated with thrombosis must be treated with LMWHs; there is no need to adjust the dose in patients with CrCl > 30; with CrCl = 15-30, dose adjustment is advised, and suspended when CrCl is < 15. CONCLUSION We provide useful advice for complex, clinically relevant situations that clinicians treating CAT must face devoid of any unequivocal, strong, evidence-based recommendations.
Collapse
Affiliation(s)
- Paula Jiménez-Fonseca
- Medical Oncology Department, Hospital Universitario Central de Asturias, ISPA, Avenida Roma, Oviedo 33011, Spain.
| | - Enrique Gallardo
- Medical Oncology Department, Hospital Universitario Parc Tauli, Sabadell, Spain
| | - Fernando Arranz Arija
- Medical Oncology Department, Complejo Asistencial Universitario de Palencia, Palencia, Spain
| | - Jesús Manuel Blanco
- Medical Oncology Department, Hospital Universitario de Donosti, Donosti-San Sebastián, Spain
| | - Ana Callejo
- Medical Oncology Department, Hospital Universitario Vall d'Hebron, Vall d'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Diego Cacho Lavin
- Medical Oncology Department, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Joaquín Mosquera
- Medical Oncology Department, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Alberto Rodrigo
- Medical Oncology Department, Hospital Arnau de Vilanova, Lleida, Spain
| | | | - María Vares Gonzaléz
- Internal Medicine Department, Hospital Universitario de A Coruña, A Coruña, Spain
| | - Andrés Muñoz
- Medical Oncology Department, Hospital Universitario Gregorio Marañon, Madrid, Spain
| | - Alberto Carmona-Bayonas
- Hematology and Medical Oncology Department, Hospital Universitario Morales Meseguer, UMU, IMIB, Murcia, Spain
| |
Collapse
|
6
|
Can thromboprophylaxis build a link for cancer patients undergoing surgical and/or chemotherapy treatment? The MeTHOS cohort study. Support Care Cancer 2022; 30:6973-6984. [PMID: 35552827 PMCID: PMC9213358 DOI: 10.1007/s00520-022-07096-1] [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: 11/29/2021] [Accepted: 04/27/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients with active cancer have a 4-sevenfold increased risk for venous thromboembolism (VTE) especially during systematic anticancer treatment. Simultaneously, surgery is an additional risk factor. METHODS The Metaxas's Hospital THromboprophylaxis program in Oncological & Surgical Patients (MeTHOS) is a prospective, phase IV, observational, non-interventional cohort study, aiming to record the thromboprophylaxis practice patterns in high-risk active cancer patients undergoing surgical and/or chemotherapy treatment. RESULTS We are reporting results from 291 ambulatory patients (median age: 67 years, Q1-Q3: 59-73 years, 54.6% males) who received anti-neoplastic treatment and administered thromboprophylaxis. 59.8% had cardiovascular disease (mostly hypertension), 76.6% were reported as having at least one comorbidity, while 27.5% and 15.8% accumulated two and three comorbidities, respectively. 94.9% of the patients were receiving highly thrombogenic agents such as platinum-based agents, 5-FU, immunotherapy, antiangiogenics/anti-VEGF, or erythropoietin. 26.5% of the patients were initially surgically treated. In terms of anticoagulation, all patients were treated with tinzaparin (fixed dose, 10,000 Anti-Xa IU, OD). The median anticoagulation duration was 6.2 months. Six thrombotic events were observed (2.06%, 95% CI: 0.76-4.43%): 5 were DVT, and one PE. With respect to safety, 7 bleeding events occurred (2.6%, 95% CI: 1.0-5.3%); 6 of them were minor. CONCLUSIONS Thromboprophylaxis with LMWH in patients with active cancer and high thrombotic burden was safe and effective. Intermediate dose of tinzaparin seems to be an appropriate agent for cancer-associated thromboprophylaxis management. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov: NCT04248348.
Collapse
|
7
|
Ording AG, Søgaard M, Nielsen PB, Lip GYH, Larsen TB, Grove EL, Skjøth F. Oral anti-coagulant treatment patterns in atrial fibrillation patients diagnosed with cancer: A Danish nationwide cohort study. Br J Haematol 2022; 197:223-231. [PMID: 35194786 DOI: 10.1111/bjh.18060] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
Abstract
Data on the use of oral anti-coagulants (OAC) for stroke prevention in cancer patients with atrial fibrillation (AF) are sparse. Nationwide cohort study of patients with AF (2012-2018) and an indication for OAC who were diagnosed with cancer at least one year later (N = 12 756). We identified treatment with OAC at cancer diagnosis and the following year and described the incidence of discontinuing or switching between warfarin and direct oral anti-coagulants (DOACs). We also described baseline characteristics associated with OAC non-persistence. One third of the cancer patients received no OAC therapy, whereas 42% received warfarin and 24% received DOAC treatment. Switching incidence between OACs was higher for those receiving warfarin treatment (8.6%) than DOAC treatment (1.7%) within one year. Treatment discontinuation was 61% for warfarin and 26% for DOAC. Females were less likely to discontinue DOAC than males (ratio 0.77, 95% confidence interval: 0.66, 0.90). Increasing cancer stage was associated with discontinuation of DOAC, but not warfarin. OAC for stroke prevention in AF was used by two thirds of patients with newly diagnosed cancer. Switching between OACs and discontinuation was more common for warfarin than DOAC, and females had higher persistence with DOACs.
Collapse
Affiliation(s)
- Anne Gulbech Ording
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Liverpool Centre for Cardiovascular Sciences, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Torben Bjerregaard Larsen
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Flemming Skjøth
- Unit for Thrombosis and Drug Research, Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.,Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| |
Collapse
|
8
|
Salgado M, Brozos-Vázquez E, Campos B, González-Villarroel P, Pérez ME, Vázquez-Tuñas ML, Arias D. Venous Thromboembolism In Cancer Patients: "From Evidence to Care". Clin Appl Thromb Hemost 2022; 28:10760296221098717. [PMID: 35538861 PMCID: PMC9102132 DOI: 10.1177/10760296221098717] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This article seeks to review the current status of treatment and prevention of venous thromboembolic disease (VTE) in cancer patients after the addition of direct oral anticoagulants (DOAC) to the therapeutic arsenal available. The suitability of DOAC use in complex clinical situations, poorly represented in clinical trials, is controversial and difficult for care activity, making the recommendations in clinical practice guidelines the focus of special attention in this area. Recently, several randomized trials have compared low molecular weight heparin (LMWH) to DOAC for the management of CAT. Potential drug interactions with DOACs or the increased risk of bleeding in intraluminal tumors require special precautions, as do metastatic or primary brain disease and comorbid conditions, such as renal or liver failure, which are not suitably represented in pivotal studies. Furthermore, few data are available for situations involving elevated bleeding risk, with thrombocytopenia levels below the inclusion criterion of clinical trials, or recurrence during active anticoagulant therapy. Similarly, it is less clear that patients and physicians accept the presumption that oral DOAC administration is more convenient than subcutaneous LMWH, particularly when drug absorption may be compromised. The non-inclusion or under-representation of patients at higher risk for complications with anticoagulation in randomized clinical trials, makes their use complex in certain situations in health care. This paper provides a practical review of current clinical guideline recommendations regarding LMWH and/ or DOAC to treat and prevent CAT, as well as the most controversial clinical conditions for their use.
Collapse
Affiliation(s)
- Mercedes Salgado
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Elena Brozos-Vázquez
- Medical Oncology Department, 59535Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Begoña Campos
- Medical Oncology Department, 309716Hospital Universitario Lucus Augusti, Lugo, Spain
| | | | - María Eva Pérez
- Medical Oncology Department, 16811Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | | | - David Arias
- Medical Oncology Department, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| |
Collapse
|
9
|
Lopez-Bauza A, Jara-Palomares L. Symptomatic azygous vein thrombosis: Clinical case and literature review. Arch Bronconeumol 2021; 57:506-509. [PMID: 35698966 DOI: 10.1016/j.arbr.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 12/16/2020] [Indexed: 06/15/2023]
Affiliation(s)
- Angela Lopez-Bauza
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain; Instituto de Biomedicina de Sevilla (IBiS), Spain
| | - Luis Jara-Palomares
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, Spain; Instituto de Biomedicina de Sevilla (IBiS), Spain; CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
| |
Collapse
|
10
|
Gervaso L, Dave H, Khorana AA. Venous and Arterial Thromboembolism in Patients With Cancer: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2021; 3:173-190. [PMID: 34396323 PMCID: PMC8352228 DOI: 10.1016/j.jaccao.2021.03.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/07/2021] [Accepted: 03/09/2021] [Indexed: 12/20/2022] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a major cause of morbidity and mortality in patients with cancer. Arterial thromboembolism, including myocardial infarction and stroke, is also prevalent. Risk differs in subgroups, with higher rates observed in specific cancers including pancreas, stomach, and multiple myeloma. Thromboprophylaxis is recommended for most patients with active cancer hospitalized for medical illnesses and after major cancer surgery. Outpatient thromboprophylaxis is not routinely recommended, but emerging data suggest that a high-risk population that benefits from pharmacological thromboprophylaxis can be identified using a validated risk tool. Direct oral anticoagulants are emerging as the preferred new option for the treatment of cancer-associated VTE, although low-molecular-weight heparin remains a standard for patients at high bleeding risk. Management of VTE beyond the first 6 months and challenging clinical situations including intracranial metastases and thrombocytopenia require careful management in balancing the benefits and risks of anticoagulation and remain major knowledge gaps in evidence.
Collapse
Key Words
- ASCO, American Society of Clinical Oncology
- ASH, American Society of Hematology
- AT, antithrombin
- ATE, arterial thromboembolism
- CAT, cancer-associated thrombosis
- CI, confidence interval
- CRNMB, clinically relevant nonmajor bleeding
- CVA, cerebrovascular event
- DOAC, direct oral anticoagulant
- DVT, deep venous thrombosis
- ESMO, European Society of Medical Oncology
- GI, gastrointestinal
- HR, hazard ratio
- ICH, intracranial hemorrhage
- ISTH, International Society on Thrombosis and Haemostasis
- KS, Khorana score
- LMWH, low-molecular-weight heparin
- MI, myocardial infarction
- MM, multiple myeloma
- NNT, number needed to treat
- PE, pulmonary embolism
- PPV, positive predictive value
- RAM, risk assessment model
- SPE, segmental pulmonary embolism
- SSC, Scientific and Standardization Committee
- SSPE, subsegmental pulmonary embolism
- UHF, unfractionated heparin
- VKA, vitamin K antagonist
- VTE, venous thromboembolism
- VVT, visceral vein thrombosis
- arterial thromboembolism
- cancer-associated thrombosis
- prophylaxis
- risk assessment models
- treatment
- venous thromboembolism
Collapse
Affiliation(s)
- Lorenzo Gervaso
- Division of Gastrointestinal Medical Oncology and Neuroendocrine Tumors, Istituto Europeo di Oncologia, European Institute of Oncology, Milan, Italy
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | - Heloni Dave
- Maharaja Sayajirao University, Medical College, Vadodara, Gujarat, India
| | - Alok A. Khorana
- Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
11
|
Lopez-Bauza A, Jara-Palomares L. Symptomatic Azygous Vein Thrombosis: Clinical Case and Literature Review. Arch Bronconeumol 2021; 57:S0300-2896(20)30559-7. [PMID: 33509623 DOI: 10.1016/j.arbres.2020.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/13/2020] [Accepted: 12/16/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Angela Lopez-Bauza
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, España; Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, España
| | - Luis Jara-Palomares
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, España; Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/CSIC/Universidad de Sevilla, España; CIBERES, Instituto de Salud Carlos III, Madrid, España.
| |
Collapse
|
12
|
Hemorrhagic shock necessitating resuscitation and damage control surgery after needle biopsy: A report of two cases. Trauma Case Rep 2020; 31:100389. [PMID: 33385057 PMCID: PMC7770969 DOI: 10.1016/j.tcr.2020.100389] [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] [Accepted: 12/06/2020] [Indexed: 11/21/2022] Open
Abstract
Percutaneous needle biopsy is minimally invasive and widely performed. Bleeding is an important complication of needle biopsy. Because the wound created by the needle is small, the recognition of bleeding in the body may be delayed, and this delay can lead to hemorrhagic shock and death. We report two cases of hemorrhagic shock in which the trauma triad of death developed after needle biopsy and the patients required resuscitation and damage control surgery. Needle biopsy is less invasive but cannot stop bleeding, and so surgery should be considered to ensure hemostasis in a compromised patient.
Collapse
|
13
|
Dong Y, Wang Y, Ma RL, Liu M, Gao JZ, Su WY, Yan L, Sun JJ. Efficacy and safety of direct oral anticoagulants versus low-molecular-weight heparin in patients with cancer: a systematic review and meta-analysis. J Thromb Thrombolysis 2020; 48:400-412. [PMID: 31062143 DOI: 10.1007/s11239-019-01871-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The efficacy and safety of direct oral anticoagulants (DOACs) versus low-molecular-weight heparin (LMWH) are still debated in the treatment of patients with cancer, and the optimal duration of therapy remains uncertain. Electronic databases (PubMed, Embase, and Cochrane Library) were searched to retrieve studies on the efficacy and safety of DOACs versus LMWH in treating patients with cancer from January 1980 to October 2018. The primary efficacy and safety endpoints were recurrent venous thromboembolism (VTE) and major bleeding. Our study included two randomized controlled trials (RCTs) and nine observational studies, together comprising 4509 patients with cancer. The pooled estimates indicated that DOACs led to a modest reduction recurrent VTE in the RCTs [RR: 0.63, 95% confidence interval (CI), 0.42-0.96, P = 0.03] and in the observational studies (RR: 0.74, 95% CI, 0.58-0.93, P = 0.011), without increasing the risk of major bleeding for observational studies (P = 0.805), but increased for RCTs (P = 0.017). The same trends were observed in the rivaroxaban subgroup. Moreover, subgroup analyses according to the treatment duration indicated that DOACs significantly reduced the incidence of recurrent VTE (P = 0.006 at 6 months; P < 0.001 at 12 months) without significant differences in major bleeding compared with LMWH at 6 or 12 months. Patients with cancer who received DOACs exhibited a significant reduction in recurrent VTE with no increased risk of major bleeding compared with LMWH. DOACs may be an alternative choice for long-term anticoagulant therapy in patients with cancer.
Collapse
Affiliation(s)
- Ying Dong
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, No. 1, Tong Dao North Street, Inner Mongolia, Hohhot, 010050, People's Republic of China
| | - Yi Wang
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, No. 1, Tong Dao North Street, Inner Mongolia, Hohhot, 010050, People's Republic of China
| | - Rui-Lian Ma
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, No. 1, Tong Dao North Street, Inner Mongolia, Hohhot, 010050, People's Republic of China
| | - Ming Liu
- Department of Breast Surgery, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, People's Republic of China
| | - Jun-Zhen Gao
- Department of Respiratory Medicine, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, People's Republic of China
| | - Wu-Yun Su
- Department of Medical Oncology, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, People's Republic of China
| | - Li Yan
- Department of Respiratory Medicine, Affiliated Hospital of Inner Mongolia Medical University, Hohhot, People's Republic of China
| | - Jian-Jun Sun
- Department of Pharmacy, Affiliated Hospital of Inner Mongolia Medical University, No. 1, Tong Dao North Street, Inner Mongolia, Hohhot, 010050, People's Republic of China.
| |
Collapse
|
14
|
Khan Y, Zaidi SO, Razak BS, Zaki M, Malik BH. Use of New Oral Anticoagulants / Direct Oral Anticoagulants in Malignant Patients. Cureus 2020; 12:e7007. [PMID: 32206471 PMCID: PMC7077741 DOI: 10.7759/cureus.7007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 02/16/2020] [Indexed: 12/13/2022] Open
Abstract
Vitamin K antagonists are being used in the last five decades as an effective anticoagulant. However, for the past few years, new oral anticoagulants (NOACs) have been introduced as newer anticoagulant agents, which are gradually replacing the previously used vitamin K antagonist. Yet, these agents have not fully replaced the use of warfarin and heparin. NOACs have few advantages over the vitamin K antagonist as they act on a specific factor of coagulation cascade rather than inhibiting the whole vitamin K synthesis. In this article, all the data has been searched electronically on PubMed and PRISMA guidelines were not followed. Instead, we used MOOSE statements and the data searched on PubMed was from articles published in the last five years. A total of 12,269 patients were observed;,out of which 64.19% had active cancer and 35.80% was observed as a control group comprised of both male or female participants. Approximately 61.14% were using NOACs, 42.83% were on warfarin, and 2.72% were on low-molecular-weight heparin (LMWH). The NOACs used in different patients were in the following percentages; edoxaban (6.81%), apixaban (5.28%), dabigatran (10.09%), and rivaroxaban (10.02%). The use of NOACs has been increasing day by day but these agents have not completely replaced the warfarin or heparin, because of some demerits associated with the use of warfarin and some conditions where these drugs should be avoided. All NOACs have either hepatic or renal clearance so the hepatic activity and creatinine clearance rate must be monitored before the start of NOACs. The drug interaction between anticancer drugs and NOACs is still not fully reported. The effects of NOACs in AF and VTE are therapeutically effective, but in oncology patients several other co-factors are also involved with the use of NOACs due to which, it is either contraindicated or in some cases dose adjustment is required. However, very little information has been collected and more investigation must be done in this perspective.
Collapse
Affiliation(s)
- Yusra Khan
- Pharmacy, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Syed Owais Zaidi
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bibi S Razak
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mariann Zaki
- Family Medicine, Nova Southeastern University School of Osteopathic Medicine, Sarasota, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| |
Collapse
|
15
|
Sorigue M, Cañamero E, Siguenza P, Nomdedeu M, López-Núñez JJ. Recent developments and persisting challenges in the prevention and treatment of venous thromboembolism in patients with hematological malignancies. Leuk Lymphoma 2020; 61:1277-1291. [DOI: 10.1080/10428194.2020.1713321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Marc Sorigue
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Eloi Cañamero
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Patricia Siguenza
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
| | - Meritxell Nomdedeu
- Laboratory of Hematology, ICO-Hospital Germans Trias i Pujol, IJC, UAB, Badalona, Spain
| | - Juan J. López-Núñez
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
| |
Collapse
|
16
|
Li X, Partovi S, Gadani S, Martin C, Beck A, Vedantham S. Gastrointestinal Malignancies and Venous Thromboembolic Disease: Clinical Significance and Endovascular Interventions. ACTA ACUST UNITED AC 2020; 4:260-266. [PMID: 34296054 DOI: 10.1055/s-0040-1716739] [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: 10/23/2022]
Abstract
Gastrointestinal malignancy encompasses a wide range of disease processes. Its incidence and mortality rate rank among the highest of all cancers. Venous thromboembolic disease is a common complication of gastrointestinal malignancy. Anticoagulation remains the first-line therapy. However, for patients who cannot tolerate or have failed anticoagulation, inferior vena cava (IVC) filter placement may be an option. Furthermore, to improve symptom resolution and reduce the severity of postthrombotic syndrome, catheter-directed thrombolysis (CDT) may be an option. Recent randomized trials including the ATTRACT (Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis) trial have shed new light on the efficacy and safety of CDT and related methods. Overall, the decision to proceed with IVC filter placement or CDT must be individualized.
Collapse
Affiliation(s)
- Xin Li
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Sasan Partovi
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Sameer Gadani
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Charles Martin
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Avi Beck
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic Main Campus, Cleveland, Ohio
| | - Suresh Vedantham
- Section of Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
17
|
Al‐Samkari H, Song AB, Connors JM. Cancer‐associated thrombosis: Where do we stand? ACTA ACUST UNITED AC 2019. [DOI: 10.1002/acg2.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Hanny Al‐Samkari
- Division of Hematology Massachusetts General Hospital, Harvard Medical School Boston MA USA
| | - Andrew B. Song
- Division of Hematology Massachusetts General Hospital, Harvard Medical School Boston MA USA
| | - Jean M. Connors
- Division of Hematology Brigham and Women’s Hospital, Harvard Medical School Boston MA USA
| |
Collapse
|
18
|
Song AB, Rosovsky RP, Connors JM, Al-Samkari H. Direct oral anticoagulants for treatment and prevention of venous thromboembolism in cancer patients. Vasc Health Risk Manag 2019; 15:175-186. [PMID: 31417269 PMCID: PMC6593743 DOI: 10.2147/vhrm.s132556] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/05/2019] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE) is a common cause of morbidity and mortality in patients with cancer. Compared with the general population, cancer patients with VTE have higher rates of both VTE recurrence and bleeding. While low molecular weight heparin (LMWH) has been the mainstay of treatment for cancer-associated VTE for over a decade, direct oral anticoagulants (DOACs) have recently emerged as a new therapeutic option due to their ease of administration and because they do not require laboratory monitoring. Several large randomized clinical trials have been performed or are ongoing at the time of writing, comparing DOACs with LMWH in this population. Three of these trials have thus far been published and suggest that DOACs are a reasonable alternative to LMWH for management of cancer-associated VTE. Despite the advantages offered by DOACs, these agents may not be appropriate for certain patient groups owing to increased risk of bleeding, organ compromise, extremes of weight, and other issues. Finally, data are emerging suggesting that DOACs may be useful for primary thromboprophylaxis in cancer patients in conjunction with validated risk assessment scores. In this evidence-based review, data for the use of DOACs to treat cancer-associated VTE will be examined, focusing on efficacy, safety, and timing of treatment. Guidance on choosing the optimal anticoagulant for a given patient is also offered.
Collapse
Affiliation(s)
- Andrew B Song
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel P Rosovsky
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|