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Patell R, Hsu C, Shi M, Grosso MA, Duggal A, Buller HR, Raskob G, Zwicker JI. Impact of mild thrombocytopenia on bleeding and recurrent thrombosis in cancer. Haematologica 2024; 109:1849-1856. [PMID: 37855029 PMCID: PMC11141682 DOI: 10.3324/haematol.2023.284192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/09/2023] [Indexed: 10/20/2023] Open
Abstract
Thrombocytopenia occurs frequently in patients with cancer-associated thrombosis (CAT), however prospective evaluation of clinical outcomes following randomization to anticoagulants is limited. The HOKUSAI VTE Cancer study was a randomized, open-label, non-inferiority, phase III trial comparing dalteparin with edoxaban in CAT patients. This post hoc analysis of Hokusai VTE Cancer Study was performed to compare outcomes in patients with platelet count ≤100x109/L at one or more specified time points (baseline, 1-month, or 3-month) versus those without thrombocytopenia. Cumulative incidences at 180 days were calculated with death as a competing risk. The primary outcome was major bleeding; secondary outcomes were clinically relevant non-major bleeding (CRNMB), recurrent thrombosis, and survival. The analysis included 1,045 patients with primarily solid tumor malignancies (89%), median age 65 years, and 52% male. The thrombocytopenia group comprised 9.6% (N=101) of the cohort and relative to the non-thrombocytopenia cohort (N=944), experienced significantly higher major bleeding (9.0% vs. 4.0%, sub-distribution hazard ratio [SHR] =2.4; P=0.02) and CRNMB (17.9% vs. 9.6%, SHR=2.0; P=0.01). Thrombocytopenia did not impact recurrent venous thromboembolic event (VTE) (9.8% vs. 7.4%, SHR=1.3; P=0.37) nor overall mortality (21.8% vs. 26.0%, HR=0.9; P=0.48). Major bleeding was higher in patients with thrombocytopenia and gastrointestinal malignancies receiving edoxaban versus dalteparin (16.8% vs. 0; P<0.01) but similar for patients with other malignancies (P=0.30). In patients with hematologic malignances and thrombocytopenia major bleeding was higher for patients receiving dalteparin compared to edoxaban (19.0% vs. 0; P<0.01). Mild thrombocytopenia was associated with a doubling in risk of major hemorrhage in patients receiving anticoagulation for CAT. Bleeding risk for edoxaban and dalteparin varied in gastrointestinal and hematologic malignances in patients with thrombocytopenia (clinicaltrails gov. Identifier: NCT02073682).
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Affiliation(s)
- Rushad Patell
- Division of Hematology and Hematologic Malignancies, BIDMC, Boston, MA
| | - Charles Hsu
- Division of Hematology and Hematologic Malignancies, BIDMC, Boston, MA, USA; Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Minggao Shi
- Daiichi Sankyo Pharma Development, Edison, NJ
| | | | - Anil Duggal
- Daiichi Sankyo Pharma Development, Edison, NJ
| | - Harry R Buller
- Department of Vascular Medicine, Amsterdam Academic Medical Center, Amsterdam, The Netherlands
| | - Gary Raskob
- Hudson College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Jeffrey I Zwicker
- Department of Medicine, Hematology Service, Memorial Sloan Kettering Cancer Center, New York, NY.
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2
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Huroy M, Selby R, Sutradhar S, Galanaud JP, Abdulrehman J. Peak plasma anti-Xa direct oral anticoagulant levels after gastrointestinal surgeries: A retrospective cohort. Thromb Res 2024; 238:85-87. [PMID: 38692087 DOI: 10.1016/j.thromres.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/11/2024] [Accepted: 04/17/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Menal Huroy
- Department of Medicine, University of Toronto, ON, Canada
| | - Rita Selby
- Department of Laboratory Medicine and Pathobiology, University of Toronto; Division of Hematology, Department of Medicine, University of Toronto, ON, Canada
| | - Subir Sutradhar
- Division of General Surgery, Department of Surgery, Lakeridge Health, ON, Canada
| | - Jean-Philippe Galanaud
- Division of General Internal Medicine, Department of Medicine, University of Toronto, ON, Canada
| | - Jameel Abdulrehman
- Division of Hematology, Department of Medicine, University of Toronto, ON, Canada.
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3
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Mokart D, Serre E, Bruneel F, Kouatchet A, Lemiale V, Chow-Chine L, Faucher M, Sannini A, Valade S, Bisbal M, Gonzalez F, Servan L, Darmon M, Azoulay E. Acute pulmonary embolism in cancer patients admitted to intensive care unit: Impact of anticoagulant treatment on 90-day mortality and risk factors, results of a multicentre retrospective study. Thromb Res 2024; 237:129-137. [PMID: 38583310 DOI: 10.1016/j.thromres.2024.03.027] [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: 02/16/2024] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is a life-threatening situation in cancer patients. In this situation, anticoagulant therapy is complex to administer due to the risk of bleeding. Only few studies have been conducted when these patients are admitted to the intensive care unit (ICU). The aim of this study was to assess the association between anticoagulation strategies as well as other factors with 90-day mortality in patients with cancer and PE admitted to ICU. Major bleeding was also evaluated according to the type of anticoagulation. METHODS Retrospective study carried out in 4 ICUs in France over a 12-year period (2009-2021). All patients with cancer and PE were included. An overlap propensity score weighting analysis was performed in the subgroup of patients treated with either unfractionated heparins (UFH) alone or low-molecular-weight heparins (LMWH) alone on 90-day mortality and major bleeding. RESULTS A total of 218 consecutive cancer patients admitted to ICU and presenting PE were included. The 90-day mortality rate was 42 % for the global cohort. After propensity score analysis in the subgroup of patients treated with either "UFH alone" (n = 80) or "LMWH alone" (n = 71), the 90-day mortality was similar in patients treated with UFH alone (42.6 %) vs LMWH alone (39.9 %): OR = 1.124, CI 95 % [0.571-2.214], p = 0.750. There was a significant increased toward major bleeding rates in the "UFH alone" group (25.5 %) as compared to "LMWH alone" group (11.5 %), p = 0.04. CONCLUSION In 218 patients admitted to ICU and presenting PE, the 90-day mortality rate was 42 %. Treatment with UFH alone was associated with a mortality comparable to treatment with LMWH alone but it appeared to be more prone to major bleeding.
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Affiliation(s)
- Djamel Mokart
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France.
| | - Edouard Serre
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Fabrice Bruneel
- Medical Intensive Care Unit, University Hospital of Angers, Angers, France
| | - Achille Kouatchet
- Medical-Surgical Intensive Care Unit, Versailles Center, Mignot Hospital, Le Chesnay, France
| | - Virginie Lemiale
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Laurent Chow-Chine
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Marion Faucher
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Antoine Sannini
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Sandrine Valade
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Magali Bisbal
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Frederic Gonzalez
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Luca Servan
- Medical-Surgical Intensive Care Unit, Paoli-Calmettes Institute, Marseille, France
| | - Michaël Darmon
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP, Saint-Louis University Hospital, Paris, France
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Patel JN, Jiang C, Owzar K, Hertz DL, Wang J, Mulkey FA, Kelly WK, Halabi S, Furukawa Y, Lassiter C, Dorsey SG, Friedman PN, Small EJ, Carducci MA, Kelley MJ, Nakamura Y, Kubo M, Ratain MJ, Morris MJ, McLeod HL. Pharmacogenetic and clinical risk factors for bevacizumab-related gastrointestinal hemorrhage in prostate cancer patients treated on CALGB 90401 (Alliance). THE PHARMACOGENOMICS JOURNAL 2024; 24:6. [PMID: 38438359 PMCID: PMC10912014 DOI: 10.1038/s41397-024-00328-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 03/06/2024]
Abstract
The objective of this study was to discover clinical and pharmacogenetic factors associated with bevacizumab-related gastrointestinal hemorrhage in Cancer and Leukemia Group B (Alliance) 90401. Patients with metastatic castration-resistant prostate cancer received docetaxel and prednisone ± bevacizumab. Patients were genotyped using Illumina HumanHap610-Quad and assessed using cause-specific risk for association between single nucleotide polymorphisms (SNPs) and gastrointestinal hemorrhage. In 1008 patients, grade 2 or higher gastrointestinal hemorrhage occurred in 9.5% and 3.8% of bevacizumab (n = 503) and placebo (n = 505) treated patients, respectively. Bevacizumab (P < 0.001) and age (P = 0.002) were associated with gastrointestinal hemorrhage. In 616 genetically estimated Europeans (n = 314 bevacizumab and n = 302 placebo treated patients), grade 2 or higher gastrointestinal hemorrhage occurred in 9.6% and 2.0% of patients, respectively. One SNP (rs1478947; HR 6.26; 95% CI 3.19-12.28; P = 9.40 × 10-8) surpassed Bonferroni-corrected significance. Grade 2 or higher gastrointestinal hemorrhage rate was 33.3% and 6.2% in bevacizumab-treated patients with the AA/AG and GG genotypes, versus 2.9% and 1.9% in the placebo arm, respectively. Prospective validation of these findings and functional analyses are needed to better understand the genetic contribution to treatment-related gastrointestinal hemorrhage.
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Affiliation(s)
- Jai N Patel
- Department of Cancer Pharmacology & Pharmacogenomics, Atrium Health Levine Cancer Institute, Charlotte, NC, USA.
| | - Chen Jiang
- Alliance Statistics and Data Management Center, Duke University, Durham, NC, USA
| | - Kouros Owzar
- Alliance Statistics and Data Management Center, Duke University, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Daniel L Hertz
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Janey Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Flora A Mulkey
- Alliance Statistics and Data Management Center, Duke University, Durham, NC, USA
| | - William K Kelly
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Susan Halabi
- Alliance Statistics and Data Management Center, Duke University, Durham, NC, USA
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Yoichi Furukawa
- Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Cameron Lassiter
- University of Maryland School of Nursing (Miltenyi Biotech at time of publication), Baltimore, MD, USA
| | - Susan G Dorsey
- University of Maryland School of Nursing (Miltenyi Biotech at time of publication), Baltimore, MD, USA
| | - Paula N Friedman
- Department of Pharmacology and Center for Pharmacogenomics, Northwestern University, Evanston, IL, USA
| | - Eric J Small
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Carducci
- Johns Hopkins School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Michael J Kelley
- Durham VA Medical Center/Duke University Medical Center, Durham, NC, USA
| | - Yusuke Nakamura
- Center for Personalized Therapeutics, University of Chicago (Japanese Foundation for Cancer Research, Ariake, Tokyo at time of publication), Chicago, IL, USA
| | - Michiaki Kubo
- Riken Center for Integrative Medical Sciences (Haradoi Hospital, Fukuoka, Japan at time of publication), Kanagawa, Japan
| | - Mark J Ratain
- Center for Personalized Therapeutics, University of Chicago (Japanese Foundation for Cancer Research, Ariake, Tokyo at time of publication), Chicago, IL, USA
| | - Michael J Morris
- Division of Solid Tumor Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Cohen AT, Noxon V, Dhamane AD, Shah S, Hines DM, Alfred T, Chaves J, Luo X. Effectiveness and safety of anticoagulants among patients with venous thromboembolism and active cancer who also had prior bleed or prior renal disease. Curr Med Res Opin 2024; 40:545-553. [PMID: 38332714 DOI: 10.1080/03007995.2024.2313092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Patients with active cancer and venous thromboembolism (VTE) have elevated risk of recurrent VTE (rVTE) and major bleeding (MB). The risk is even higher within those with a prior bleeding event or renal disease. There is a need to understand the risk of rVTE and MB of commonly used anticoagulants among these high-risk patients. METHODS VTE patients with active cancer and treated with apixaban, warfarin, or low molecular weight heparin (LMWH) within 30 days of VTE were identified from five claims databases in the United States. Inverse probability of treatment weighting (IPTW) was used to balance patient characteristics. The post-IPTW population was stratified by prior bleed or renal disease status. Cox proportional hazards models were used to evaluate interactions between treatment and prior bleed or renal disease on risk of rVTE and MB, with p value <.1 considered significant. RESULTS Study criteria were met by 30,586 VTE cancer patients: 35.0% had prior bleed and 29.0% had renal disease. For apixaban, LMWH, and warfarin cohorts, the incidence (events per 100 person-years) of MB was higher in patients with prior bleed (17.48 vs 7.58, 25.61 vs 13.11, and 20.38 vs 8.97) or renal disease (15.79 vs 8.71, 22.11 vs 15.90, and 18.49 vs 10.39) vs those without the conditions. Generally, there were no significant interactions between anticoagulant use and prior bleed or renal disease on rVTE and MB (p for interaction >.1). CONCLUSION The incidence of MB was higher among those with prior bleed or renal disease. Effects of apixaban, warfarin, or LMWH were generally consistent regardless of prior bleed or renal disease status.
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Affiliation(s)
- Alexander T Cohen
- Department of Hematological Medicine, Guy's & St Thomas' NHS Foundation Trust, King's College London, London, UK
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Wang L, Ma X, Chen Y, Gao S, Pan W, Chen J, Su L, He H, Long Y, Yin C, Zhou X. Factors influencing DVT formation in sepsis. Thromb J 2024; 22:11. [PMID: 38229151 DOI: 10.1186/s12959-024-00582-y] [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: 11/29/2023] [Accepted: 01/11/2024] [Indexed: 01/18/2024] Open
Abstract
INTRODUCTION Sepsis is a global public health burden. Deep vein thrombosis (DVT) is the third most common cause of death from cardiovascular disease after heart attacks and strokes. We designed this experiment to investigate the factors influencing DVT formation in patients with sepsis. METHODS In this survey, 918 septic patients admitted to Peking Union Medical College Hospital, who underwent DVT screening were enrolled. The data were collected from June 8, 2013 to October 12, 2022. The differences between septic patients with and without DVT were studied from following aspects: basic information, comorbidities, inflammatory cytokines, albumin, source of infection, sequential organ failure assessment (SOFA) score, coagulation and prognosis. MAIN RESULTS In this study, the prevalence of DVT in patients with sepsis was 0.23. Elderly patients with sepsis were prone to DVT (p value < 0.001). In terms of comorbidities, septic patients with hypertension and atrial fibrillation were prone to DVT (p value 0.045 and 0.048). Inflammatory cytokines, such as procalcitonin (PCT), C-reactive protein (CRP), interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor (TNF)-α, had no significant correlation with DVT in patients with sepsis (p value 0.364, 0.882, 0.912, 0.789, 0.245, and 0.780). Levels of serum albumin correlated with DVT in patients with sepsis (p value 0.003). The SOFA total score had no relationship with DVT formation (p value 0.254). Coagulation and respiration function were negatively correlated with DVT (p value 0.018). Liver function was positively correlated with DVT (p value 0.020). Patients in the DVT group had longer duration of mechanical ventilation and longer intensive care unit (ICU) stays (p value < 0.001 and 0.006). There was no significant difference in survival in septic patients with and without DVT (p value 0.868). CONCLUSIONS The SOFA total score had no relationship with DVT formation. The function of each organ had different effects on DVT formation. Better coagulation and respiration function, easier DVT formation. Poorer liver function, easier DVT formation. DVT was associated with longer duration of mechanical ventilation and longer ICU stays.
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Affiliation(s)
- Lu Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xudong Ma
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Yujie Chen
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Sifa Gao
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Wei Pan
- Information Center Department, Department of Information Management, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Jieqing Chen
- Information Center Department, Department of Information Management, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Longxiang Su
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Chang Yin
- National Institute of Hospital Administration, Beijing, 100730, China.
| | - Xiang Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
- Information Center Department, Department of Information Management, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Al-Samkari H. Optimal management of chemotherapy-induced thrombocytopenia with thrombopoietin receptor agonists. Blood Rev 2024; 63:101139. [PMID: 37914568 PMCID: PMC10872905 DOI: 10.1016/j.blre.2023.101139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 11/03/2023]
Abstract
Chemotherapy-induced thrombocytopenia (CIT) is a common complication of antineoplastic therapy, resulting in antineoplastic therapy dose reductions, treatment delays, treatment discontinuation, and morbid bleeding events. Despite several decades of research into thrombopoietic growth factors in CIT, there are presently no available U.S. FDA- or EMA-approved agents to treat CIT. However, a respectable body of evidence has been published evaluating the thrombopoietin receptor agonists (TPO-RAs) for the management and prevention of CIT in patients with solid tumors, and critical studies are ongoing with the TPO-RAs romiplostim and avatrombopag. When employed in the appropriate patient population and used properly, TPO-RAs can successfully and safely manage CIT for extended periods of time with minimal apparent risks. This comprehensive review discusses the evidence for TPO-RAs in CIT in patients with solid tumors, provides detailed guidance for their use in the clinic, and discusses ongoing essential clinical trials in management of CIT.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Yau CE, Low CE, Ong NY, Rana S, Chew LJR, Tyebally SM, Chai P, Yeo TC, Chan MY, Lee MX, Tan LL, Koo CY, Lee ARYB, Sia CH. Non-Vitamin K Antagonist Oral Anticoagulants versus Low Molecular Weight Heparin for Cancer-Related Venous Thromboembolic Events: Individual Patient Data Meta-Analysis. Cancers (Basel) 2023; 15:5887. [PMID: 38136433 PMCID: PMC10741613 DOI: 10.3390/cancers15245887] [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: 11/06/2023] [Revised: 12/09/2023] [Accepted: 12/16/2023] [Indexed: 12/24/2023] Open
Abstract
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality in cancer patients. Low molecular weight heparin (LMWH) has been the standard of care but new guidelines have approved the use of non-vitamin K antagonist oral anticoagulants (NOAC). By conducting an individual patient data (IPD) meta-analysis of randomised controlled trials (RCTs) comparing the outcomes of NOAC versus LMWH in cancer patients, we aim to determine an ideal strategy for the prophylaxis of VTE and prevention of VTE recurrence. Three databases were searched from inception until 19 October 2022. IPD was reconstructed from Kaplan-Meier curves. Shared frailty, stratified Cox and Royston-Parmar models were fit to compare the outcomes of venous thromboembolism recurrence and major bleeding. For studies without Kaplan-Meier curves, aggregate data meta-analysis was conducted using random-effects models. Eleven RCTs involving 4844 patients were included. Aggregate data meta-analysis showed that administering NOACs led to a significantly lower risk of recurrent VTE (RR = 0.65; 95%CI: 0.50-0.84) and deep vein thrombosis (DVT) (RR = 0.60; 95%CI: 0.40-0.90). In the IPD meta-analysis, NOAC when compared with LMWH has an HR of 0.65 (95%CI: 0.49-0.86) for VTE recurrence. Stratified Cox and Royston-Parmar models demonstrated similar results. In reducing risks of recurrent VTE and DVT among cancer patients, NOACs are superior to LMWHs without increased major bleeding.
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Affiliation(s)
- Chun En Yau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Chen Ee Low
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Natasha Yixuan Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Sounak Rana
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Lucas Jun Rong Chew
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Sara Moiz Tyebally
- Division of Cardiology, Department of Medicine, Ng Teng Fong General Hospital, Singapore 609606, Singapore
| | - Ping Chai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Tiong-Cheng Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Mark Y. Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Matilda Xinwei Lee
- Department of Haematology-Oncology, National University Cancer Institute, Singapore 119228, Singapore;
| | - Li-Ling Tan
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Chieh-Yang Koo
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
| | - Ainsley Ryan Yan Bin Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
| | - Ching-Hui Sia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore; (C.E.Y.); (C.E.L.); (S.R.); (L.J.R.C.); (P.C.); (T.-C.Y.); (M.Y.C.); (A.R.Y.B.L.)
- Department of Cardiology, National University Heart Centre, Singapore 119074, Singapore; (L.-L.T.); (C.-Y.K.)
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9
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Al-Samkari H. Treatment of chemotherapy-induced thrombocytopenia with monotherapy versus combination therapy: the devil is in the details. Res Pract Thromb Haemost 2023; 7:102250. [PMID: 38193065 PMCID: PMC10772883 DOI: 10.1016/j.rpth.2023.102250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 10/26/2023] [Indexed: 01/10/2024] Open
Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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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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11
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Kumar S, Yoon S, Milioglou I, Tashtish N, Farmakis I, Dallan LAP, Mogalapalli A, Arruda M, Filby SJ. Left Atrial Appendage Closure Outcomes in Patients With Cancer at a Single Tertiary Center. Am J Cardiol 2023; 202:176-181. [PMID: 37441832 DOI: 10.1016/j.amjcard.2023.06.068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023]
Abstract
Atrial fibrillation is the most common arrhythmia in patients with underlying malignancy. Patients with cancer have a higher risk of bleeding, and at the same time, carry an elevated risk of thromboembolism related to the hypercoagulable state, type of cancer, and anticancer treatment, rendering safe anticoagulation challenging in this population. Left atrial appendage closure is an alternative treatment option in patients with atrial fibrillation and high bleeding risk; however, the data on patients with cancer are limited. Our study aimed to compare the long-term outcomes in patients with cancer receiving left atrial appendage closure using the WATCHMAN device. This is a prospective, single-center study comparing outcomes in 389 patients who underwent percutaneous left atrial appendage closure using the WATCHMAN device over 5 years in a single, large academic hospital in the United States. The postprocedural outcomes of mortality, stroke, and major bleeding were evaluated in patients with and without cancer. Our study included 57 patients with cancer and 332 without cancer. The baseline characteristics were similar between the 2 groups. Metastatic disease was present in 16.4% of patients, and 25% were receiving active treatment at the time of the procedure. The median follow-up time was 354 (interquartile range 85 to 790) days. There was no difference in mortality (hazard ratio [HR] 1.3, 95% confidence interval [CI] 0.72 to 2.35, p = 0.38), major bleeding episodes (HR 1.2, 95% CI 0.45 to 3.33, p = 0.68), and stroke (HR 0.64, 95% CI 0.19 to 2.21, p = 0.49) at 3 years after the procedure in patients with and without cancer. There was no difference in the composite outcome (postprocedural mortality, stroke, and major bleeding) between the 2 groups (HR 1.25, CI 0.75 to 2.07, p = 0.38). Percutaneous left atrial appendage closure in patients with cancer appears to be safe and has a similar long-term risk compared with patients without cancer.
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Affiliation(s)
- Sundeep Kumar
- Division of Cardiology, Harrington Heart & Vascular Institute
| | - SungHan Yoon
- Division of Cardiology, Harrington Heart & Vascular Institute
| | - Ioannis Milioglou
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Nour Tashtish
- Division of Cardiology, Harrington Heart & Vascular Institute
| | - Ioannis Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | | | - Akhil Mogalapalli
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Mauricio Arruda
- Division of Cardiology, Harrington Heart & Vascular Institute
| | - Steven J Filby
- Division of Cardiology, Harrington Heart & Vascular Institute.
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12
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Couturaud F, Mahé I, Schmidt J, Gleize JC, Lafon T, Saighi A, Sedjelmaci F, Bertoletti L, Mismetti P. Adult breast, lung, pancreatic, upper and lower gastrointestinal cancer patients with hospitalized venous thromboembolism in the national French hospital discharge database. BMC Cancer 2023; 23:531. [PMID: 37301828 DOI: 10.1186/s12885-023-10877-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/23/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) and cancer are strongly associated. In France, evidence on patients with pancreatic, upper GI [gastrointestinal], lower GI, lung, or breast cancer-associated VTE and their hospital management is limited. The aims of this study were to provide data on the number of hospitalized VTE events among cancer patients, the patients' characteristics, and their hospital management to estimate the burden of disease and the hospital burden of cancer-related VTE and to provide guidance on research. METHODS This longitudinal, observational, and retrospective study was based on the comprehensive hospital discharge database (PMSI). Adult patients (≥ 18 years old) hospitalized with a cancer of interest in 2016 and hospitalized (within 2 years with VTE (captured a as a principal, related, or significant associated diagnosis) were included in the study. RESULTS We identified 340,946 cancer patients, of which 7.2% (24,433 patients) were hospitalized with VTE. The proportions of hospitalized VTE were 14.6% (3,237) for patients with pancreatic cancer, 11.2% (8,339) for lung cancer, 9.9% (2,232) for upper GI cancer, 6.7% (7,011) for lower GI cancer, and 3.1% (3,614) for breast cancer. Around two thirds of cancer patients with a hospitalized VTE had active cancer (with metastases and/or receiving chemotherapy during the six months prior to the index date): from 62% of patients with pancreatic cancer to 72% with breast cancer. Around a third of patients were admitted to the hospital through the emergency room, up to 3% of patients stayed in an intensive care unit. The average length of stay ranged from 10 (breast cancer) to 15 days (upper GI cancer). Nine (lower GI cancer) to 18% (pancreatic cancer) of patients died during the VTE hospital stay. CONCLUSIONS The burden of cancer-associated VTE is substantial, both in terms of the number of patients affected and in the hospital use. These findings offer guidance on future research on VTE prophylaxis in a very high-risk population, particularly in patients with active cancer.
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Affiliation(s)
- F Couturaud
- Univ Brest, INSERM U1304-GETBO, Département de médecine interne et pneumologie, CHU Brest, Brest, France.
- FCRIN INNOVTE, Saint-Etienne, France.
| | - I Mahé
- FCRIN INNOVTE, Saint-Etienne, France
- Université de Paris, APHP, Hôpital Louis Mourier, Service de Médecine Interne, Colombes, France
- Innovative Therapies in Haemostasis, INSERM, Paris, France
| | - J Schmidt
- FCRIN INNOVTE, Saint-Etienne, France
- CHU de Clermont-Ferrand, Clermont-Ferrand, France
| | | | | | | | | | - L Bertoletti
- FCRIN INNOVTE, Saint-Etienne, France
- Service de Médecine Vasculaire Et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU de Saint-Etienne, Saint-Etienne, France
| | - P Mismetti
- FCRIN INNOVTE, Saint-Etienne, France
- Service de Médecine Vasculaire Et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU de Saint-Etienne, Saint-Etienne, France
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Raposeiras-Roubín S, Abu-Assi E, Fernández Sanz T, Barreiro Pardal C, Muñoz Pousa I, Melendo Viu M, Domínguez Erquicia P, Ledo Piñeiro A, Lizancos Castro A, González Bermúdez I, Rosselló X, Ibáñez B, Íñiguez Romo A. Bleeding and embolic risk in patients with atrial fibrillation and cancer. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2023; 76:344-352. [PMID: 36321538 DOI: 10.1016/j.rec.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/19/2022] [Indexed: 04/29/2023]
Abstract
INTRODUCTION AND OBJECTIVES The impact of cancer on clinical outcomes in patients with atrial fibrillation (AF) is unclear. The aim of this study was to assess how cancer influences the prediction and risk of embolic and hemorrhagic events in patients with AF. METHODS The study population comprised 16 056 patients from a Spanish health area diagnosed with AF between 2014 and 2018. Of these, 1137 (7.1%) had a history of cancer. During a median follow-up of 4.9 years, we assessed the relationship between cancer and bleeding and embolic events by competing risk analysis, considering death as a competing risk. RESULTS No association was detected between an increased risk of embolic events and cancer overall (sHR, 0.73; 95%CI, 0.41-1.26), active cancer, or any subgroup of cancer. However, cancer was associated with an increased risk of bleeding, although only in patients with active cancer (sHR, 1.42; 95%CI, 1.20-1.67) or prior radiotherapy (sHR, 1.40; 95%CI, 1.19-1.65). Both the CHA2DS2-VASc and HAS-BLED scores showed suboptimal performance to predict embolic and bleeding risk (c-statistic <0.50), respectively, in nonanticoagulated patients with active cancer. The ratio between the increase in bleeding and the decrease in embolisms with anticoagulation was similar in patients with and without cancer (5.6 vs 7.8; P <.001). CONCLUSIONS Cancer was not associated with an increased risk of embolic events in AF patients, only with an increased risk of bleeding. However, active cancer worsened the ability of the CHA2DS2-VASc and HAS-BLED scores to predict embolic and bleeding events, respectively, in nonanticoagulated patients.
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Affiliation(s)
- Sergio Raposeiras-Roubín
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
| | - Emad Abu-Assi
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | | | | | - Isabel Muñoz Pousa
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Maria Melendo Viu
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | | | - Ana Ledo Piñeiro
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | - Andrea Lizancos Castro
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
| | | | - Xavier Rosselló
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Universitari Son Espases, Palma de Mallorca, Balearic Islands, Spain
| | - Borja Ibáñez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain; Servicio de Cardiología, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Andrés Íñiguez Romo
- Servicio de Cardiología, Hospital Universitario Álvaro Cunqueiro, Vigo, Pontevedra, Spain
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Shevell L, Ochs M, Schaefer J. Prophylactic Anticoagulation in Patients with Cancer: When and How? Curr Oncol Rep 2023; 25:201-209. [PMID: 36705880 DOI: 10.1007/s11912-023-01358-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Cancer-associated thrombosis is a leading cause of death among patients with cancer. Historically, thromboprophylaxis efforts have focused on the highest risk patients with cancer, including post-operative patients and hospitalized patients. This review covers not only thromboprophylaxis for these groups but also emerging data supporting prophylaxis in ambulatory medical oncology patients. RECENT FINDINGS Several leading guidelines, backed by clinical trial data, now support the use of direct oral anticoagulants for select high-risk outpatients for primary thromboprophylaxis. However, uptake of these findings remains low. Pharmacologic venous thromboembolism prophylaxis strategies continue to improve. However, it remains challenging to balance competing risks of bleeding and thrombosis. The morbidity and mortality associated with cancer associated thrombosis may be preventable. Understanding advancements in risk prediction, anticoagulant options, and implementation of existing data, is critical to provide optimal patient care.
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Affiliation(s)
- Lauren Shevell
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Madeleine Ochs
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Jordan Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
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15
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Alsheef M, Bazarbashi S, Warsi A, Alfraih F, Almoomen A, Osman A, Owaidah T. The Saudi Consensus for the Management of Cancer-Associated Thromboembolism: A Modified Delphi-Based Study. TH OPEN : COMPANION JOURNAL TO THROMBOSIS AND HAEMOSTASIS 2023; 7:e14-e29. [PMID: 36751300 PMCID: PMC9825204 DOI: 10.1055/s-0042-1758856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/10/2022] [Indexed: 01/09/2023]
Abstract
Background Cancer is a well-known risk factor of preventable thromboembolic disease. This study aims to provide guidance on the prevention and management of cancer-associated thrombosis (CT) that tailors prophylactic and therapeutic options for medical and surgical oncology patients presenting to health care settings in Saudi Arabia. Methods The present consensus was developed in concordance with the modified Delphi-based approach, which incorporates a face-to-face meeting between two voting rounds to gain experts' feedback on the proposed statements. All experts were either oncologists, hematologists, or hemato-oncologist with an active clinical and research profile in hemato-oncology. Results The experts highlighted that the comparatively high incidence of inherited thrombophilia among the Saudi population may account for a higher CT burden in the Kingdom than in other parts of the world. However, due to the lack of literature that assesses CT in Saudi Arabia, primary venous thromboembolism prophylaxis should be tailored according to a valid risk assessment of cancer patients and should be implemented in routine practice. For hospitalized medical oncology patients, the experts agreed that prophylaxis with low-molecular-weight heparin (LMWH) should be offered, regardless of the presence of acute illness. For ambulatory medical oncology patients, LMWH or direct oral anticoagulants (DOACs) prophylaxis should be offered for high-risk patients. Concerning surgical patients, they agreed that all oncology patients undergoing surgery should be offered thromboprophylaxis. In terms of secondary prophylaxis, the experts recommended continuing a prophylactic dose of anticoagulant (LMWH or DOAC), for an appropriate period depending on the cancer type and stage. Finally, they also provided a set of statements on management of CT in Saudi Arabia. Conclusion The present modified Delphi-based study combined the best available evidence and clinical experience with the current health care policies and settings in Saudi Arabia to build a consensus statement on the epidemiology, prevention, and management of CT.
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Affiliation(s)
- Mohammed Alsheef
- Department of Medicine, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Shouki Bazarbashi
- College of Medicine, Al-Faisal University Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Ashraf Warsi
- Department of Haematology, Ministry of National Guard-Health Affairs, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Jeddah, Saudi Arabia,Department of Medicine, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia
| | - Feras Alfraih
- College of Medicine, Al-Faisal University Medical Oncology, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | - Ahmed Osman
- Pfizer Pharmaceuticals, Riyadh, Saudia Arabia
| | - Tarek Owaidah
- Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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16
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Ballestri S, Romagnoli E, Arioli D, Coluccio V, Marrazzo A, Athanasiou A, Di Girolamo M, Cappi C, Marietta M, Capitelli M. Risk and Management of Bleeding Complications with Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Venous Thromboembolism: a Narrative Review. Adv Ther 2023; 40:41-66. [PMID: 36244055 PMCID: PMC9569921 DOI: 10.1007/s12325-022-02333-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/21/2022] [Indexed: 01/25/2023]
Abstract
Atrial fibrillation (AF) and venous thromboembolism (VTE) are highly prevalent conditions with a significant healthcare burden, and represent the main indications for anticoagulation. Direct oral anticoagulants (DOACs) are the first choice treatment of AF/VTE, and have become the most prescribed class of anticoagulants globally, overtaking vitamin K antagonists (VKAs). Compared to VKAs, DOACs have a similar or better efficacy/safety profile, with reduced risk of intracerebral hemorrhage (ICH), while the risk of major bleeding and other bleeding harms may vary depending on the type of DOAC. We have critically reviewed available evidence from randomized controlled trials and observational studies regarding the risk of bleeding complications of DOACs compared to VKAs in patients with AF and VTE. Special patient populations (e.g., elderly, extreme body weights, chronic kidney disease) have specifically been addressed. Management of bleeding complications and possible resumption of anticoagulation, in particular after ICH and gastrointestinal bleeding, are also discussed. Finally, some suggestions are provided to choose the optimal DOAC to minimize adverse events according to individual patient characteristics and bleeding risk.
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Affiliation(s)
- Stefano Ballestri
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy.
| | - Elisa Romagnoli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Dimitriy Arioli
- Internal Medicine and Critical Care Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Valeria Coluccio
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Alessandra Marrazzo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Afroditi Athanasiou
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Maria Di Girolamo
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Cinzia Cappi
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
| | - Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Mariano Capitelli
- Internal Medicine Unit, Hospital of Pavullo-Department of Internal Medicine, Azienda USL, 41126, Pavullo, Modena, Italy
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Andreani L, Del Chiaro A, Ipponi E, Di Sacco F, Caterino M, Capanna R. Use of Tranexamic Acid to Reduce PostOperative Bleeding in Orthopaedic Oncology. Acta Med Litu 2022. [DOI: 10.15388/amed.2022.29.2.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Orthopaedic oncology often causes major blood losses that may put at risk patients’ hemodynamic balance and their overall clinical stability. To this date, transfusion therapy still represents the pivotal treatment to counterbalance the reduction in hemoglobin levels which occur after surgery. Although effective, transfusions are expensive and inevitably associated with a number of complications and therefore other solutions, such as procoagulative drugs, could play an important role to prevent massive blood losses.Material and methods: We reviewed the clinical intercourse of 37 patients who underwent major bone resection due to malignant tumors of the lower limb. Cases were divided in two different groups: group G1 consisting of 12 patients treated intraoperatively with tranexamic acid and group G2 which was made of 25 controls.Results: On average, patients treated with tranexamic acid (G1) required transfusion of 3.9 concentrated blood cells units during surgery and 0.9 units during the postoperative course. Other patients (G2), for their part, required on average 3.1 units intraoperatively and 2.1 units postoperatively. No significant difference was found in intraoperative transfusion rate (p=0.402). Instead, postoperative transfusions were significantly less frequent for patients treated with tranexamic acid (p=0.023). None of the 12 patients treated with tranexamic acid had evidence of Deep Vein Thrombosis.Conclusion: Our outcomes indicate that the use of TXA was effective in reducing blood losses also for major surgical interventions in orthopedic oncology.
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Goshua G, Bendapudi PK, Lee AI. Thrombosis questions from the inpatient wards. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:481-490. [PMID: 36485139 PMCID: PMC9819989 DOI: 10.1182/hematology.2022000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The multifaceted pathophysiologic processes that comprise thrombosis and thromboembolic diseases take on a particular urgency in the hospitalized setting. In this review, we explore 3 cases of thrombosis from the inpatient wards: purpura fulminans, cancer-associated thrombosis with thrombocytopenia, and coronavirus disease 2019 (COVID-19) and the use of dose-escalated anticoagulation therapy and antiplatelet agents. We discuss the evaluation and management of purpura fulminans and the roles of plasma transfusion, protein C and antithrombin replacement, and anticoagulation in treating this disease. We present a framework for evaluating the etiologies of thrombocytopenia in cancer and review 2 strategies for anticoagulation management in patients with cancer-associated thrombosis and thrombocytopenia, including recent prospective data supporting the use of dose-modified anticoagulation based on platelet count. Last, we dissect the major clinical trials of therapeutic- and intermediate-dose anticoagulation and antiplatelet therapy in hospitalized patients with COVID-19, reviewing key recommendations from consensus guidelines while highlighting ways in which institutional and patient-tailored practices regarding antithrombotic therapies in COVID-19 may differ. Together, the cases highlight the diverse and dramatic presentations of macro- and microvascular thrombosis as encountered on the inpatient wards.
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Affiliation(s)
- George Goshua
- Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Pavan K Bendapudi
- Division of Hematology, Blood Transfusion Service, Massachusetts General Hospital; Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center; and Harvard Medical School, Boston, MA
| | - Alfred Ian Lee
- Section of Hematology, Yale School of Medicine, New Haven, CT
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Riesgo hemorrágico y embólico de los pacientes con fibrilación auricular y cáncer. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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20
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Catheter-Directed Interventions for the Treatment of Lower Extremity Deep Vein Thrombosis. LIFE (BASEL, SWITZERLAND) 2022; 12:life12121984. [PMID: 36556349 PMCID: PMC9783165 DOI: 10.3390/life12121984] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 11/29/2022]
Abstract
Lower extremity deep vein thrombosis (DVT) leads to significant morbidity including pain, swelling, and difficulty walking in the affected limb. If left untreated, DVT increases the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE), and post thrombotic syndrome (PTS). The objective of this review was to identify catheter-directed interventions and their success rates for the treatment of lower extremity DVT. A comprehensive search of current and emerging catheter-directed interventions for lower extremity DVT treatment was conducted in PubMed and Google Scholar. Clinical trials, retrospective and prospective observational studies, and case reports were identified to classify percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), and pharmacomechanical CDT (PCDT) devices based on their mechanism of action and indication of use. Catheter-directed interventions such as PMT, CDT, and PCDT offer an alternative therapeutic strategy for DVT management, particularly in patients with limb-threatening conditions and absolute contraindications to anticoagulants. Currently, there are limited guidelines for the use of mechanical and pharmacomechanical devices because of the lack of clinical evidence available for their use in treatment. Future studies are required to determine the short and long-term effects of using catheter-directed interventions as well as their effectiveness in treating acute versus subacute and chronic DVT.
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21
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Sex and Circadian Timing Modulate Oxaliplatin Hematological and Hematopoietic Toxicities. Pharmaceutics 2022; 14:pharmaceutics14112465. [PMID: 36432655 PMCID: PMC9699532 DOI: 10.3390/pharmaceutics14112465] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/24/2022] [Accepted: 10/30/2022] [Indexed: 11/17/2022] Open
Abstract
Oxaliplatin was nearly twice as hematotoxic, with optimal circadian timing differing by 6 h, in women as compared to men with colorectal cancers. Hence, we investigated sex- and timing-related determinants of oxaliplatin hematopoietic toxicities in mice. Body-weight loss (BWL), blood cell counts, bone marrow cellularity (BMC) and seven flow-cytometry-monitored hematopoietic progenitor populations were evaluated 72 h after oxaliplatin chronotherapy administration (5 mg/kg). In control animals, circadian rhythms of circulating white blood cells showed a peak at ZT5 in both sexes, whereas BMC was maximum at ZT20 in males and ZT13h40 in females. All BM progenitor counts presented robust rhythms with phases around ZT3h30 in females, whereas only three of them rhythmically cycled in males with a ≈ -6 h phase shift. In treated females, chronotoxicity rhythms occurred in BWL, WBC, BMC and all BM progenitors with the best timing at ZT15, ZT21, ZT15h15 and ZT14h45, respectively. In males, almost no endpoints showed circadian rhythms, BWL and WBC toxicity being minimal, albeit with a substantial drop in BM progenitors. Increasing dose (10 mg/kg) in males induced circadian rhythms in BWL and WBC but not in BM endpoints. Our results suggest complex and sex-specific clock-controlled regulation of the hematopoietic system and its response to oxaliplatin.
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22
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J 2022; 43:4229-4361. [PMID: 36017568 DOI: 10.1093/eurheartj/ehac244] [Citation(s) in RCA: 666] [Impact Index Per Article: 333.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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23
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Højen AA, Nielsen PB, Overvad TF, Albertsen IE, Klok FA, Rolving N, Søgaard M, Ording AG. Long-Term Management of Pulmonary Embolism: A Review of Consequences, Treatment, and Rehabilitation. J Clin Med 2022; 11:jcm11195970. [PMID: 36233833 PMCID: PMC9571065 DOI: 10.3390/jcm11195970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 09/29/2022] [Accepted: 10/01/2022] [Indexed: 12/02/2022] Open
Abstract
The concept of pulmonary embolism is evolving. Recent and emerging evidence on the treatment of specific patient populations, its secondary prevention, long-term complications, and the unmet need for rehabilitation has the potential to change clinical practice for the benefit of the patients. This review discusses the recent evidence from clinical trials, observational studies, and guidelines focusing on anticoagulation treatment, rehabilitation, emotional stress, quality of life, and the associated outcomes for patients with pulmonary embolism. Guidelines suggest that the type and duration of treatment with anticoagulation should be based on prevalent risk factors. Recent studies demonstrate that an anticoagulant treatment that is longer than two years may be effective and safe for some patients. The evidence for extended treatment in cancer patients is limited. Careful consideration is particularly necessary for pulmonary embolisms in pregnancy, cancer, and at the end of life. The rehabilitation and prevention of unnecessary deconditioning, emotional distress, and a reduced quality of life is an important, but currently they are unmet priorities for many patients with a pulmonary embolism. Future research could demonstrate optimal anticoagulant therapy durations, follow-ups, and rehabilitation, and effective patient-centered decision making at the end of life. A patient preferences and shared decision making should be incorporated in their routine care when weighing the benefits and risks with primary treatment and secondary prevention.
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Affiliation(s)
- Anette Arbjerg Højen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Peter Brønnum Nielsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Thure Filskov Overvad
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Clinical Pharmacology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Ida Ehlers Albertsen
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, 2333 Leiden, The Netherlands
| | - Nanna Rolving
- Department of Physical and Occupational Therapy, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Public Health, Aarhus University, 8200 Aarhus, Denmark
| | - Mette Søgaard
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Medicine, Aalborg University, 9000 Aalborg, Denmark
| | - Anne Gulbech Ording
- Unit for Thrombosis and Drug Research, Aalborg University Hospital, 9000 Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, 9000 Aalborg, Denmark
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24
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Matzdorff A. Venous Thromboembolism in Women with Cancer with an Additional Focus on Breast and Gynecological Cancers. Hamostaseologie 2022; 42:309-319. [DOI: 10.1055/a-1913-2873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AbstractCancer-associated venous thromboembolism (VTE) is common in women with cancer. Many clinical practice guidelines provide guidance for prevention and treatment; however, there are no specific recommendations for women. This is unfortunate because the proportion of women with breast- and gynecological cancers is high among patients with cancer-associated VTE. Thromboembolism often heralds cancer progression and poor prognosis and should—besides adequate anticoagulant management—also prompt reassessment and, if necessary, changes in cancer treatment. Recently, the new class of direct-acting oral anticoagulants (DOACs) has started to replace low-molecular-weight heparin as standard thromboprophylaxis and therapy in cancer patients. They are very effective, but they also carry a relevant risk of bleeding. Therefore, despite their ease of use, not every tumor patient qualifies for a DOAC, and this is especially true for gynecological tumor patients. Each prescription must be weighed individually. This review addresses specific aspects of VTE prophylaxis and management in women with cancer. Every physician who treats breast and gynecological cancers should be familiar with prophylaxis, diagnosis, and therapy of cancer-associated VTE. At the same time, patients should be informed by their physician what symptoms to look for and whom to contact if these symptoms occur, even outside of office hours and on weekends.
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Affiliation(s)
- Axel Matzdorff
- Department of Internal Medicine II, Asklepios Clinic Uckermark, Schwedt, Germany
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25
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Lyon AR, López-Fernández T, Couch LS, Asteggiano R, Aznar MC, Bergler-Klein J, Boriani G, Cardinale D, Cordoba R, Cosyns B, Cutter DJ, de Azambuja E, de Boer RA, Dent SF, Farmakis D, Gevaert SA, Gorog DA, Herrmann J, Lenihan D, Moslehi J, Moura B, Salinger SS, Stephens R, Suter TM, Szmit S, Tamargo J, Thavendiranathan P, Tocchetti CG, van der Meer P, van der Pal HJH. 2022 ESC Guidelines on cardio-oncology developed in collaboration with the European Hematology Association (EHA), the European Society for Therapeutic Radiology and Oncology (ESTRO) and the International Cardio-Oncology Society (IC-OS). Eur Heart J Cardiovasc Imaging 2022; 23:e333-e465. [PMID: 36017575 DOI: 10.1093/ehjci/jeac106] [Citation(s) in RCA: 87] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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26
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and Mitigation of Bleeding Risk in Atrial Fibrillation and Venous Thromboembolism: Executive Summary of a European and Asia-Pacific Expert Consensus Paper. Thromb Haemost 2022; 122:1625-1652. [PMID: 35793691 DOI: 10.1055/s-0042-1750385] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
While there is a clear clinical benefit of oral anticoagulation in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision for initiating and continuing anticoagulation is often based on a careful assessment of both thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static "one-off" assessment based on baseline factors but is dynamic, being influenced by aging, incident comorbidities, and drug therapies. In this executive summary of a European and Asia-Pacific Expert Consensus Paper, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with a view to summarizing "best practice" when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, and review established bleeding risk factors and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism, are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hertfordshire, United Kingdom.,Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge and Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, L'Hospitalet de Llobregat, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, Spain
| | - Andrea Rubboli
- Department of Cardiovascular Diseases - AUSL Romagna, Division of Cardiology, S. Maria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, München, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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27
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Raposeiras-Roubin S, Abu-Assi E, Marchán A, Fernández-Sanz T, Barreiro-Pardal C, Pousa IM, Erquicia PD, Ledo-Piñeiro A, González-Bermúdez I, Viu MM, Íñiguez-Romo A. Validation of Embolic and Bleeding Risk Scores in Patients With Atrial Fibrillation and Cancer. Am J Cardiol 2022; 180:44-51. [DOI: 10.1016/j.amjcard.2022.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 06/18/2022] [Accepted: 06/22/2022] [Indexed: 11/29/2022]
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28
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Wan Puteh SE, Ibrahim R, Yusak S, Nik Adnan NN, Ahmat ANMF. Cancer-Associated Thrombosis: Implications toward Health-Related Quality of Life. Semin Thromb Hemost 2022; 48:490-496. [PMID: 35772403 DOI: 10.1055/s-0042-1744365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Sharifa Ezat Wan Puteh
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Roszita Ibrahim
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
| | - Suhana Yusak
- Department of Radiotherapy and Oncology, National Cancer Institute, Putrajaya, Malaysia
| | | | - Azmi Nor Mohd Farez Ahmat
- Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.,Department of Pharmacy, National Cancer Institute, Putrajaya, Malaysia
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29
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Held N, Jung B, Baumann Kreuziger L. Management of cancer-associated thrombosis with thrombocytopenia: Impact of the ISTH guidance statement. Res Pract Thromb Haemost 2022; 6:e12726. [PMID: 35664532 PMCID: PMC9133434 DOI: 10.1002/rth2.12726] [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: 06/17/2021] [Revised: 04/01/2022] [Accepted: 04/12/2022] [Indexed: 11/09/2022] Open
Abstract
Background Optimal management of cancer-associated thrombosis (CAT) in patients with thrombocytopenia remains difficult given competing risks of recurrent thrombosis and increased bleeding. We determine the impact of the ISTH Scientific and Standardization Committee (SCC) guidance on CAT management and thrombocytopenia on platelet transfusion, bleeding, and recurrent thrombosis. Methods A retrospective review was performed of patients with CAT and thrombocytopenia who required anticoagulation for VTE for 11 months before and after implementation of the ISTH SCC guidance. Medical records were reviewed to identify the type of VTE event, number of platelet transfusions, incidence of bleeding, and VTE recurrence within pre- and postintervention time periods. Results A total of 41 and 80 cases were included in the preintervention and postintervention periods, respectively. The preintervention group showed a trend toward less acute VTE events (39% vs 55%; P = .05). The postintervention period had an increased per-patient platelet transfusion (median, 2.5 vs 4; P = .05). Nonmajor bleeding was increased in the postintervention group (2% vs 16%; P = 0.03) and included all six (8%) major hemorrhages (P = .09). There was numerically less recurrent thrombosis in the postintervention group (20% vs 8%; P = .07), which was not significantly different when accounting for acuity of VTE. Management adherence was strong, at 91%, in the postintervention group. Conclusion The ISTH guidance on management of cancer-associated thrombosis in patients with thrombocytopenia was successfully implemented in an academic medical center. There was no significant difference in bleeding or recurrent thrombosis outcomes after adjusting for acuity of VTE.
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Affiliation(s)
- Nicole Held
- Division of Hematology/Oncology, Department of MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
| | | | - Lisa Baumann Kreuziger
- Division of Hematology/Oncology, Department of MedicineMedical College of WisconsinMilwaukeeWisconsinUSA
- Versiti Blood Research InstituteMilwaukeeWisconsinUSA
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30
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Gorog DA, Gue YX, Chao TF, Fauchier L, Ferreiro JL, Huber K, Konstantinidis SV, Lane DA, Marin F, Oldgren J, Potpara T, Roldan V, Rubboli A, Sibbing D, Tse HF, Vilahur G, Lip GYH. Assessment and mitigation of bleeding risk in atrial fibrillation and venous thromboembolism: A Position Paper from the ESC Working Group on Thrombosis, in collaboration with the European Heart Rhythm Association, the Association for Acute CardioVascular Care and the Asia-Pacific Heart Rhythm Society. Europace 2022; 24:1844-1871. [PMID: 35323922 DOI: 10.1093/europace/euac020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/08/2022] [Indexed: 12/26/2022] Open
Abstract
Whilst there is a clear clinical benefit of oral anticoagulation (OAC) in patients with atrial fibrillation (AF) and venous thromboembolism (VTE) in reducing the risks of thromboembolism, major bleeding events (especially intracranial bleeds) may still occur and be devastating. The decision to initiate and continue anticoagulation is often based on a careful assessment of both the thromboembolism and bleeding risk. The more common and validated bleeding risk factors have been used to formulate bleeding risk stratification scores, but thromboembolism and bleeding risk factors often overlap. Also, many factors that increase bleeding risk are transient and modifiable, such as variable international normalized ratio values, surgical procedures, vascular procedures, or drug-drug and food-drug interactions. Bleeding risk is also not a static 'one off' assessment based on baseline factors but is dynamic, being influenced by ageing, incident comorbidities, and drug therapies. In this Consensus Document, we comprehensively review the published evidence and propose a consensus on bleeding risk assessments in patients with AF and VTE, with the view to summarizing 'best practice' when approaching antithrombotic therapy in these patients. We address the epidemiology and size of the problem of bleeding risk in AF and VTE, review established bleeding risk factors, and summarize definitions of bleeding. Patient values and preferences, balancing the risk of bleeding against thromboembolism are reviewed, and the prognostic implications of bleeding are discussed. We propose consensus statements that may help to define evidence gaps and assist in everyday clinical practice.
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Affiliation(s)
- Diana A Gorog
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK.,Faculty of Medicine, National Heart & Lung Institute, Imperial College, London, UK
| | - Ying X Gue
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Jose Luis Ferreiro
- Department of Cardiology, Hospital Universitario de Bellvitge, Ciber Cardiovascular (CIBERCV), L'Hospitalet de Llobregat, Barcelona, Spain.,BIOHEART-Cardiovascular Diseases Group, Cardiovascular, Respiratory and Systemic Diseases and Cellular Aging Program, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital and Sigmund Freud University, Medical Faculty, Vienna, Austria
| | - Stavros V Konstantinidis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Francisco Marin
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca (IMIB-Arrixaca), CIBERCV, Universidad de Murcia, Murcia, Spain
| | - Jonas Oldgren
- Department of Medical Sciences, Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Vanessa Roldan
- Servicio de Hematología, Hospital Universitario Morales Meseguer, Universidad de Murcia, IMIB-Arrixaca, Murcia, España
| | - Andrea Rubboli
- Division of Cardiology, Department of Cardiovascular Diseases-AUSL Romagna, SMaria delle Croci Hospital, Ravenna, Italy
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians-Universität München, Munich, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Hung-Fat Tse
- Division of Cardiology, Department of Medicine, University of Hong Kong, Hong Kong, Hong Kong
| | - Gemma Vilahur
- Research Institute Hospital de la Santa Creu i Sant Pau, IIB-Sant Pau, Barcelona, Spain.,CIBERCV Instituto de Salud Carlos III, Barcelona, Spain
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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31
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Incidence and Predictors of Bleeding in Patients With Cancer and Atrial Fibrillation. Am J Cardiol 2022; 167:139-146. [PMID: 35027138 DOI: 10.1016/j.amjcard.2021.11.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 11/24/2021] [Accepted: 11/29/2021] [Indexed: 11/22/2022]
Abstract
Despite patients with cancer having a higher incidence of atrial fibrillation (AF), little is known about the predictors of outcomes in this population. This study aimed to assess the incidence and predictors of bleeding in patients with AF and cancer. The study population comprised 16,056 patients from a Spanish health area diagnosed with AF between 2014 and 2018 (1,137 with cancer). Competing risk analysis were used to evaluate the association of cancer and bleeding. Discrimination and calibration of bleeding risk scores were assessed by the concordance statistic and the Brier score, respectively. During a median follow-up of 4.9 years, the incidence of bleeding in patients with cancer was 13.2 per 100 patients/year. After multivariate adjustment, a significant association between cancer and bleeding was detected (subdistribution hazard ratio [sHR] 1.18, 95% CI 1.07 to 1.30, p = 0.001), specifically in patients with active cancer or previous radiotherapy. Early age, male gender, diabetes, and anticoagulation were independent predictors of bleeding. However, only anticoagulation with vitamin K antagonist (sHR 1.36, 95% CI 1.03 to 1.78, p = 0.026), not with direct oral anticoagulants (sHR 1.25, 95% CI 0.84 to 1.85, p = 0.270), was associated with bleeding. Discrimination and calibration of Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, and Drugs/alcohol concomitantly (HAS-BLED), AnTicoagulation and Risk factors In Atrial fibrillation (ATRIA), and Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age ≥75 years), Reduced platelet count or function, Rebleeding risk, Hypertension, Anaemia, Genetic factors, Excessive fall risk and Stroke (HEMORR2HAGES) scores were poor in patients with cancer (concordance statistic <0.6 and Brier score >0.1). In summary, cancer was associated with an increased risk of bleeding in patients with AF. The predictive ability of bleeding risk scores was poor in this population. Anticoagulation with vitamin K antagonist but not with direct oral anticoagulants, was an independent predictor of bleeding in patients with cancer.
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32
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Allende-Pérez SR, Cesarman-Maus G, Peña-Nieves A, Arcos A, Baz-Gutiérrez P, Robles J, LeBlanc TW. Venous Thromboembolism in Patients with Cancer Receiving Specialist Palliative Care. Clin Appl Thromb Hemost 2022; 28:10760296221081121. [PMID: 35225029 PMCID: PMC8894932 DOI: 10.1177/10760296221081121] [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: 11/16/2022] Open
Abstract
Context The prevalence of venous thromboembolism (VTE) in patients with cancer is particularly high at disease progression and during relapse. Patients cared for in specialized palliative care units (SPCU) are rarely included in VTE studies. Objective: We sought to study the prevalence, clinical characteristics, and survival of individuals with VTE in an SPCU setting. Methods We retrospectively included 2707 consecutive individuals with active cancer managed at a SPCU. Data were summarized using descriptive statistics and frequency for categorical variables. Overall survival was estimated by Kaplan-Meier and comparisons by log-rank test. Thrombotic events were confirmed by imaging. Results We studied 1984(73.3%) women and 723 (26.7%) men. The overall prevalence of thrombosis was 22.2% with only 6.2% occurring after initiating SPCU care, and was higher in women (24.6% vs 15.8%), particularly with gynecological tumors (cervical: 30.5%, ovarian: 29.2%). Median survival was slightly longer for patients without VTE (80 days [IQR21-334] and 69 days [IQR 25-235]; p = 0.03). Conclusions Prevalence of VTE was high and varied by tumor origin. VTE may impact survival. Though median survival is short, some patients are followed over months, suggesting that in the absence of high bleeding risk, treatment for thrombosis in an attempt to decrease the morbidity of re-thrombosis should be considered. On the other hand, few patients developed symptomatic VTE during SPCU care, making generalized primary prophylaxis probably unwarranted. Customizing anticoagulation for the risk of hemorrhage and physical performance is essential.
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Affiliation(s)
| | | | | | - Amelia Arcos
- Palliative Care Service, Mexican Secretariat of the Navy, Mexico City, Mexico
| | | | - Joanna Robles
- 12277Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas W LeBlanc
- Department of Medicine, Hematologic malignancies and cellular therapy, Duke University School of Medicine Durham, Durham, North Carolina, USA
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33
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Al-Samkari H, Kolb-Sielecki J, Safina SZ, Xue X, Jamieson BD. Avatrombopag for chemotherapy-induced thrombocytopenia in patients with non-haematological malignancies: an international, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet Haematol 2022; 9:e179-e189. [DOI: 10.1016/s2352-3026(22)00001-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 12/15/2022]
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34
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[60/m-Cancer-related venous thromboembolism : Preparation for the medical specialist examination: part 128]. Internist (Berl) 2021; 63:153-158. [PMID: 34757457 DOI: 10.1007/s00108-021-01204-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
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35
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Wang CL, Wu VCC, Tu HT, Huang YT, Chen SW, Chu PH, Wen MS, Huang HL, Chang SH. Risk of major bleeding associated with concomitant use of anticancer drugs and direct oral anticoagulant in patients with cancer and atrial fibrillation. J Thromb Thrombolysis 2021; 53:633-645. [PMID: 34557973 DOI: 10.1007/s11239-021-02570-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2021] [Indexed: 12/21/2022]
Abstract
This study evaluated the risk of major bleeding associated with concomitant use of direct oral anticoagulant (DOAC) and anticancer drugs (ACDs), which share metabolic pathways, in patients with atrial fibrillation (AF) and cancer. We performed a retrospective cohort study using Taiwan's National Health Insurance database and included patients with AF and cancer who received DOAC prescriptions from 1 to 2012 to 31 December 2017. The incidence of major bleeding in person-quarters with concomitant use of DOAC and any of 15 ACDs with inhibitory or competitive effects of CYP3A4 or P-gp activity (docetaxel, vinorelbine, methotrexate, irinotecan, etoposide, doxorubicin, cyclophosphamide, imatinib, nilotinib, abiraterone, bicalutamide, tamoxifen, anastrozole, cyclosporine, tacrolimus) was compared with that in person-quarters with DOAC alone. Adjusted incidence-rate differences between DOAC use with and without concurrent ACDs were estimated using Poisson regression models weighted by the inverse probability of treatment. In 13,158 patients with AF and cancer (76.9 ± 8.9 years; male 60%), 1545 major bleeding events occurred during 90,540 DOAC-exposed person-quarters. Concurrent use of DOAC and any of 15 ACDs occurred in only 18% of patients. Compared with use of DOAC alone, concomitant use of DOAC and these ACDs was not associated with an increased risk of major bleeding. Co-medication with DOAC and ACDs with inhibitory or competitive effects on CYP3A4 or P-gp activity was not associated with a higher risk of major bleeding than DOAC alone. Our findings may provide clinicians with confidence regarding the safety of concurrent use of DOAC and ACDs in patients with AF and cancer.
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Affiliation(s)
- Chun-Li Wang
- Division of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Victor Chien-Chia Wu
- Division of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Hui-Tzu Tu
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yu-Tung Huang
- Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan
| | - Shao-Wei Chen
- College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of Cardiothoracic and Vascular Surgery, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Hsuan-Li Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Tzu Chi Hospital, New Taipei City, Taiwan. .,School of Post-baccalaureate Chinese Medicine, Tzu Chi University, Hualien, Taiwan.
| | - Shang-Hung Chang
- Division of Cardiology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan City, Taiwan. .,Center for Big Data Analytics and Statistics, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan City, Taiwan. .,Graduate Institute of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan.
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Falanga A, Gal GL, Carrier M, Abdel-Razeq H, Ay C, Martin AJM, Rocha ATC, Agnelli G, Elalamy I, Brenner B. Management of Cancer-Associated Thrombosis: Unmet Needs and Future Perspectives. TH OPEN 2021; 5:e376-e386. [PMID: 34485812 PMCID: PMC8407937 DOI: 10.1055/s-0041-1736037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 06/29/2021] [Indexed: 12/28/2022] Open
Abstract
Patients with cancer are at a high risk of symptomatic venous thromboembolism (VTE), which is a common cause of morbidity and mortality in this patient population. Increased risk of recurrent VTE and bleeding complications are two major challenges associated with therapeutic anticoagulation in these patients. Long-term therapy with low-molecular-weight heparins (LMWHs) has been the standard of care for the treatment of cancer-associated VTE given its favorable risk–benefit ratio in comparison with vitamin K antagonists. Direct oral anticoagulants (DOACs), which offer the convenience of oral administration and have a rapid onset of action, have recently emerged as a new treatment option for patients with cancer-associated thrombosis (CT). Randomized clinical trial data with head-to-head comparisons between DOACs and LMWHs showed that overall, DOACs have a similar efficacy profile but a higher risk of bleeding was observed in some of these studies. This review aims to identify unmet needs in the treatment of CT. We discuss important considerations for clinicians tailoring anticoagulation (1) drug–drug interactions, (2) risk of bleeding (e.g., gastrointestinal bleeding), (3) thrombocytopenia, hematological malignancies, (4) metastatic or primary brain tumors, and (5) renal impairment. Additional research is warranted in several clinical scenarios to help clinicians on the best therapeutic approach.
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Affiliation(s)
- Anna Falanga
- Department of Medicine and Surgery, School of Medicine, University of Milano-Bicocca, Monza, Italy.,Department of Immunohematology and Transfusion Medicine, Thrombosis and Hemostasis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Grégoire Le Gal
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine, Comprehensive Cancer Center Vienna, Medical University of Vienna, Vienna, Austria.,Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Andrés J Muñoz Martin
- Medical Oncology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Ana Thereza Cavalcanti Rocha
- Departamento de Saúde da Família, Faculdade de Medicina da Bahia, Universidade Federal da Bahia - UFBA, Salvador, BA, Brazil
| | - Giancarlo Agnelli
- Internal Vascular and Emergency Medicine - Stroke Unit, University of Perugia, Perugia, Italy
| | - Ismail Elalamy
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia.,Hematology and Thrombosis Centre, Hôpital Tenon, INSERM U938, Sorbonne Université, AP-HP, Paris, France
| | - Benjamin Brenner
- Department of Obstetrics and Gynecology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Hematology, Rambam Health Care Campus, Haifa, Israel
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Benzidia I, Crichi B, Montlahuc C, Rafii H, N'Dour A, Sebuhyan M, Gauthier H, Ait Abdallah N, Benillouche P, Villiers S, Le Maignan C, Farge D. Effectiveness of a multidisciplinary care program for the management of venous thromboembolism in cancer patients: a pilot study. J Thromb Thrombolysis 2021; 53:417-424. [PMID: 34296382 DOI: 10.1007/s11239-021-02512-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Treatment of Venous thromboembolism (VTE) in cancer patients is challenging due to higher risk of VTE recurrence or bleeding under anticoagulants. We assessed the effectiveness of a dedicated "Allo-Thrombosis Cancer" multidisciplinary care program (AlloTC-MCP) that incorporated individualized care, regular follow-ups, telephone counselling, and a patient education program. METHODS AND MATERIALS From September 2017 to October 2019, 100 consecutive cancer patients with new VTE onset were enrolled in this observational single-center prospective pilot study and received standard (control group, n = first 50 patients enrolled) or AlloTC-MCP care (n = next 50 patients enrolled) over a 6-month VTE treatment follow-up period. Primary end-point was the percentage of adherence to the International Clinical Practice Guidelines (ITAC-CPGs) at 6 (M6) month follow-up. RESULTS Among the 100 patients with different cancer types (22% genitourinary, 19% breast, 16% gastrointestinal, 15% lymphoma, 11% lung and 17% others), 51 patients (61%) had metastatic disease and 31 (31%) received chemotherapy alone. Main baseline cancer and VTE clinical characteristics did not differ between the 2 groups. Adherence rates to ITAC-CPGs was significantly higher in the AlloTC-MCP group (100% (M0), 72% (M3) and 68% (M6)) compared with the control group (84% (M0), 8% (M3) and 16% (M6)). Quality of Life (QoL) was significantly improved in the AlloTC-MCP group 6 months after inclusion. CONCLUSION The "AlloTC-MCP" was associated with improved adherence to ITAC-CPGs and merits further expansion.
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Affiliation(s)
- Ilham Benzidia
- Internal Medicine: Autoimmune and Vascular Disease Unit (UF04), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Benjamin Crichi
- Internal Medicine: Autoimmune and Vascular Disease Unit (UF04), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Claire Montlahuc
- Clinical Research Unit Lariboisière Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Hanadi Rafii
- Université de Paris, IRSL, EA-3518, Recherche clinique appliquée à l'hématologie, F-75010, Paris, France
| | - Arlette N'Dour
- Internal Medicine: Autoimmune and Vascular Disease Unit (UF04), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Maxime Sebuhyan
- Internal Medicine: Autoimmune and Vascular Disease Unit (UF04), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Hélène Gauthier
- Department of Medical Oncology, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Nassim Ait Abdallah
- Internal Medicine: Autoimmune and Vascular Disease Unit (UF04), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France
| | - Philippe Benillouche
- C.S.E. Radiology and Medical Imaging Center, 13 Rue Beaurepaire, 75010, Paris, France
| | - Stéphane Villiers
- Department of Anesthesiology, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Christine Le Maignan
- Department of Medical Oncology, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Dominique Farge
- Internal Medicine: Autoimmune and Vascular Disease Unit (UF04), Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 1 Avenue Claude Vellefaux, 75010, Paris, France. .,Université de Paris, IRSL, EA-3518, Recherche clinique appliquée à l'hématologie, F-75010, Paris, France. .,Department of Medicine, McGill University, Montreal, QC, Canada.
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Knoll W, Fergusson N, Ivankovic V, Wang TF, Caiano L, Auer R, Carrier M. Extended thromboprophylaxis following major abdominal/pelvic cancer-related surgery: A systematic review and meta-analysis of the literature. Thromb Res 2021; 204:114-122. [PMID: 34175749 DOI: 10.1016/j.thromres.2021.06.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Postoperative venous thromboembolism (VTE) is a significant source of morbidity and mortality in cancer patients undergoing major abdominopelvic surgery. Many guidelines recommend the use of extended duration postoperative low molecular weight heparin (LMWH) thromboprophylaxis, although the evidence for its overall safety and efficacy is unclear. AIMS We sought to assess the 30-day postoperative rates of VTE and bleeding complications following major abdominopelvic cancer surgery and to explore the potential risks and benefits of extended duration thromboprophylaxis with LMWH in such setting. METHODS A systematic search of the literature was conducted. Observational studies and RCTs of adult patients that underwent abdominopelvic cancer surgery were included. Pooled proportions for the outcome measures and pooled relative risks for the extended duration thromboprophylaxis analyses were generated. RESULTS A total of 68 studies (1,631,118 patients) were included in the analysis. The 30-day postoperative rate of VTE was 1.7% (95%CI: 1.5 to 1.9, I2 = 98%). The postoperative rate of clinically-relevant bleeding complications was 3.5% (95%CI: 1.6 to 6.1, I2 = 99%). Extended duration thromboprophylaxis was associated with a significant reduction in the incidence of clinical VTE (1.0% vs 2.1%; Risk ratio (RR) 0.48, 95%CI: 0.31 to 0.74; I2 = 0), without a significant increase in clinically-relevant bleeding (4.0% vs. 4.9%; RR 1.0, 95%CI: 0.66 to 1.5, I2 = 0). CONCLUSIONS The overall risk of symptomatic VTE within 30 days of surgery was relatively low. Extended LMWH thromboprophylaxis following major abdominopelvic cancer surgery was associated with a reduced incidence of clinical VTE without an increase in clinically-relevant bleeding.
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Affiliation(s)
- William Knoll
- Faculty of Medicine, Queen's University, Kingston, Canada; Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Nathan Fergusson
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Victoria Ivankovic
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Tzu-Fei Wang
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lucia Caiano
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Rebecca Auer
- Department of Surgery, University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine University of Ottawa, The Ottawa Hospital Research Institute, Ottawa, Canada.
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Kim SY, Ro SJ, Koh SR, Lim H. Thromboembolism after cardiac surgery in a patient with cancer-related thrombosis and severe thrombocytopenia: A case report. Medicine (Baltimore) 2021; 100:e26152. [PMID: 34087871 PMCID: PMC8183770 DOI: 10.1097/md.0000000000026152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/11/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Patients with cancer have elevated risk of both venous thromboembolism and bleeding compared with patients without cancer due to cancer- and patient-specific factors. Balancing the increased and competing risks of clotting and bleeding in these patients can be difficult because management of cancer-associated thrombosis requires anticoagulation despite its known increased risks for bleeding. The adjustment of blood transfusion or cessation of anticoagulants can be a challenge in surgical diagnosis or treatment of cancer patients with such an imbalanced coagulate status. PATIENT CONCERNS A 45-year-old woman with no underlying disease was suspected of ovarian cancer and was awaiting diagnostic laparoscopic exploration surgery. DIAGNOSES While waiting for the surgery, the patient developed chest pain and underwent stent insertion under diagnosis of myocardial infarction. Two weeks later, endocarditis developed, and replacement of the aortic valve and mitral valve was planned. In addition, the patient developed multiple thromboembolisms and was administered anticoagulants to eliminate vegetation of valves and multiple thromboses. Her blood test showed anemia (7.4 g/dL) and severe thrombocytopenia (24 × 109/L). INTERVENTIONS The patient underwent double valve replacement. OUTCOMES A color change of the left lower extremity was noted 5 hours after double valve replacement, and angiography was performed. Thrombectomy was performed under diagnosis of thrombosis in the left iliac artery. One month later, the patient underwent laparoscopic exploration surgery as scheduled. LESSONS This case will help establish the criteria of blood coagulation for surgical treatment of cancer patients with imbalanced clotting and bleeding.
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40
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Bando YK. Cancer and Coronary Heart Disease - To Bleed or Not to Bleed, That Is the Question. Circ J 2021; 85:847-849. [PMID: 33828025 DOI: 10.1253/circj.cj-21-0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yasuko K Bando
- Department of Cardiology, Nagoya University Graduate School of Medicine
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41
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Choi YJ, Choi YW, Chae JW, Yun HY, Shin S. Clinical Benefits of Oral Anticoagulant Use in Cancer Patients at Increased Risk for Venous Thromboembolism per Khorana Index. Risk Manag Healthc Policy 2021; 14:1855-1867. [PMID: 33994816 PMCID: PMC8114826 DOI: 10.2147/rmhp.s306760] [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: 02/15/2021] [Accepted: 04/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Cancer patients are at increased risk for venous thromboembolism (VTE) due to cancer-induced hypercoagulability. However, current guidelines do not routinely recommend prophylactic use of oral anticoagulants to prevent VTE in cancer patients. Objective To evaluate the efficacy and safety of novel oral anticoagulants (NOACs) versus no anticoagulant use (no-use) and, additionally, differential effects between NOACs and warfarin, in VTE and adverse bleeding prevention among cancer patients, in consideration of risk stratification by gender, high-risk chemotherapy exposure, and Khorana index. Methods This national health insurance data-based study with a 180-day follow-up enrolled cancer patients with or without oral anticoagulant use in 2017. The primary outcome was VTE risk in oral anticoagulant users vs non-users. Four propensity score-matched comparison pairs were designed: use vs no-use, NOAC vs no-use, warfarin vs no-use, and NOAC vs warfarin. A logistic regression model was used to investigate between-group differences in VTE and bleeding risk. Results When compared to no-use, NOACs showed substantial effects in preventing VTE complications (OR=0.40, p<0.001), primarily deep vein thrombosis (DVT) events (OR=0.38, p<0.001), in both male and female cancer patients as well as those with a Khorana score ≥1. Adverse bleeding risk was comparable or lower in NOAC-receiving female patients (p=0.13) and male patients (p=0.04), respectively. In contrast, no protective effects were found with warfarin compared to no-use in controlling thrombosis and adverse bleeding risk. In a head-to-head comparison of NOACs versus warfarin, DVT risk in those patients exposed to high-risk chemotherapy was significantly decreased with NOAC use (OR=0.19, p=0.03). Conclusion NOACs can be a promising thromboprophylactic option in both male and female cancer patients with VTE risk.
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Affiliation(s)
- Yeo Jin Choi
- Department of Clinical Pharmacy, Graduate School of Clinical Pharmacy, CHA University, Seongnam, Gyeonggi-do, 13488, Republic of Korea
| | - Yong Won Choi
- Department of Hematology-Oncology, School of Medicine, Ajou University, Suwon, Gyeonggi-do, 16499, Republic of Korea
| | - Jung-Woo Chae
- College of Pharmacy, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Hwi-Yeol Yun
- College of Pharmacy, Chungnam National University, Daejeon, 34134, Republic of Korea
| | - Sooyoung Shin
- College of Pharmacy, Ajou University, Suwon, Gyeonggi-do, 16499, Republic of Korea.,Research Institute of Pharmaceutical Science and Technology (RIPST), Ajou University, Suwon, Gyeonggi-do, 16499, Republic of Korea
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42
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Swan D, Newland A, Rodegheiro F, Thachil J. Thrombosis in immune thrombocytopenia - current status and future perspectives. Br J Haematol 2021; 194:822-834. [PMID: 33822358 DOI: 10.1111/bjh.17390] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Immune thrombocytopenia (ITP) is an autoimmune disorder in which a combination of defective platelet production and enhanced clearance leads to thrombocytopenia. The primary aim for therapy in patients with this condition is the prevention of bleeding. However, more recently, increased rates of venous and arterial thrombotic events have been reported in ITP, even in the context of marked thrombocytopenia. In this review we discuss the epidemiology, aetiology and management of thrombotic events in these patients. We consider the impact of ITP therapies on the increased thrombotic risk, in particular the use of thrombopoietin-receptor agonists (TPO-RAs), as well as factors inherent to ITP itself. We also discuss the limited evidence available to guide clinicians in the treatment of these complex cases.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, University Hospital Galway, Galway, Republic of Ireland
| | - Adrian Newland
- Department of Haematology, The Royal London Hospital, London, UK
| | | | - Jecko Thachil
- Department of Haematology, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Bravo Villa V, Romero J, Rojas-Zaldivar E, Cervantes M, Villa-Márquez MDR, Baz P, Cesarman-Maus G. Apixaban in low-weight patients with cancer-associated thrombosis: A cross sectional study of drug levels. Res Pract Thromb Haemost 2021; 5:421-425. [PMID: 33870027 PMCID: PMC8035794 DOI: 10.1002/rth2.12492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 12/02/2020] [Accepted: 12/11/2020] [Indexed: 12/21/2022] Open
Abstract
Introduction Apixaban, a direct factor Xa inhibitor, has been shown to be at least as safe and probably more effective than dalteparin for the treatment of cancer-associated thrombosis (CAT) as reported in the ADAM-VTE and Caravaggio studies, which included a low percentage of underweight patients. Lower-weight-based dosing is supported by cancer-specific studies such as half-dose edoxaban in the Hokusai-VTE cancer trial in individuals weighing <60 kg. Objective To examine apixaban plasma trough levels in low-weight individuals with CAT, stably anticoagulated with full or half-dose apixaban. Methods This was a cross-sectional study of 61 routinely treated patients with active cancer and venous thromboembolism comparing three groups: patients weighing >60 kg treated with apixaban 5 mg twice daily, patients weighing ≤60 kg also receiving apixaban 5 mg twice daily, and patients weighing ≤60 kg given half-dose apixaban (2.5 mg twice daily). Apixaban plasma steady-state trough levels were determined on a single occasion. Results Mean apixaban plasma trough levels were similar for patients weighing >60 kg on full-dose apixaban to those weighing ≤60 kg taking 2.5 mg twice daily (mean, 109 ng/dL; 95% confidence interval [CI], 74-145; standard deviation [SD]: 77.6; and mean,101 ng/dL, 95% CI, 67-135; SD: 80, respectively). Mean values for low-weight patients (≤60 kg) on the full 5 mg twice-daily dosing tended to be higher (mean, 136 ng/dL; 95%CI, 70-201; SD:114), without statistical significance (P = .22). Conclusions This study supports the rationale for studying weight-based adjustments in apixaban dosing in prospective studies evaluating safety and efficacy of dose reduction in low-weight patients with cancer.
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Affiliation(s)
- Verónica Bravo Villa
- Hematology Department Instituto Nacional de Cancerología México City CDMX México
| | - Job Romero
- Hematology Department Instituto Nacional de Cancerología México City CDMX México
| | | | - Martha Cervantes
- Clinical Laboratory Instituto Nacional de Cancerología México City CDMX México
| | | | - Patricia Baz
- Hematology Department Instituto Nacional de Cancerología México City CDMX México
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O'Brien KL, Chen Y, Uhl L. Assessing inpatient platelet ordering practice: evaluation of computer provider order entry overrides. Vox Sang 2020; 116:702-712. [PMID: 33615489 DOI: 10.1111/vox.13050] [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: 08/09/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Judicious utilization of platelet products protects a limited resource and mitigates risks of transfusion. At many institutions, computer physician order entry systems provide prompts to guide transfusion decisions; many capture the indication for transfusion, and generate metadata when orders are dissonant with guidelines. We conducted a retrospective review to examine adherence to and overrides of hospital guidelines for platelet transfusion to identify opportunities for improved transfusion practice. MATERIALS AND METHODS Physician override reports (1/1/2018-3/31/2019) were examined and physician-entered justification comments accompanying override orders were extracted, in addition to patient-specific data (clinical service, age, sex, and pretransfusion platelet count). Two transfusion medicine physicians independently assessed comments in context of patient data and institutional guidelines and categorized as: indicated, protocol driven, or not indicated. Following adjudication, consensus was reached between the two reviewers. Override keyword frequencies were also determined. RESULTS Over 15-months, 1373 override orders were placed for 558 unique patients (25% of all adult inpatient platelet transfusions). haematology/oncology providers placed 573 (42%) override orders (261 unique patients), 46% of which were categorized as "not indicated", based on consensus review. Overall, 470 (34%) override orders were categorized as "not indicated". Examples of recurring key words included "bleeding/risk of bleeding", "falling platelet count", "platelet goal of XX". CONCLUSIONS A large percentage of override orders for platelet transfusions were determined to be "not indicated" and out of compliance with institutional guidelines. The metadata captured identified concerns regarding clinical transfusion practice and opportunities for revised indications (e.g. threshold for retinal haemorrhage).
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Affiliation(s)
- Kerry L O'Brien
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yigu Chen
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Lynne Uhl
- Department of Pathology, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
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45
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Gastrointestinal metastatic breast cancer unmasked by anticoagulation. CURRENT PROBLEMS IN CANCER: CASE REPORTS 2020. [DOI: 10.1016/j.cpccr.2020.100002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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46
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Riess H, Verhamme P, Weitz JI, Young A, Bauersachs R, Beyer-Westendorf J, Crowther M, Maraveyas A. Treatment of cancer-associated thrombosis: The evolution of anticoagulant choice and clinical insights into practical management. Crit Rev Oncol Hematol 2020; 157:103125. [PMID: 33254037 DOI: 10.1016/j.critrevonc.2020.103125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 06/30/2020] [Accepted: 10/02/2020] [Indexed: 12/21/2022] Open
Abstract
Low-molecular-weight heparin (LMWH) therapy is recommended over vitamin K antagonists (VKAs) for the treatment of cancer-associated thrombosis (CAT) and extended therapy is recommended in those with active cancer to prevent recurrent thrombosis. However, the inconvenience of daily subcutaneous injections and the cost of LMWH therapy hinder long-term use. Observational data demonstrate that persistence with LMWH therapy is low in clinical practice and that many patients are switched to oral alternatives - namely VKAs and direct oral anticoagulants (DOACs). Recently, the efficacy and safety of apixaban, edoxaban, and rivaroxaban versus LMWH therapy for the treatment of CAT have been demonstrated in randomized trials. This review provides a critical evaluation of studies with DOACs in this setting and an update on the guidance regarding anticoagulant use for the treatment of CAT. In recognition of the heterogeneity of patients with cancer and the challenges of CAT, patient cases with expert clinical perspectives are presented.
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Affiliation(s)
- Hanno Riess
- Department of Haematology and Oncology, Charite - Universitatmedizin Berlin, Germany.
| | - Peter Verhamme
- Department of Cardiovascular Medicine, University Hospitals Leuven, Belgium
| | - Jeffrey I Weitz
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Annie Young
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital "Carl Gustav Carus" Dresden, Fetscherstrasse 74, D-01307, Dresden, Germany; King's Thrombosis Service, Department of Haematology, King's College London, London, United Kingdom
| | - Mark Crowther
- McMaster University and the Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Anthony Maraveyas
- Hull York Medical School and Hull University Teaching Hospitals NHS Trust, Hull, United Kingdom
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47
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Management of Cancer-Associated Thrombosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00851-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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48
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Zhang X, Cai X, Pan J. Correlation Between PAI-1 Gene 4G/5G Polymorphism and the Risk of Thrombosis in Ph Chromosome-Negative Myeloproliferative Neoplasms. Clin Appl Thromb Hemost 2020; 26:1076029620935207. [PMID: 32683889 PMCID: PMC7372617 DOI: 10.1177/1076029620935207] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Thrombosis has been recognized as one of the most significant risk factors of high mortality and disability in patients with Philadelphia (Ph) chromosome negative myeloproliferative neoplasms (MPNs). However, the risk factors of thrombotic events in these patients have not been completely understood. In this study, the clinical data of 58 patients with Ph-MPNs were obtained and analyzed, including 34 cases of essential thrombocytopenia (ET), 23 thrombotic events happened in 21 (36%) patients, among which 60% (14 of 23) with cerebral infarction, 17% (4 of 23) with coronary heart disease and 23% (5 of 23) with venous thrombosis. There were no significant differences in age, sex, and blood cell count between polycythemia vera (PV) and ET patients who have experienced thrombotic events and those who have not. In ET patients, the incidence of thrombotic events in plasminogen activator inhibitor-1 (PAI-1) genotype 4G4G was significantly higher than that in genotype 4G5G and genotype 5G5G (P < .05). The incidence of thrombotic events in PV and ET patients with infection was higher than those without infection (P < .05). Using logistic regression analysis, we found that PAI-1 genotype 4G4G and infection were associated with thrombotic events (odds ratio 6.744, 95% CI: 1.195-38.056 and 15.641 95% CI: 3.327-73.522). The 4G/4G polymorphism of PAI-1 gene and infection are independent risk factors of thrombotic events in patients with Ph-MPNs. PAI-1 gene 4G4G and infection in ET and PV patients with Janus kinase 2 (JAK2) V617F mutation were shown to be high risk of thrombotic events. Therefore, clinical doctors should put more attention on PAI-1 genotype 4G4G and infection in JAK2 V617F mutated patients with Ph-MPNs to prevent the thrombosis.
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Affiliation(s)
- Xueya Zhang
- Department of Hematology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Xuerong Cai
- Department of Respiratory Medicine, The Quanzhou First Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
| | - Jingxin Pan
- Department of Hematology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian Province, China
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49
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Leiva O, Connors JM, Al-Samkari H. Impact of Tumor Genomic Mutations on Thrombotic Risk in Cancer Patients. Cancers (Basel) 2020; 12:cancers12071958. [PMID: 32707653 PMCID: PMC7409200 DOI: 10.3390/cancers12071958] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/13/2020] [Accepted: 07/16/2020] [Indexed: 12/19/2022] Open
Abstract
Venous thromboembolism (VTE) is common in patients with cancer and is an important contributor to morbidity and mortality in these patients. Early thromboprophylaxis initiated only in those cancer patients at highest risk for VTE would be optimal. Risk stratification scores incorporating tumor location, laboratory values and patient characteristics have attempted to identify those patients most likely to benefit from thromboprophylaxis but even well-validated scores are not able to reliably distinguish the highest-risk patients. Recognizing that tumor genetics affect the biology and behavior of malignancies, recent studies have explored the impact of specific molecular aberrations on the rate of VTE in cancer patients. The presence of certain molecular aberrations in a variety of different cancers, including lung, colon, brain and hematologic tumors, have been associated with an increased risk of VTE and arterial thrombotic events. This review examines the findings of these studies and discusses the implications of these findings on decisions relating to thromboprophylaxis use in the clinical setting. Ultimately, the integration of tumor molecular genomic information into clinical VTE risk stratification scores in cancer patients may prove to be a major advancement in the prevention of cancer-associated thrombosis.
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Affiliation(s)
- Orly Leiva
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA 02215, USA;
- Harvard Medical School, Boston, MA 02215, USA;
| | - Jean M. Connors
- Harvard Medical School, Boston, MA 02215, USA;
- Hematology Division, Brigham and Women’s Hospital, Boston, MA 02215, USA
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA 02215, USA;
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, MA 02114, USA
- Correspondence: ; Tel.: +1-617-643-6214
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Venous Thromboembolism in Cancer Patients on Simultaneous and Palliative Care. Cancers (Basel) 2020; 12:cancers12051167. [PMID: 32384641 PMCID: PMC7281278 DOI: 10.3390/cancers12051167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/25/2022] Open
Abstract
Simultaneous care represents the ideal integration between early supportive and palliative care in cancer patients under active antineoplastic treatment. Cancer patients require a composite clinical, social and psychological management that can be effective only if care continuity from hospital to home is guaranteed and if such a care takes place early in the course of the disease, combining standard oncology care and palliative care. In these settings, venous thromboembolism (VTE) represents a difficult medical challenge, for the requirement of acute treatments and for the strong impact on anticancer therapies that might be delayed or, even, totally discontinued. Moreover, cancer patients not only display high rates of VTE occurrence/recurrence but are also more prone to bleeding and this forces clinicians to optimize treatment strategies, balancing between hemorrhages and thrombus formation. VTE prevention is, therefore, regarded as a double-edged sword. Indeed, while on one hand the appropriate use of antithrombotic agents can reduce VTE occurrence, on the other it significantly increases the bleeding risk, especially in the frail patients who present with multiple co-morbidities and poly-therapy that can interact with anticoagulant drugs. For these reasons, thromboprophylaxis should start while active cancer treatment is ongoing, according to a simultaneous care model in a patient-centered perspective.
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