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Laporte S, Benhamou Y, Bertoletti L, Frère C, Hanon O, Couturaud F, Moustafa F, Mismetti P, Sanchez O, Mahé I. [Translation into French and republication of: "Management of cancer-associated thromboembolism in vulnerable population"]. Rev Med Interne 2024; 45:366-381. [PMID: 38789323 DOI: 10.1016/j.revmed.2024.05.019] [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: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 05/26/2024]
Abstract
Although all patients with cancer-associated thrombosis (CAT) have a high morbidity and mortality risk, certain groups of patients are particularly vulnerable. This may expose the patient to an increased risk of thrombotic recurrence or bleeding (or both), as the benefit-risk ratio of anticoagulant treatment may be modified. Treatment thus needs to be chosen with care. Such vulnerable groups include older patients, patients with renal impairment or thrombocytopenia, and underweight and obese patients. However, these patient groups are poorly represented in clinical trials, limiting the available data on which treatment decisions can be based. Meta-analysis of data from randomised clinical trials suggests that the relative treatment effect of direct oral factor Xa inhibitors (DXIs) and low molecular weight heparin (LMWH) with respect to major bleeding could be affected by advanced age. No evidence was obtained for a change in the relative risk-benefit profile of DXIs compared to LMWH in patients with renal impairment or of low body weight. The available, albeit limited, data do not support restricting the use of DXIs in patients with TAC on the basis of renal impairment or low body weight. In older patients, age is not itself a critical factor for choice of treatment, but frailty is such a factor. Patients over 70 years of age with CAT should undergo a systematic frailty evaluation before choosing treatment and modifiable bleeding risk factors should be addressed. In patients with renal impairment, creatine clearance should be assessed and monitored regularly thereafter. In patients with an eGFR less than 30mL/min/1.72m2, the anticoagulant treatment may need to be adapted. Similarly, platelet count should be assessed prior to treatment and monitored regularly. In patients with grade 3-4, thrombocytopenia (less than 50,000platelets/μL) treatment with a LMWH at a reduced dose should be considered. For patients with CAT and low body weight, standard anticoagulant treatment recommendations are appropriate, whereas in obese patients, apixaban may be preferred.
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Affiliation(s)
- S Laporte
- Unité de recherche clinique, innovation et pharmacologie, hôpital Nord, CHU de Saint-Étienne, Sainbiose Inserm, université Jean-Monnet, 42000 Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Y Benhamou
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine interne, CHU Charles-Nicolle, université de Rouen Normandie, Inserm U1096, Normandie université, Rouen, France
| | - L Bertoletti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, équipe dysfonction vasculaire et hémostase, CHU de Saint-Étienne, Inserm UMR1059, université Jean-Monnet, Inserm CIC-1408, Saint-Étienne, France
| | - C Frère
- Inserm UMRS 1166, GRC 27 Greco, DMU BioGeMH, hôpital de la Pitié-Salpêtrière, Assistance publique-Hôpitaux de Paris, Sorbonne université, Paris, France
| | - O Hanon
- Service de gérontologie, hôpital Broca, AP-HP, EA 4468, université de Paris Cité, Paris, France
| | - F Couturaud
- F-CRIN INNOVTE network, Saint-Étienne, France; Département de médecine interne, médecine vasculaire et pneumologie, CHU de Brest, Inserm U1304-Getbo, université de Brest, Brest, France
| | - F Moustafa
- F-CRIN INNOVTE network, Saint-Étienne, France; Département urgence, Inrae, UNH, hôpital de Clermont-Ferrand, université Clermont-Auvergne, Clermont-Ferrand, France
| | - P Mismetti
- F-CRIN INNOVTE network, Saint-Étienne, France; Service de médecine vasculaire et thérapeutique, hôpital Nord, CHU de Saint-Étienne, Saint-Étienne, France
| | - O Sanchez
- F-CRIN INNOVTE network, Saint-Étienne, France; Innovations thérapeutiques en hémostase, université Paris Cité, Inserm UMR S1140, Paris, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France
| | - I Mahé
- F-CRIN INNOVTE network, Saint-Étienne, France; Innovations thérapeutiques en hémostase, université Paris Cité, Inserm UMR S1140, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France
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Laporte S, Benhamou Y, Bertoletti L, Frère C, Hanon O, Couturaud F, Moustafa F, Mismetti P, Sanchez O, Mahé I. Management of cancer-associated thromboembolism in vulnerable population. Arch Cardiovasc Dis 2024; 117:45-59. [PMID: 38065754 DOI: 10.1016/j.acvd.2023.11.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/17/2023] [Indexed: 12/27/2023]
Abstract
Although all patients with cancer-associated thrombosis (CAT) have a high morbidity and mortality risk, certain groups of patients are particularly vulnerable. This may expose the patient to an increased risk of thrombotic recurrence or bleeding (or both), as the benefit-risk ratio of anticoagulant treatment may be modified. Treatment thus needs to be chosen with care. Such vulnerable groups include older patients, patients with renal impairment or thrombocytopenia, and underweight and obese patients. However, these patient groups are poorly represented in clinical trials, limiting the available data, on which treatment decisions can be based. Meta-analysis of data from randomised clinical trials suggests that the relative treatment effect of direct oral factor Xa inhibitors (DXIs) and low molecular weight heparin (LMWH) with respect to major bleeding could be affected by advanced age. No evidence was obtained for a change in the relative risk-benefit profile of DXIs compared to LMWH in patients with renal impairment or of low body weight. The available, albeit limited, data do not support restricting the use of DXIs in patients with CAT on the basis of renal impairment or low body weight. In older patients, age is not itself a critical factor for choice of treatment, but frailty is such a factor. Patients over 70 years of age with CAT should undergo a systematic frailty evaluation before choosing treatment and modifiable bleeding risk factors should be addressed. In patients with renal impairment, creatine clearance should be assessed and monitored regularly thereafter. In patients with an eGFR<30mL/min/1.72m2, the anticoagulant treatment may need to be adapted. Similarly, platelet count should be assessed prior to treatment and monitored regularly. In patients with grade 3-4, thrombocytopenia (<50,000 platelets/μL) treatment with a LMWH at a reduced dose should be considered. For patients with CAT and low body weight, standard anticoagulant treatment recommendations are appropriate, whereas in obese patients, apixaban may be preferred.
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Affiliation(s)
- Silvy Laporte
- SAINBIOSE Inserm, unité de recherche clinique, innovation et pharmacologie, hôpital Nord, université Jean-Monnet, CHU de Saint-Étienne, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France.
| | - Ygal Benhamou
- UNI Rouen U1096, service de médecine interne, Normandie université, CHU Charles-Nicolle, Rouen, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Laurent Bertoletti
- Service de médecine vasculaire et thérapeutique, CHU de Saint-Étienne, INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, INSERM, CIC-1408, CHU Saint-Étienne, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Corinne Frère
- Inserm UMRS 1166, GRC 27 GRECO, DMU BioGeMH, hôpital de la Pitié-Salpêtrière, Sorbonne université, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Olivier Hanon
- Service de Gérontologie, hôpital Broca, AP-HP, EA 4468, Université de Paris Cité, Paris, France
| | - Francis Couturaud
- Inserm U1304 - GETBO, département de médecine interne, médecine vasculaire et pneumologie, université de Brest, CHU de Brest, Brest, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Farès Moustafa
- Inrae, UNH, département urgence, hôpital de Clermont-Ferrand, université Clermont Auvergne, Clermont-Ferrand, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU Saint-Etienne, Hôpital Nord, Saint-Étienne, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Olivier Sanchez
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de pneumologie et de soins intensifs, hôpital européen Georges-Pompidou, AP-HP, Paris, France; F-CRIN INNOVTE network, Saint-Étienne, France
| | - Isabelle Mahé
- Université Paris Cité, Inserm UMR S1140, innovations thérapeutiques en hémostase, Paris, France; Service de médecine interne, hôpital Louis-Mourier, AP-HP, Colombes, France; F-CRIN INNOVTE network, Saint-Étienne, France
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Napolitano M, Siragusa S. The Role of Injectables in the Treatment and Prevention of Cancer-Associated Thrombosis. Cancers (Basel) 2023; 15:4640. [PMID: 37760609 PMCID: PMC10526875 DOI: 10.3390/cancers15184640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/05/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Cancer-associated thrombosis (CAT) is a leading cause of death among patients with cancer. CAT can manifest itself as venous thromboembolism (VTE), in the form of deep vein thrombosis or pulmonary embolism, or arterial thromboembolism. The pathophysiology of CAT is complex and depends on cancer-, patient-, treatment- and biomarkers-related factors. Treatment of VTE in patients with cancer is complex and includes three major classes of anticoagulant agents: heparin and its derivatives, e.g., low molecular weight heparins, direct oral anticoagulants (DOACs), and vitamin K inhibitors. Given the tremendous heterogeneity of clinical situations in patients with cancer and the challenges of CAT, there is no single universal treatment option for patients suffering from or at risk of CAT. Initial studies suggested that patients seemed to prefer an anticoagulant that would not interfere with their cancer treatment, suggesting the primacy of cancer over VTE, and favoring efficacy and safety over convenience of route of administration. Recent studies show that when the efficacy and safety aspects are similar, patients prefer the oral route of administration. Despite this, injectables are a valid option for many patients with cancer.
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Affiliation(s)
- Mariasanta Napolitano
- Haematology Unit, Thrombosis and Haemostasis Reference Regional Center, University of Palermo, 90121 Palermo, Italy;
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A systematic review of the efficacy and safety of anticoagulants in advanced chronic kidney disease. J Nephrol 2022; 35:2015-2033. [PMID: 36006608 PMCID: PMC9584987 DOI: 10.1007/s40620-022-01413-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/19/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have an increased risk of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulants have not been studied in randomised controlled trials with CrCl < 30 ml/min. The objective of this review was to identify the impact of different anticoagulant strategies in patients with advanced CKD including dialysis. METHODS We conducted a systematic review of randomized controlled trials and cohort studies, searching electronic databases from 1946 to 2022. Studies that evaluated both thrombotic and bleeding outcomes with anticoagulant use in CrCl < 50 ml/min were included. RESULTS Our initial search yielded 14,503 papers with 53 suitable for inclusion. RCTs comparing direct oral anticoagulants (DOACs) versus warfarin for patients with VTE and CrCl 30-50 ml/min found no difference in recurrent VTE events (RR 0.68(95% CI 0.42-1.11)) with reduced bleeding (RR 0.65 (95% CI 0.45-0.94)). Observational data in haemodialysis suggest lower risk of recurrent VTE and major bleeding with apixaban versus warfarin. Very few studies examining outcomes were available for therapeutic and prophylactic dose low molecular weight heparin for CrCl < 30 ml/min. Findings for patients with AF on dialysis were that warfarin or DOACs had a similar or higher risk of stroke compared to no anticoagulation. For patients with AF and CrCl < 30 ml/min not on dialysis, anticoagulation should be considered on an individual basis, with limited studies suggesting DOACs may have a preferable safety profile. CONCLUSION Further studies are still required, some ongoing, in patients with advanced CKD (CrCl < 30 ml/min) to identify the safest and most effective treatment options for VTE and AF.
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Pulmonary Embolism in the Cancer Associated Thrombosis Landscape. J Clin Med 2022; 11:jcm11195650. [PMID: 36233519 PMCID: PMC9570910 DOI: 10.3390/jcm11195650] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/11/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022] Open
Abstract
In cancer patients, pulmonary embolism (PE) is the second leading cause of death after the cancer itself, most likely because of difficulties in diagnosing the disease due to its nonclassical presentation. The risk of PE recurrence and possibly the case-fatality rate depends on whether the patient presents a symptomatic PE, an unsuspected PE, a subsegmental PE, or a catheter-related PE. Choosing the best therapeutic option is challenging and should consider the risk of both the recurrence of thrombosis and the occurrence of bleeding. The purpose of this review is to provide an overview of the clinical characteristics and the treatment of cancer-associated PE, which could benefit clinicians to better manage the deadliest form of thrombosis associated with cancer. After a brief presentation of the epidemiological data, we will present the current attitude towards the diagnosis and the management of cancer patients with PE. Finally, we will discuss the perspectives of how the medical community can improve the management of this severe medical condition.
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Messi M, Beneyto Afonso C, Stalder O, Méan M, Righini M, Rodondi N, Aujesky D. Long-term clinical outcomes in older patients with acute venous thromboembolism who have renal impairment. Thromb Res 2022; 218:64-71. [PMID: 35994838 DOI: 10.1016/j.thromres.2022.08.001] [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: 04/08/2022] [Revised: 07/27/2022] [Accepted: 08/02/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Renal impairment (RI) may induce an inflammatory/procoagulant state as well as platelet dysfunction. Little is known on the prevalence of RI and long-term prognosis of older patients with venous thromboembolism (VTE) who have concomitant RI. METHODS In a prospective multicenter cohort, we analyzed 912 patients aged ≥65 years with acute VTE. Using the CKD-EPI formula, we defined three categories of baseline renal function: estimated glomerular filtration rate ≥60 ml/min/1.73m2 (no RI), 30-59 ml/min/1.73m2 (moderate RI), and <30 ml/min/1.73m2 (severe RI). The outcomes were VTE recurrence, major bleeding, and overall mortality. We examined the association between renal function and clinical outcomes using competing risk regression models, adjusting for relevant confounders and periods of anticoagulation. RESULTS We followed 912 patients over a median duration of 29.6 months. Overall, 313 (34%) patients had moderate and 51 (6%) severe RI. One hundred and seven patients (12%) had VTE recurrence, 125 (14%) had major bleeding, and 186 (20%) died during follow-up. After adjustment, severe RI was associated with a 2-fold increased risk of major bleeding (sub-hazard ratio [SHR] 2.1, 95% CI 1.1-4.0) compared to no RI, but not with VTE recurrence (SHR 0.6, 95% CI 0.2-1.8) or overall mortality (hazard ratio 1.0, 95% CI 0.6-1.9). Moderate RI was not significantly associated with adverse clinical outcomes. CONCLUSIONS RI was common among older patients with acute VTE. Severe RI was associated with a 2-fold increased long-term risk of major bleeding, without a risk increase in terms of VTE recurrence and overall mortality. Older patients with moderate RI did not carry worse prognosis.
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Affiliation(s)
- Mia Messi
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Freiburgstrasse 18, 3010 Bern, Bern, Switzerland.
| | - Carlota Beneyto Afonso
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Freiburgstrasse 18, 3010 Bern, Bern, Switzerland.
| | - Odile Stalder
- CTU Bern, University of Bern, Mittelstrasse 43, 3012 Bern, Bern, Switzerland.
| | - Marie Méan
- Department of General Internal Medicine, Lausanne University Hospital, Rue du Bugnon 46, 1011 Lausanne, Vaud, Switzerland.
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospital and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Geneva, Switzerland.
| | - Nicolas Rodondi
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Freiburgstrasse 18, 3010 Bern, Bern, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Mittelstrasse 43, 3012 Bern, Bern, Switzerland.
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital and University of Bern, Freiburgstrasse 18, 3010 Bern, Bern, Switzerland.
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Treatment of venous thromboembolism in cancer patients: The dark side of the moon. Cancer Treat Rev 2021; 96:102190. [PMID: 33812338 DOI: 10.1016/j.ctrv.2021.102190] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 02/08/2023]
Abstract
Venous thromboembolism (VTE) is a common complication in patients with cancer. The risk of emergent VTE is four- to seven-fold higher in cancer patients compared to non-cancer patients. Although the therapeutic armamentarium for cancer-associated VTE has been recently implemented, anticoagulant treatment remains challenging because of the increased risk of recurrent VTE and bleeding. Several international societies and expert panels released clinical practice guidelines on VTE treatment which are mostly focused on the general cancer population. Nevertheless, recommendations for the management of VTE in patients with peculiar clinical presentations are inconsistent and remain elusive due to the lack of pertinent evidence. The challenging clinical scenarios include, among others, patients with thrombocytopenia, renal impairment, gastrointestinal cancer, primary or metastatic brain cancer, distal thrombosis of the lower extremities, catheter-related VTE, splanchnic thrombosis, incidental VTE, extreme body weight, recurrent VTE during treatment, as well as the optimal duration of anticoagulant treatment in patients with active disease who have received 3 to 6 months of anticoagulation. Herein, we present a critical overview on VTE management in these challenging clinical settings, discuss potential approaches, and include some calls to action for future clinical research.
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Catella J, Bertoletti L, Mismetti P, Ollier E, Samperiz A, Soler S, Suriñach JM, Mahé I, Lorente MA, Braester A, Monreal M. Severe renal impairment and risk of bleeding during anticoagulation for venous thromboembolism. J Thromb Haemost 2020; 18:1728-1737. [PMID: 32299150 DOI: 10.1111/jth.14837] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 08/31/2023]
Abstract
BACKGROUND Detection of severe renal impairment in patients with venous thromboembolism (VTE) is mandatory both for selecting anticoagulant therapy and for evaluating major bleeding risk, increased by severe renal impairment. OBJECTIVES To determine whether the Cockcroft and Gault (CG) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas identify severe renal impairment in the same VTE patients presenting the same risk of major bleeding. PATIENTS/METHODS We compared clinical characteristics and outcomes during the first 3 months of anticoagulation between VTE patients in the RIETE registry with severe renal impairment according to the CG and/or CKD-EPI formula (estimated glomerular filtration rate <30 mL/min and <30 mL/min/1.73 m2 , respectively). The primary outcome was major bleeding. RESULTS Up to October 2017, 41 796 patients were included in RIETE. Among the 4676 patients with severe renal impairment according to at least one of the formulas, this was not confirmed by the other formula in 1904 (40.7%). Major bleeding risk was increased in every patient subgroup with severe renal impairment vs patients without this condition (CG or CKD-EPI < 30: odds ratio [OR] = 2.26, 95% confidence interval [CI 2.01-2.53], only CG < 30: OR = 1.72, 95% CI [1.37-2.13], only CKD-EPI < 30: OR = 2.34, 95% CI [1.77-3.05], CG+CKD-EPI < 30: OR = 2.47, 95% CI [2.16-2.83], all vs CG+CKD-EPI > 30). CONCLUSION The CG and CKD-EPI formulas identify different subgroups of patients with severe renal impairment, leading to discordant results in 40.7% of these patients. Irrespective of the formula used for their identification, patients with severe renal impairment have a higher risk of major bleeding under anticoagulant therapy.
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Affiliation(s)
- Judith Catella
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France
- F-CRIN INNOVTE network, Saint-Etienne, France
| | - Edouard Ollier
- INSERM, UMR1059, Equipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- URCIP, CHU de St-Etienne, Saint-Etienne, France
| | - Angel Samperiz
- Department of Internal Medicine, Hospital Reina Sofía, Tudela, Spain
| | - Silvia Soler
- Department of Internal Medicine, Hospital Olot i Comarcal de la Garrotxa, Gerona, Spain
| | - José Maria Suriñach
- Department of Internal Medicine, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Isabelle Mahé
- F-CRIN INNOVTE network, Saint-Etienne, France
- Department of Internal Medicine, Hôpital Louis Mourier (APHP), University Paris 7, Colombes, France
| | | | - Andrei Braester
- Department of Haematology, Galilee Medical Center, Nahariya, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Germans Trias i Pujol, Badalona, Spain
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Otašević V, Antić D, Mihaljević B. Venous thromboembolic complications in lymphoma patients. MEDICINSKI PODMLADAK 2020. [DOI: 10.5937/mp71-29196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Lymphomas represent a heterogeneous group of malignant hematological diseases with high risk for development of venous thromboembolic complications (VTE). Consequently, VTE significantly impacts morbidity and mortality in these patients. Another concern is the financial burden of the healthcare system caused by diagnostic and therapeutic procedures of cancer-associated thrombosis (CAT). The complex biology of lymphoma, in conjunction with patient and treatment related risk factors for the development of VTE, results in a procoagulant hemostatic dysregulation. Considering the incidence of VTE in patients with lymphoma, there is an emerging demand for both reliable risks assessment model (RAM) for prediction of VTE, as well as for effective VTE prophylaxis and treatment. The clinical course of patients with malignant diseases is accompanied by a wide range of potential treatment complications, making the task of prevention and treatment of VTE even more challenging. In recent years, great progress has been achieved in understanding the pathophysiological mechanisms of thrombotic complications, while the significant number of randomized controlled trials (RCT) have provided standards of prophylaxis and treatment of VTE complications in patients with malignancy. In comparison to previous recommendations and guidelines for CAT, the use of direct oral anticoagulants (DOAC) has been gradually approaching low molecular weight heparins (LMWH) in terms of efficacy and safety profile in these indications. This systematic review is focused on the latest pathophysiological advances, risk factors assessment, prophylactic and therapeutic recommendations and guidelines concerning VTE in patients with lymphoma.
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Liu Y, Gu Y, Yi F, Cao B. [Retrospective Analysis of Risk Factors for Venous Thromboembolism in 283 Patients with Lung Cancer during Systemic Therapy]. ZHONGGUO FEI AI ZA ZHI = CHINESE JOURNAL OF LUNG CANCER 2019; 22:419-426. [PMID: 31315780 PMCID: PMC6712267 DOI: 10.3779/j.issn.1009-3419.2019.07.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
背景与目的 肺癌患者是静脉血栓栓塞症(venous thrombo-embolism, VTE)的高危人群,合并VTE者具有较高的死亡率。本研究旨在明确接受系统性治疗肺癌患者的VTE发生情况及影响因素。 方法 回顾性分析2016年1月-2018年12月在北京大学第三医院肿瘤化疗与放射病科接受系统性治疗的283例肺癌患者,卡方检验分析VTE与临床特征间的关系,多因素回归分析影响VTE的高危因素。 结果 283例肺癌患者中,VTE发生率为12.01%(34/283)。有下肢静脉曲张组的VTE发生率为50.00%(5/10),显著高于无下肢静脉曲张组的9.89%(27/273)(P=0.001)。远处转移患者的VTE发生率为14.05%(26/185),高于带瘤但无远处转移患者的14.00%(7/50),且高于无瘤患者的2.08%(1/48)(P=0.024)。肿瘤活动组的VTE发生率为16.93%(21/124),显著高于稳定组的8.18%(3/159)(P=0.025)。首次药物治疗前白蛋白 < 35g/L组VTE发生率为22.00%(11/50),显著高于≥35 g/L组的9.87%(23/233)(P=0.017);D-二聚体 > 0.3 μg/mL组VTE发生率为17.93%(26/145),显著高于≤0.3 μg/mL组的5.80%(8/138)(P=0.006)。接受PICC的患者上肢静脉血栓的发生率为9.71%(17/175),显著高于未行PICC组的1.85%(2/108)(P=0.010)。肺癌病理类型、白细胞、血红蛋白、血小板计数及是否接受抗血管生成药物治疗等因素与VTE的发生率无关。多因素分析显示下肢静脉曲张、低白蛋白血症、D-二聚体升高是VTE的独立影响因素。 结论 有无下肢静脉曲张、血白蛋白和D-二聚体水平或许是预测肺癌患者系统性治疗期间发生VTE更为有效的因子,可进一步建立新的预测模型并进行前瞻性验证。
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Affiliation(s)
- Yan'e Liu
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing 100191, China
| | - Yangchun Gu
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing 100191, China
| | - Fumei Yi
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing 100191, China
| | - Baoshan Cao
- Department of Medical Oncology and Radiation Sickness, Peking University Third Hospital, Beijing 100191, China
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Oncologic Emergencies: Too Much Clotting-Venous Thromboembolism in Malignancy. J Emerg Med 2019; 57:825-835. [PMID: 31627886 DOI: 10.1016/j.jemermed.2019.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/16/2019] [Accepted: 08/02/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Malignancy predisposes patients to higher risk of venous thromboembolism (VTE), which is the second leading cause of death in patients with cancer. OBJECTIVE This narrative review evaluates VTE in malignancy and the emergency medicine investigation and management of this patient population. DISCUSSION Patients with malignancy are at higher risk of VTE, including deep venous thrombosis (DVT) and pulmonary embolism (PE). Risk factors include the underlying cancer, other hematologic disorders, cancer therapies, and underlying comorbidities. While patients with malignancy and VTE can present similarly to those without malignancy, incidental VTE is more common in cancer patients. Existing scores such as the Wells and Revised Geneva score can assist in risk stratification in patients with malignancy. A negative D-dimer result in the appropriately risk-stratified patient can be used to exclude VTE, though D-dimer is more commonly elevated at baseline in patients with malignancy. Several scoring systems may be useful to predict recurrent risk of VTE, including the Khorana and Ottawa scores. Treatment includes anticoagulation with direct oral anticoagulants (DOACs) or low molecular weight heparin (LMWH). Outpatient therapy may be appropriate in select patients. CONCLUSIONS This narrative review provides key updates in the assessment and management of cancer patients with VTE.
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12
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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.
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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
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13
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Amin A, Neuman WR, Lingohr-Smith M, Menges B, Lin J. Venous Thromboembolism Prophylaxis and Risk for Acutely Medically Ill Patients Stratified by Different Ages and Renal Disease Status. Clin Appl Thromb Hemost 2019; 25:1076029618823287. [PMID: 30808218 PMCID: PMC6714996 DOI: 10.1177/1076029618823287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The objectives of this study were to examine venous thromboembolism (VTE) prophylaxis
patterns and risk for VTE events during hospitalization and in the outpatient continuum of
care among patients hospitalized for acute illnesses in the United States with
stratification by different age groups and renal disease status. Acutely ill hospitalized
patients were identified from the MarketScan databases (January 1, 2012-June 30, 2015) and
grouped by age (<65, 65-74, ≥75 years old) and whether or not they had a baseline
diagnosis of renal disease, separately. Of acutely ill hospitalized patients, 60.1% (n =
10 748) were <65 years old, 15.7% (n = 2803) were 65 to 74 years old, and 24.3% (n =
4344) were ≥75 years old; 32.9% (n = 5892) had baseline renal disease. Among the study
cohorts, the majority of patients received no VTE prophylaxis regardless of age or
baseline renal status (52.1%-63.6%). Rates of VTE during hospitalization and in the 6
months postdischarge were 4.7%, 4.6%, and 4.5% for patients <65, 65 to 74, and ≥75
years old, respectively, and 6.3% and 3.8% for patients with and without baseline renal
disease. The risk for VTE was elevated for 30 to 40 days after index admission regardless
of age and renal disease status.
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Affiliation(s)
- Alpesh Amin
- 1 Irvine School of Medicine, Univeristy of California, Irvine, CA, USA
| | | | | | | | - Jay Lin
- 3 Novosys Health, Green Brook, NJ, USA
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Abstract
PURPOSE OF REVIEW Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients, and its management is often associated with complications including risk of recurrent VTE and bleeding. Here, we review the current data on pitfalls during anticoagulation in cancer patients and measures necessary to avoid them. RECENT FINDINGS Although low-molecular-weight heparin monotherapy has been the standard of treatment for several years, emerging data for direct oral anticoagulants (DOACs) are leading to new paradigms in treatment. Reports of recent randomized trials suggest a lower risk of recurrent thrombosis but higher risk of bleeding, particularly in gastrointestinal cancer patients, with DOACs. Careful patient selection and individualization of therapy based on risk of bleeding as well as recurrent VTE are keys. Problems like bleeding, recurrence, thrombocytopenia, drug-drug interactions, renal impairment, nausea-vomiting along with concerns about adherence arise during anticoagulation in cancer patients. However, with adequate pre-treatment assessment, correct anticoagulant selection and proper monitoring during anticoagulation, these issues can be addressed safely and effectively.
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Affiliation(s)
- Harsh K Patel
- Kansas City VA Medical Center, 4801 Linwood Blvd, Kansas City, MO, 64128, USA
| | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, 10201 Carnegie Ave./CA60, Cleveland, OH, 44195, USA.
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15
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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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16
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Lu HY, Liao KM. Increased risk of deep vein thrombosis in end-stage renal disease patients. BMC Nephrol 2018; 19:204. [PMID: 30115029 PMCID: PMC6097196 DOI: 10.1186/s12882-018-0989-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 07/20/2018] [Indexed: 02/07/2023] Open
Abstract
Background Previous studies have shown that chronic kidney disease increases the risk of deep vein thrombosis (DVT). DVT is the risk of pulmonary embolism among persons with end-stage renal disease (ESRD). Information on the incidence of DVT in ESRD is limited, and no studies have been conducted in the Asian population. The aim of our study was to investigate the incidence of DVT in Asian ESRD patients by comparing with the non-ESRD patients and to identify the associated risk factors. Methods This study retrieved patients who were diagnosed with ESRD (ICD-9-CM codes 585 or 586) between January 1, 2004, and December 31, 2010, from the National Health Insurance Research Database in Taiwan. All ESRD patients had received a catastrophic illness card from the Ministry of Health and Welfare in Taiwan, with the major illness identified as ESRD. Patients who had DVT before the index date or who had incomplete records were excluded from the analysis. A total of 4865 ESRD patients were enrolled. There are 3564 ESRD patients included after exclusion of patients with previous DVT and patients with incomplete records. The control subjects were randomly selected as the patients without ESRD by matching study subjects according to age (±3 years), gender, and the year of admission at a 2:1 ratio from the same dataset. Results The incidence rate of DVT was substantially higher in the ESRD group than in the without-ESRD group (20.9 vs. 1.46 per 10^4 person-years). The adjusted hazard ratio (aHR 13.92; 95% CI 9.25–20.95) of DVT for the ESRD patients was 13.92 times that for the non-ESRD patients. ESRD patients older than 50 years had a higher risk of DVT (aHR 1.65; 95% CI 1.13–2.40; P = 0.01). Hyperlipidemia was significantly associated with an increased risk of DVT (aHR 1.73; 95% CI 1.08–2.78; P = 0.02). ESRD patients with three or more comorbidities were substantially more likely to have DVT (aHR 1.45; 95% CI 1.03–2.03; P = 0.03). Conclusions ESRD patients had a higher risk of DVT than non-ESRD patients. Among the ESRD patients, being older than 50 years and having dyslipidemia increased the risk of DVT.
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Affiliation(s)
- Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National, Yunlin University of Science and Technology, Yun-Lin, Taiwan
| | - Kuang-Ming Liao
- Department of Internal Medicine, Chi Mei Medical Center, Chiali, Taiwan.
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17
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Evaluation of risk factors and assessment models for predicting venous thromboembolism in lung cancer patients. Med Oncol 2018; 35:63. [PMID: 29616356 PMCID: PMC5882764 DOI: 10.1007/s12032-018-1120-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 03/30/2018] [Indexed: 02/07/2023]
Abstract
The aim of the study was to investigate the prognostic significance of selected risk assessment models (RAMs) for predicting venous thromboembolism (VTE) events in patients undergoing outpatient chemotherapy for lung cancer. We evaluated the following VTE-risk assessment tools: Khorana risk score (KRS), PROTECHT score, CONKO score and COMPASS-cancer-associated thrombosis score (COMPASS-CAT). Retrospective analyses were performed on 118 patients with lung cancer, 20 of whom developed VTE with a median of 2.5 months from diagnosis. Patients receiving gemcitabine-based regimen (25%), patients with a history of atrial fibrillation (AF) and patients with chronic kidney disease developed VTE more often than other patients. In the multivariate analysis, high COMPASS-CAT score (OR 8.73; 95% CI 1.01–75.22, P = 0.049), gemcitabine chemotherapy (OR 3.37; 95% CI 1.09–10.39, P = 0.035) and AF (OR 7.19; 95% CI 1.89–27.33, P = 0.004) were all significantly associated with VTE development. VTE occurred in; 13% (n = 2) of the KRS high-risk group, 17.7% (n = 11) of the PROTECHT high-risk group, 15% (n = 4) of the CONKO high-risk group and 23.8% (n = 20) of the COMPASS-CAT high-risk group (n = 84). Only the COMPASS-CAT score was able to identify 100% of patients who developed VTE, and best discriminated between patients with high and low risk of VTE development (C statistic 0.89). The ROC analysis indicated a cutoff value of 11 points (95% CI 0.821–0.962) for COMPASS-CAT for VTE development in patients with lung cancer. In conclusion, in our study of all the VTE–RAMs analyzed, the COMPASS-CAT model was the most accurate predictor of VTE development in patients with lung cancer.
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18
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Voigtlaender M, Langer F. Management of cancer-associated venous thromboembolism - a case-based practical approach. VASA 2018; 47:77-89. [PMID: 29325495 DOI: 10.1024/0301-1526/a000684] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In patients with solid tumours or haematological malignancies, venous thromboembolism (VTE) is a leading cause of death and significantly contributes to morbidity and healthcare resource utilization. Current practice guidelines recommend long-term anticoagulation with low-molecular-weight heparin (LMWH) as the treatment of choice for cancer-associated VTE, based on clinical trial data showing an overall improved safety and efficacy profile of LMWH compared to vitamin K antagonists. However, several open questions remain, e. g. with regard to the intensity and duration of LMWH therapy; moreover, recent real-world evidence indicates that adherence to parenteral anticoagulation with LMWH over the course of treatment is poor in clinical practice. In this regard, the direct oral factor Xa or thrombin inhibitors (DOACs) have emerged as potential alternatives in the management of patients with cancer-associated VTE, albeit findings from randomized controlled studies with a direct head-to-head comparison of DOACs with LMWH, the current standard of care, are still lacking. Based on the case of a lymphoma patient experiencing symptomatic pulmonary embolism during immunochemotherapy, this article aims at both highlighting the current state-of-the-art approach to cancer-associated VTE and pointing out some of the unresolved, controversial issues clinicians have to face when taking care of haematology and oncology patients with already established or with high risk of developing VTE. These issues include the management of patients with incidental pulmonary embolism or thrombocytopenia, the use of DOACs, and the initiation of pharmacological thromboprophylaxis in non-surgical cancer patients.
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Elalamy I, Falanga A. Meeting Report EuroG20 Meeting on Cancer-Associated Thrombosis (CAT) Bergamo, Italy 7 April 2016. Cancer Invest 2018; 36:73-91. [PMID: 29420084 DOI: 10.1080/07357907.2018.1425698] [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: 10/18/2022]
Abstract
The EuroG20 meeting on cancer-associated thrombosis (CAT) convened in Bergamo, Italy on 7 April 2016 to discuss a selection of controversial topics in CAT management. This satellite meeting besides ICTHIC in Bergamo has the objective to propose an European Guidance on CAT in various complex situations where evidence-based guidelines are lacking, driven by eminence-based thoughts of 20 experts and key opinion leaders in thrombosis from EU area and 8 experts from the rest of the world.
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Affiliation(s)
- I Elalamy
- a Biological Hematology Department, Hôpital TENON APHP Hôpitaux Universitaires de l'Est Parisien , INSERM UMRS 938 Sorbonne Université , Paris , France
| | - A Falanga
- b Department of Immunohematology and Transfusion Medicine & the Hemostasis and Thrombosis Center , Hospital Papa Giovanni XXIII , Piazza OMS , Bergamo , Italy
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20
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Huang T, Dong Z. Osthole protects against inflammation in a rat model of chronic kidney failure via suppression of nuclear factor-κB, transforming growth factor-β1 and activation of phosphoinositide 3-kinase/protein kinase B/nuclear factor (erythroid-derived 2)-like 2 signaling. Mol Med Rep 2017; 16:4915-4921. [PMID: 28765904 DOI: 10.3892/mmr.2017.7125] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 02/06/2017] [Indexed: 11/06/2022] Open
Abstract
Multiple pharmacological applications of osthole have been previously recognized, including antioxidant, anti-inflammatory, anti‑platelet and estrogenic effects, and resistance to pain. The present study investigated the protective effects of osthole against inflammation in a rat model of chronic kidney failure (CRF) and the underlying mechanisms. Osthole treatment with significantly reversed CRF‑induced changes in serum creatinine, calcium, phosphorus and blood urea nitrogen levels in CRF rats. Male Sprague‑Dawley rats (age, 8 weeks) received 200 mg/kg 2% adenine suspension to induce CRF in the model group. In the osthole‑treated group, rats received 200 mg/kg 2% adenine suspension + osthole (40 mg/kg, intravenously). The results revealed that treatment with osthole significantly inhibited CRF‑induced tumor necrosis factor‑α, interleukin (IL)‑8 and IL‑6 expression, and suppressed nuclear factor‑κB (NF‑κB) protein expression in CRF rats. Osthole treatment significantly attenuated the protein expression of transforming growth factor‑β1 (TGF‑β1), reduced monocyte chemoattractant protein‑1 activity and increased the phosphoinositide 3‑kinase (PI3K)/protein kinase B (Akt) ratio in CRF rats. These results suggested that osthole protects against inflammation in a rat model of CRF via suppression of NF‑κB and TGF‑β1, and activation of PI3K/Akt/nuclear factor (erythroid‑derived 2)‑like 2 signaling. Therefore, osthole may represent a potential therapeutic agent for the treatment of CRF.
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Affiliation(s)
- Tao Huang
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
| | - Zhen Dong
- Department of Kidney Transplantation, The Affiliated Hospital of Qingdao University, Qingdao, Shandong 266000, P.R. China
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Garasto S, Fusco S, Onder G, Sganga F, Mammarella F, Volpato S, Ruggiero C, Abbatecola AM, Lattanzio F, Corsonello A. Inappropriate prescription of low molecular weight heparins for thromboprophylaxis among older hospitalized patients. Aging Clin Exp Res 2017; 29:483-490. [PMID: 27114077 DOI: 10.1007/s40520-016-0571-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/11/2016] [Indexed: 01/09/2023]
Abstract
AIM To investigate the prevalence and clinical correlates of overprescribing and underprescribing of low molecular weight heparins (LMWHs) for thromboprophylaxis among older medical inpatients. METHODS Eight hundred seventy six patients (mean age 81.5 ± 7.6 years, female gender 57.2 %) enrolled in a multicenter observational study of seven acute care wards of geriatric medicine in Italy. The risk of venous thromboembolism was ascertained by calculating the Padua score for each patient. Patients receiving appropriate prescription of LMHW during stay were compared to those receiving LMHW with a Padua score <4 (overprescribing group). Similarly, patients with a high thromboembolic risk (Padua score ≥4) but not receiving LMHW (underprescribing group) were compared to patients appropriately not receiving LMHW during stay. Independent correlates of overprescribing and underprescribing were investigated by logistic regression analysis. RESULTS Overall, 42.8 % of patients had a Padua score ≥4. LMWHs were overprescribed in 7.3 % and underprescribed in 25.2 % of patients. The number of lost basic activities of daily living (BADL) (OR = 0.25; 95 % CI 0.15-0.41) and the number of diagnoses (OR = 0.76; 95 % CI 0.61-0.95) were inversely associated with LMWH overprescription. Conversely, older age (75-84 years: OR = 2.39; 95 % CI 1.10-5.19-85 years or more: OR = 3.25, 95 % CI 1.40-7.61), anemia (OR = 1.80, 95 % CI 1.05-3.16), pressure sores (OR = 4.15, 95 % CI 1.20-14.3), number of lost BADL at the admission (OR = 3.92, 95 % CI 2.86-5.37) and number of diagnoses (OR = 1.29, 95 % CI 1.15-1.44) qualified as significant correlates of LMWH underprescription. DISCUSSION Underprescription and, to a lesser extent, overprescription still represent an issue among older medical inpatients. CONCLUSION Implementing risk-stratifying scores into clinical practice may improve appropriateness of LMWHs prescribing during hospitalization.
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Affiliation(s)
- Sabrina Garasto
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), C. da Muoio Piccolo, 87100, Cosenza, Italy
| | - Sergio Fusco
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), C. da Muoio Piccolo, 87100, Cosenza, Italy.
| | - Graziano Onder
- Center for Medicine of Aging, Policlinico A. Gemelli, University of Sacro Cuore, Rome, Italy
| | - Federica Sganga
- Center for Medicine of Aging, Policlinico A. Gemelli, University of Sacro Cuore, Rome, Italy
| | - Federica Mammarella
- Center for Medicine of Aging, Policlinico A. Gemelli, University of Sacro Cuore, Rome, Italy
| | - Stefano Volpato
- Department of Science and Medicine, University of Ferrara, Ferrara, Italy
| | - Carmelinda Ruggiero
- Department of Medicine, Institute of Gerontology and Geriatrics, University of Perugia, Perugia, Italy
| | | | - Fabrizia Lattanzio
- Scientific Direction, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - Andrea Corsonello
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), C. da Muoio Piccolo, 87100, Cosenza, Italy
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Farge D, Bounameaux H, Brenner B, Cajfinger F, Debourdeau P, Khorana AA, Pabinger I, Solymoss S, Douketis J, Kakkar A. International clinical practice guidelines including guidance for direct oral anticoagulants in the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol 2017; 17:e452-e466. [PMID: 27733271 DOI: 10.1016/s1470-2045(16)30369-2] [Citation(s) in RCA: 264] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/13/2016] [Accepted: 07/14/2016] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) is the second leading cause of death in patients with cancer. These patients are at an increased risk of developing VTE and are more likely to have a recurrence of VTE and bleeding while taking anticoagulants. Management of VTE in patients with cancer is a major therapeutic challenge and remains suboptimal worldwide. In 2013, the International Initiative on Thrombosis and Cancer (ITAC-CME), established to reduce the global burden of VTE in patients with cancer, published international guidelines for the treatment and prophylaxis of VTE and central venous catheter-associated thrombosis. The rapid global adoption of direct oral anticoagulants for management of VTE in patients with cancer is an emerging treatment trend that needs to be addressed based on the current level of evidence. In this Review, we provide an update of the ITAC-CME consensus recommendations based on a systematic review of the literature ranked according to the Grading of Recommendations Assessment, Development, and Evaluation scale. These guidelines aim to address in-hospital and outpatient cancer-associated VTE in specific subgroups of patients with cancer.
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Affiliation(s)
- Dominique Farge
- Assistance Publique-Hôpitaux de Paris, Internal Medicine: Autoimmune and Vascular Disease Unit, Saint-Louis Hospital, Paris, France; Sorbonne Paris Cité, Paris 7 Diderot University, Paris, France.
| | - Henri Bounameaux
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Francis Cajfinger
- Assistance Publique-Hôpitaux de Paris, Service d'oncologie, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Internal Medicine, Medical University Vienna, Vienna, Austria
| | - Susan Solymoss
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ajay Kakkar
- Thrombosis Research Institute, London, UK; University College London, London, UK
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Elalamy I, Mahé I, Ageno W, Meyer G. Long-term treatment of cancer-associated thrombosis: the choice of the optimal anticoagulant. J Thromb Haemost 2017; 15:848-857. [PMID: 28222250 DOI: 10.1111/jth.13659] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Indexed: 01/20/2023]
Abstract
Patients with cancer-associated thrombosis (CAT) carry a higher risk of recurrence, bleeding and mortality as compared with non-cancer patients. The specific profiles of cancer patients, combining frequent co-morbidities, the use of anti-tumoral therapies and the cancer progression itself, represent a major therapeutic challenge for choosing a long-term anticoagulant treatment. This review discusses the practical basis of making a choice between the available drugs for a long-term antithrombotic strategy, linked to their pharmacology, mechanism of action, evidence of clinical benefits, and advantages and limitations in such a complex clinical context. In patients with cancer, low-molecular-weight heparins (LMWHs) are the preferred option for the secondary prevention of venous thromboembolism according to current guidelines, because their efficacy is significantly superior to vitamin K antagonists (VKAs). Even though LMWHs are effective and safe in cancer patients, they require daily subcutaneous injections, which may be problematic for a long-term therapy that may exceed 6 months' duration. Compared with VKAs, non-vitamin-K antagonist oral anticoagulants or direct oral anticoagulants (DOACs) are more target specific and do not require laboratory monitoring, whereas the oral route of administration makes them potentially attractive alternatives to LMWH. In randomized controlled trials in the general population DOACs have been shown to be non-inferior to VKAs in terms of efficacy with a lower rate of clinically relevant or major bleeding. However, given the limited number of cancer patients enrolled in these studies (with poorly defined active cancer), available trials are inconclusive regarding the usefulness of DOACs in the cancer setting. Ongoing head-to-head comparisons vs. LMWH in patients with CAT may allow an informed choice to be made regarding the DOAC option.
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Affiliation(s)
- I Elalamy
- Biological Hematology Department, Hôpital TENON APHP Hôpitaux Universitaires de l'Est Parisien, INSERM UMRS 938 Université Pierre et Marie Curie, Paris 6, Paris, France
| | - I Mahé
- Internal Medicine Department, Hôpital Louis Mourier, APHP, Colombes, France
- Université Paris-Diderot Paris 7, EA 7334, Sorbonne Paris Cité, Paris, France
| | - W Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - G Meyer
- Respiratory and Intensive Care, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Université Paris Descartes Paris 5, Sorbonne Paris Cité, Paris, France
- INSERM UMRS 970, CIC 1418, Paris, France
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Bauersachs RM. LMWH in cancer patients with renal impairment – better than warfarin? Thromb Res 2016; 140 Suppl 1:S160-4. [DOI: 10.1016/s0049-3848(16)30116-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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