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Thromboembolic events and thromboprophylaxis associated with immunomodulators in multiple myeloma patients: a real-life study. J Cancer Res Clin Oncol 2021; 148:975-984. [PMID: 34143239 DOI: 10.1007/s00432-021-03693-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/09/2021] [Indexed: 01/06/2023]
Abstract
PURPOSE The aim of this study is to assess international guidelines implementation concerning thromboprophylaxis strategy in myeloma patients treated with immunomodulatory drugs. METHODS This retrospective study includes multiple myeloma patients treated with immunomodulatory drugs between 2014 and 2017 in the Hematology department of a teaching hospital (Hospices Civils de Lyon, France) and followed by the multidisciplinary care plan for cancer outpatients ONCORAL (ONCological care for outpatients with ORAL anticancer drugs). Data from immunomodulatory drugs administration, thromboprophylaxis strategy and thrombotic events were collected from medical files. Adherence to 2010 International Myeloma Working Group (IMWG) guidelines was assessed. RESULTS 213 patients received at least one immunomodulatory drug: lenalidomide (60.9%), pomalidomide (24.0%) and thalidomide (15.1%). About two third of treatment lines (66.2%) were in accordance with IMWG recommendations. Among the others, 30.5% and 69.5% had thromboprophylaxis, respectively, superior or inferior to IMWG recommendations. 37 venous thrombotic events and 4 arterial thromboembolisms (one patient experienced both a stroke and deep venous thrombosis simultaneously) were reported. CONCLUSION Thromboprophylaxis was systematically performed in myeloma patients treated with immunomodulatory drugs in this real-life retrospective cohort. However, the choice of anticoagulant or anti-platelet agent remains debatable, as adherence to existing guidelines was variable.
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Schoen MW, Carson KR, Luo S, Gage BF, Li A, Afzal A, Sanfilippo KM. Venous thromboembolism in multiple myeloma is associated with increased mortality. Res Pract Thromb Haemost 2020; 4:1203-1210. [PMID: 33134785 PMCID: PMC7590313 DOI: 10.1002/rth2.12411] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/29/2020] [Accepted: 06/05/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In multiple myeloma, venous thromboembolism (VTE) is common, and treatments for myeloma, such as lenalidomide, increase the risk of thrombosis while improving survival. The association between VTE and survival is not well known. OBJECTIVES To determine the association between VTE and survival in multiple myeloma (MM) while adjusting for known confounders that affect risk of thrombosis and survival, including patient characteristics and treatment in a retrospective cohort of US veterans. PATIENTS/METHODS A cohort of patients with newly diagnosed MM treated within Veterans Health Administration between September 1, 1999, and June 30, 2014, was created to assess the association between VTE and mortality using Cox proportional hazards regression modeling while accounting for known prognostic factors and treatments. RESULTS The cohort comprised 4446 patients with myeloma, including 2837 patients diagnosed after lenalidomide approval in July 2006. VTE occurred in 327 (7.4%) patients within 1 year and occurred at a median of 77 days (interquartile range, 37-153) after starting therapy for MM. In all patients, VTE was associated with increased mortality at 6 months (adjusted hazard ratio [aHR], 1.67; 95% confidence interval [CI], 1.18-2.37). Patients in the post-lenalidomide cohort with VTE had an increased mortality at both 6 months (aHR, 2.31; 95% CI, 1.52-3.51) and 12 months (aHR, 1.66; 95% CI, 1.19-2.33) after treatment initiation. DISCUSSION This study shows that VTE during the first 6-12 months of therapy is associated with increased mortality in patients with MM. Studies evaluating thromboprophylaxis in patients at high risk of thrombosis are needed.
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Affiliation(s)
- Martin W. Schoen
- Division of Hematology and OncologySaint Louis University School of MedicineSaint LouisMOUSA
- Saint Louis Veterans Affairs Medical CenterSaint LouisMOUSA
| | | | - Suhong Luo
- Saint Louis Veterans Affairs Medical CenterSaint LouisMOUSA
| | - Brian F. Gage
- Division of General Medical SciencesWashington University School of MedicineSaint LouisMOUSA
| | - Ang Li
- Section of Hematology‐OncologyBaylor College of MedicineSeattleWAUSA
| | - Amber Afzal
- Division of HematologyWashington University School of MedicineSaint LouisMOUSA
| | - Kristen M. Sanfilippo
- Saint Louis Veterans Affairs Medical CenterSaint LouisMOUSA
- Division of HematologyWashington University School of MedicineSaint LouisMOUSA
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Zoppellaro G, Veronese N, Granziera S, Gobbi L, Stubbs B, Cohen AT. Primary thromboembolic prevention in multiple myeloma patients: An exploratory meta-analysis on aspirin use. Semin Hematol 2018; 55:182-184. [DOI: 10.1053/j.seminhematol.2017.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/18/2017] [Accepted: 08/05/2017] [Indexed: 12/22/2022]
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Palmaro A, Rougé-Bugat ME, Gauthier M, Despas F, Moulis G, Lapeyre-Mestre M. Real-life practices for preventing venous thromboembolism in multiple myeloma patients: a cohort study from the French health insurance database. Pharmacoepidemiol Drug Saf 2017; 26:578-586. [PMID: 28198064 DOI: 10.1002/pds.4180] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 12/12/2016] [Accepted: 01/19/2017] [Indexed: 12/28/2022]
Abstract
PURPOSE The risk of venous thromboembolic event (VTE) in multiple myeloma is particularly increased. Current guidelines recommend systematic VTE prophylaxis with vitamin K antagonists (VKA) or low weight molecular heparin (LWMH) or unfractionated heparin (UFH) in high-risk patients, based on treatment received [e.g. use of IMiDs (thalidomide, lenalidomide and pomalidomide), alkylating agents or erythropoietin] and individual risk factors (e.g. history of VTE). The aim of this study was to describe strategy of VTE prophylaxis and prescribing of other antithrombotic agents during the first 6 months of multiple myeloma therapy, with stratification on IMiD-based regimens and drug and disease-related risk factors. METHODS A retrospective cohort study of French beneficiaries from the health insurance database (SNIIRAM, Système National d'Information Inter-Régime de l'Assurance Maladie) was designed in the Midi-Pyrénées area (South West France). Patients starting a treatment for multiple myeloma in the period 2011-2014 were identified through hospital and chronic disease diagnoses. RESULTS Among the 236 incident multiple myeloma patients, 56% male (n = 133), 67% >65 years (n = 159) and 47% (n = 110) patients received an IMiD-based regimen. In these patients, 63% (n = 69) were identified as high-risk patients with indication for low molecular weight heparin or equivalent, and 37% (n = 41) were identified as low-risk with aspirin recommended. Among the high-risk IMiDs patients, 43% (30/69) currently received a VTE prophylaxis after starting their first regimen: 70% LWMH (21/30), 40% VKA (12/30), 10% UFH (3/30) and 13% (4/30) other drugs (rivaroxaban and fondaparinux); 33% of the patients (23/69) received an antiplatelet drug only, and 23% (16/69) did not receive any antithrombotic drug. CONCLUSIONS These results revealed lack of implementation of VTE prophylaxis in one out of high-risk multiple myeloma patients with IMiD. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Aurore Palmaro
- Medical and Clinical Pharmacology department, Toulouse University Hospital, Toulouse, France.,UMR INSERM 1027, University of Toulouse, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Marie-Eve Rougé-Bugat
- UMR INSERM 1027, University of Toulouse, Toulouse, France.,Academic Department of Family Medicine, Faculty of Medicine Toulouse, University of Toulouse, Toulouse, France
| | - Martin Gauthier
- Department of Haematology, Toulouse University Hospital, Toulouse, France
| | - Fabien Despas
- Medical and Clinical Pharmacology department, Toulouse University Hospital, Toulouse, France.,UMR INSERM 1027, University of Toulouse, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
| | - Guillaume Moulis
- Medical and Clinical Pharmacology department, Toulouse University Hospital, Toulouse, France.,UMR INSERM 1027, University of Toulouse, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France.,Department of Internal Medicine, Toulouse University Hospital, Toulouse, France
| | - Maryse Lapeyre-Mestre
- Medical and Clinical Pharmacology department, Toulouse University Hospital, Toulouse, France.,UMR INSERM 1027, University of Toulouse, Toulouse, France.,CIC 1436, Toulouse University Hospital, Toulouse, France
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Ding JH, Yuan LY, Huang RB, Chen GA. Aspirin inhibits proliferation and induces apoptosis of multiple myeloma cells through regulation of Bcl-2 and Bax and suppression of VEGF. Eur J Haematol 2014; 93:329-39. [PMID: 24766194 DOI: 10.1111/ejh.12352] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Aspirin (ASA) has been frequently used for thromboprophylaxis in patients with multiple myeloma (MM) when treated with thalidomide or lenalidomide. Despite the well-recognized chemopreventive role of ASA in some solid tumors particularly for colon cancer, whether ASA displays the antimyeloma activity remains unclear. METHODS MM1.S and RPMI-8226 cell lines harboring K-Ras and N-Ras mutation, respectively, were treated with various concentrations of ASA for different hours. The cell proliferation and apoptosis were performed to explore the effects of ASA on myeloma. Then, the exact mechanisms governing ASA's antimyeloma were explored by qRT-PCR and Western blot. Also, the effect of ASA on tumor growth was observed in NOD/SCID mice bearing myeloma xenografts. RESULTS ASA of 0-10 mm concentration inhibits proliferation MM1.S and RPMI-8226 cells in time- and dose-dependent manner. The myeloma cells exposed to ASA treatment displayed concentration-dependent apoptosis, which was closely associated with activation of caspases, upregulation of Bax, and downregulation of Bcl-2 and VEGF. Study in vivo revealed that ASA administration retarded the tumor growth accompanying the survival time of mice bearing myeloma xenografts. CONCLUSIONS ASA exerted antiproliferative and pro-apoptotic action in myeloma cells in vitro and delayed the growth of human myeloma cells in vivo. The underlying mechanisms were ascribed to regulation of Bcl-2 and Bax and suppression of VEGF.
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Affiliation(s)
- Jiang-Hua Ding
- Hematology Department, the 1st Affiliated Hospital of Nanchang University, Nanchang, China
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Alexander M, Kirsa S, MacManus M, Ball D, Solomon B, Burbury K. Thromboprophylaxis for lung cancer patients--multimodality assessment of clinician practices, perceptions and decision support tools. Support Care Cancer 2014; 22:1915-22. [PMID: 24573603 DOI: 10.1007/s00520-014-2170-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/10/2014] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to report the opinions and self-reported practices of clinicians, as well as the availability of decision support tools, regarding appropriate thromboprophylaxis for patients with lung cancer to identify variation in practice and/or divergence from evidence-based clinical practice guidelines (CPG). METHODS A computer-generated survey (SurveyMonkey software) was distributed to surgical, radiation and medical oncologists with lung cancer specialisation, via membership of the Australian Lung Cancer Trials Group (ALTG) from May to September 2013. RESULTS Seventy-two clinicians, from public, private, specialist and general hospitals, completed the survey (46% response rate). Hospital-endorsed CPG were widely available (91%); however, these routinely lacked robust recommendations for the ambulatory care setting (98%) and risk stratification tools (65%). Clinicians consistently identified ambulatory care treatment modalities (chemotherapy, alone or in combination with radiotherapy) as having similar (high) thrombotic risk as surgery. Timing and duration of pharmacological thromboprophylaxis prescribing among surgical oncologists varied and were divergent from guideline recommendations. Fifty-eight percent of surveyed clinicians cited a lack of high-quality data to guide preventative strategies in lung cancer patients. CONCLUSION Clinicians consistently identified patients with lung cancer as having a high thromboembolic risk in both ambulatory and surgical settings, but with differences in recommendations and variation in practice. CPG lacked robust recommendations for the ambulatory care setting, the main arena for the multimodality lung cancer treatment paradigm.
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Affiliation(s)
- M Alexander
- Pharmacy Department, Peter MacCallum Cancer Centre, Locked Bag 1 A'Beckett Street, Melbourne, VIC, 8006, Australia,
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