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Górnicki T, Bułdyś K, Zielińska D, Chabowski M. Direct-Acting Oral Anticoagulant Therapy in Cancer Patients-A Review. Cancers (Basel) 2023; 15:2697. [PMID: 37345034 DOI: 10.3390/cancers15102697] [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: 03/21/2023] [Revised: 04/21/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023] Open
Abstract
Venous thromboembolism (VTE) is an important aspect in cancer patients. There are various pharmacological methods used for thrombotic event treatment. DOACs (direct-acting oral anticoagulants) are gaining popularity among both physicians and researchers and are slowly starting to replace VKAs (vitamin K antagonists), thus becoming a substitute or alternative option for LMWHs (low-molecular-weight heparins). In this article, we present DOACs' main therapeutic advantages and disadvantages in patients with cancer. The only major concern with using DOACs is the higher risk of bleeding; however, there are discrepancies in this matter. There are still some types of cancer for which DOACs are not recommended. Specific cancer types may influence the efficacy of DOAC therapy. Additionally, race and ethnicity may affect therapy in cancer patients with DOACs. A sizeable number of clinical trials are focused on comparing DOACs with other anticoagulants. The current guidelines of different scientific associations are not unanimous in their DOAC assessments. There is still a need for more evidence of DOACs' potential advantages over other methods of anticoagulation in cancer patients to facilitate their position in this recommendation. This literature review presents the current state of knowledge about the use of DOACs in patients with neoplastic growth.
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Affiliation(s)
- Tomasz Górnicki
- Student Research Club No. 180, Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland
- Division of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-368 Wroclaw, Poland
| | - Kacper Bułdyś
- Student Research Club No. 180, Faculty of Medicine, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Dorota Zielińska
- Department of Surgery, 4th Military Teaching Hospital, 50-981 Wroclaw, Poland
| | - Mariusz Chabowski
- Department of Surgery, 4th Military Teaching Hospital, 50-981 Wroclaw, Poland
- Division of Anesthesiological and Surgical Nursing, Department of Nursing and Obstetrics, Faculty of Health Science, Wroclaw Medical University, 51-618 Wroclaw, Poland
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2
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Bentounes NK, Melicine S, Martin AC, Smadja DM, Gendron N. Development of new anticoagulant in 2023: Prime time for anti-factor XI and XIa inhibitors. JOURNAL DE MEDECINE VASCULAIRE 2023; 48:69-80. [PMID: 37422330 DOI: 10.1016/j.jdmv.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/14/2023] [Indexed: 07/10/2023]
Abstract
Thrombosis remains one of the leading causes of death in the world. The history of anticoagulation has evolved considerably from non-specific drugs (i.e., heparins and vitamin K antagonists, VKA) to agents that directly target specific coagulation factors (i.e., argatroban, fondaparinux and direct oral anticoagulants, DOAC). Since the last decade, DOAC are widely used in clinical practice because of their ease to use with favorable pharmacological profile and not requiring monitoring, particularly for venous thromboembolism treatment and prevention and stroke prevention in atrial fibrillation. However, despite having a better safety profile than VKA, their bleeding risk is not negligible. Therefore, research is underway to develop new anticoagulant therapies with a better safety profile. One of these news approaches to reduce the risk of bleeding is to target the coagulation in the intrinsic pathway, in particular the contact activation, with the ultimate goal of preventing thrombosis without impairing hemostasis. Based on epidemiological data with patients with inherited factor XI (FXI) deficiency and preclinical studies, FXI emerged as the most promising candidate target separating hemostasis from thrombosis. This review summaries the role of FXI and FXIa in hemostasis, provides evidence of initial success with FXI pathway inhibitors in clinical trials (such as IONIS-FXIRx, fesomersen, osocimab, abelacimab, milvexian, asundexian or xisomab 3G3) and highlights the opportunities and challenges for this next generation of anticoagulants.
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Affiliation(s)
- Nûn K Bentounes
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France
| | - Sophie Melicine
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France
| | - Anne Céline Martin
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Cardiology Department, Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France
| | - David M Smadja
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France; INNOVTE, F-CRIN, Saint-Étienne, France
| | - Nicolas Gendron
- University Paris Cité, Innovative Therapies in Hemostasis, Inserm, 75006 Paris, France; Hematology Department and Biosurgical Research Lab (Carpentier Foundation), Assistance publique-Hôpitaux de Paris. Centre-Université Paris Cité (AP-HP.CUP), 20, rue Leblanc, 75015 Paris, France.
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3
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Brito-Dellan N, Tsoukalas N, Font C. Thrombosis, cancer, and COVID-19. Support Care Cancer 2022; 30:8491-8500. [PMID: 35567609 PMCID: PMC9106567 DOI: 10.1007/s00520-022-07098-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 04/28/2022] [Indexed: 01/08/2023]
Abstract
Cancer and coronavirus disease 2019 (COVID-19) have unusual similarities: they both result in a markedly elevated risk of thrombosis, exceptionally high D-dimer levels, and the failure of anticoagulation therapy in some cases. Cancer patients are more vulnerable to COVID-19 infection and have a higher mortality rate. Science has uncovered much about SARS-CoV-2, and made extraordinary and unprecedented progress on the development of various treatment strategies and COVID-19 vaccines. In this review, we discuss known data on cancer-associated thrombosis (CAT), SARS-CoV-2 infection, and COVID-19 vaccines and discuss considerations for managing CAT in patients with COVID-19. Cancer patients should be given priority for COVID-19 vaccination; however, they may demonstrate a weaker immune response to COVID-19 vaccines than the general population. Currently, the Centers for Disease Control and Prevention recommends an additional dose and booster shot of the COVID-19 vaccine after the primary series in patients undergoing active cancer treatment for solid tumors or hematological cancers, recipients of stem cell transplant within the last 2 years, those taking immunosuppressive medications, and those undergoing active treatment with high-dose corticosteroids or other drugs that suppress the immune response. The mainstay of thrombosis treatment in patients with cancer and COVID-19 is anticoagulation therapy.
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Affiliation(s)
- Norman Brito-Dellan
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX, 77030-4009, USA.
| | - Nikolaos Tsoukalas
- Medical Oncology Department, 401 General Military Hospital of Athens, Athens, Greece
| | - Carme Font
- Medical Oncology Department, Day Hospital for Outpatient Care, Hospital Clinic, Barcelona, Spain
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4
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Poenou G, Dumitru Dumitru T, Lafaie L, Mismetti V, Heestermans M, Bertoletti L. Factor XI Inhibition for the Prevention of Venous Thromboembolism: An Update on Current Evidence and Future perspectives. Vasc Health Risk Manag 2022; 18:359-373. [PMID: 35707632 PMCID: PMC9191224 DOI: 10.2147/vhrm.s331614] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/30/2022] [Indexed: 12/18/2022] Open
Abstract
During the past decade, emergence of direct oral anticoagulants (DOACs) has drastically improved the prevention of thrombosis. However, several unmet needs prevail in the field of thrombosis prevention, even in the DOACs’ era. The use of DOACs is still constrained and the drugs cannot be administered in every clinical scenario, such as an increased anticoagulant-associated bleeding risk, particularly in some specific populations (cancer – notably those with gastrointestinal or genitourinary cancer – and frail patients), the impossibility to be used in certain patients (eg, end-stage kidney failure during hemodialysis, pregnancy and breastfeeding), and their lack of efficacy in certain clinical scenarios (eg, mechanical heart valves, triple-positive antiphospholipid syndrome). Efforts to find a factor that upon antagonization prevents thrombosis but spares haemostasis have resulted in the identification of coagulation factor XI (FXI) as a therapeutic target. After briefly recapitulating the role of factor XI in the balance of haemostasis, we propose a narrative review of the key data published to date with compounds targeting factor XI to prevent thrombosis as well as the main ongoing clinical studies, opening up prospects for improving the care of patients requiring thrombosis prevention.
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Affiliation(s)
- Geraldine Poenou
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
| | - Teona Dumitru Dumitru
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
- Internal Medicine Department, University Hospital Santa Lucía, Cartagena, Murcia, Spain
- Catholic University San Antonio, Murcia, Spain
| | - Ludovic Lafaie
- Geriatric Department, University Hospital of Saint Etienne, Saint Etienne, France
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
| | - Valentine Mismetti
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- Pneumology Department, University Hospital of Saint Etienne, Saint Etienne, France
| | - Marco Heestermans
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- Auvergne-Rhône-Alpes French Blood Donation Agency, Saint-Etienne, F-42100, France
| | - Laurent Bertoletti
- Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France
- INSERM, UMR1059, Haemostasis and Vascular Dysfunction Team, Jean Monnet University, Saint-Etienne, F-42055, France
- INSERM, CIC-1408, University Hospital of Saint Etienne, Saint Etienne, France
- Correspondence: Laurent Bertoletti, Therapeutic and Vascular Medicine Department, University Hospital of Saint Etienne, Saint Etienne, France, Tel +33477827771, Fax +33477820482, Email
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5
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Zaheer A, Naumovski N, Toohey K, Niyonsenga T, Yip D, Brown N, Mortazavi R. Prediction models for venous thromboembolism in ambulatory adults with pancreatic and gastro-oesophageal cancer: protocol for systematic review and meta-analysis. BMJ Open 2022; 12:e056431. [PMID: 35246422 PMCID: PMC8900042 DOI: 10.1136/bmjopen-2021-056431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) is a common complication of cancer. Pancreatic and gastro-oesophageal cancers are among malignancies that have the highest rates of VTE occurrence. VTE can increase cancer-related morbidity and mortality and disrupt cancer treatment. The risk of VTE can be managed with measures such as using anticoagulant drugs, although the risk of bleeding may be an impeding factor. Therefore, a VTE risk assessment should be performed before the start of anticoagulation in individual patients. Several prediction models have been published, but most of them have low sensitivity and unknown clinical applicability in pancreatic or gastro-oesphageal cancers. We intend to do this systematic review to identify all applicable published predictive models and compare their performance in those types of cancer. METHODS AND ANALYSIS All studies in which a prediction model for VTE have been developed, validated or compared using adult ambulatory patients with pancreatic or gastro-oesphageal cancers will be identified and the reported predictive performance indicators will be extracted. Full text peer-reviewed journal articles of observational or experimental studies published in English will be included. Five databases (Medline, EMBASE, Web of Science, CINAHL and Cochrane) will be searched. Two reviewers will independently undertake each of the phases of screening, data extraction and risk of bias assessment. The quality of the selected studies will be assessed using Prediction model Risk Of Bias Assessment Tool. The results from the review will be used for a narrative information synthesis, and if the same models have been validated in multiple studies, meta-analyses will be done to pool the predictive performance measures. ETHICS AND DISSEMINATION There is no need for ethics approval because the review will use previously peer-reviewed articles. The results will be published. PROSPERO REGISTRATION NUMBER CRD42021253887.
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Affiliation(s)
- Asma Zaheer
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
| | - Nenad Naumovski
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Functional Foods and Nutritional Research (FFNR) Laboratory, University of Canberra Faculty of Health Sciences, Canberra, Australian Capital Territory, Australia
| | - Kellie Toohey
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- School of Health Sciences, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Theophile Niyonsenga
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Desmond Yip
- Department of Medical Oncology, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- ANU Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Nicholas Brown
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
- Office of Executive Director of Allied Health,Canberra Health Services, Garran, Canberra, Australian Capital Territory, Australia
| | - Reza Mortazavi
- Prehab, Activity, Cancer, Exercise and Survivorship (PACES) research Group, University of Canberra Faculty of Health, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Bruce, Australian Capital Territory, Australia
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6
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Frere C, Font C, Esposito F, Crichi B, Girard P, Janus N. Incidence, risk factors, and management of bleeding in patients receiving anticoagulants for the treatment of cancer-associated thrombosis. Support Care Cancer 2021; 30:2919-2931. [PMID: 34617159 DOI: 10.1007/s00520-021-06598-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/26/2021] [Indexed: 12/19/2022]
Abstract
Updated clinical practice guidelines recommend the long-term use of low-molecular-weight heparins or direct oral anticoagulants as the preferred option for the treatment of cancer-associated thrombosis (CAT), using a personalized approach matching the right drug to the right patient. In most cases, the benefit of anticoagulant therapy outweighs the risk. However, the long-term use of anticoagulants is associated with a non-negligible risk of bleeding, which constitutes a rare but serious adverse effect. Bleeding complications have been reported to be overall 2 to 3 times more frequent in cancer patients with CAT receiving anticoagulation than in non-cancer patients, with a reported incidence of major bleeding ranging from 2.4 to 16.0% in randomized controlled trials (RCT). In the absence of validated risk assessment model to predict the risk of bleeding in these patients, a careful evaluation of each individual profile, with adequate selection of the most appropriate anticoagulant for each individual patient, is warranted for overcoming management challenges, taking in account the numerous factors which may potentiate the overall bleeding risk in these complex patients, such as advanced or metastatic disease, older age, anemia, thrombocytopenia, renal impairment, liver dysfunction, and concomitant anticancer therapies. The purpose of this review is to call for awareness on bleeding complications as a major safety issue of CAT treatment and to summarize data from recent RCT and real-world studies on the incidence and risk factors for bleeding in this unique and challenging population to further help clinicians in decision-making.
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Affiliation(s)
- Corinne Frere
- Institute of Cardiometabolism And Nutrition, GRC 27 GRECO, Sorbonne Université, INSERM UMRS_1166, Paris, France
- Department of Haematology, Pitié-Salpêtrière Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Carme Font
- Department of Internal Medicine, Hospital Clinic, Barcelona, Spain
| | | | - Benjamin Crichi
- Department of Internal Medicine, Saint-Louis Hospital, Assistance Publique Hôpitaux de Paris, 75010, Paris, France
| | - Philippe Girard
- Département Thoracique, Institut Mutualiste Montsouris, Paris, France
- FCRIN INNOVTE, Paris, France
| | - Nicolas Janus
- Global Thrombosis Strategy, Medical Affairs, Leo Pharma, Voisins-le-Bretonneux, France.
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7
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Srinivasan S, Ajmal M, Pecci C, Lassar T. Edoxaban in Cardiovascular Disease Management: Review. Br J Clin Pharmacol 2021; 88:535-540. [PMID: 34365675 DOI: 10.1111/bcp.15026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/30/2022] Open
Abstract
In the past decade, direct oral anticoagulants (DOACs) have transformed the world of anti-thrombotic therapy. Edoxaban is the most recently approved DOAC. Though intended for use primarily in stroke prevention, it has found applications in various other conditions including thromboembolic and peripheral arterial disease. This review aims to provide a detailed outline of the growing indications, evidence for use in special populations, pharmacogenetics, and side effect profile of edoxaban.
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Affiliation(s)
| | - Muhammad Ajmal
- Sarver Heart Center, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Cristina Pecci
- University of Arizona, College of Medicine, Phoenix, Arizona, USA
| | - Tom Lassar
- Sarver Heart Center, University of Arizona, College of Medicine, Tucson, Arizona, USA
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8
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Interactions between cardiology and oncology drugs in precision cardio-oncology. Clin Sci (Lond) 2021; 135:1333-1351. [PMID: 34076246 DOI: 10.1042/cs20200309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 12/13/2022]
Abstract
Recent advances in treatment have transformed the management of cancer. Despite these advances, cardiovascular disease remains a leading cause of death in cancer survivors. Cardio-oncology has recently evolved as a subspecialty to prevent, diagnose, and manage cardiovascular side effects of antineoplastic therapy. An emphasis on optimal management of comorbidities and close attention to drug interactions are important in cardio-oncologic care. With interdisciplinary collaboration among oncologists, cardiologists, and pharmacists, there is potential to prevent and reduce drug-related toxicities of treatments. The cytochrome P450 (CYP450) family of enzymes and the P-glycoprotein (P-g) transporter play a crucial role in drug metabolism and drug resistance. Here we discuss the role of CYP450 and P-g in drug interactions in the field of cardio-oncology, provide an overview of the cardiotoxicity of a spectrum of cancer agents, highlight the role of precision medicine, and encourage a multidisciplinary treatment approach for patients with cancer.
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9
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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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10
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Marrinan A, Shackleton L, Kelly C, Lavin M, Glavey S, Murphy P, Quinn J. Liver injury during rivaroxaban treatment in a patient with AL amyloidosis. Eur J Clin Pharmacol 2021; 77:1073-1076. [PMID: 33427957 DOI: 10.1007/s00228-020-03084-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 12/28/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Alan Marrinan
- Department of Haematology, Beaumont Hospital, Dublin 9, Ireland.
| | - L Shackleton
- Department of Haematology, Beaumont Hospital, Dublin 9, Ireland
| | - C Kelly
- Department of Haematology, Beaumont Hospital, Dublin 9, Ireland
| | - M Lavin
- Department of Haematology, Beaumont Hospital, Dublin 9, Ireland.,Irish Centre for Vascular Biology, Royal College of Surgeons in Ireland (RCSI), Dublin 2, Ireland
| | - S Glavey
- Department of Haematology, Beaumont Hospital, Dublin 9, Ireland.,Department of Medicine, RCSI, Dublin, Ireland
| | - P Murphy
- Department of Haematology, Beaumont Hospital, Dublin 9, Ireland.,Department of Medicine, RCSI, Dublin, Ireland
| | - J Quinn
- Department of Haematology, Beaumont Hospital, Dublin 9, Ireland.,Department of Medicine, RCSI, Dublin, Ireland
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11
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Lapietra G, Serrao A, Fazio F, Petrucci MT, Chistolini A. Venous thromboembolism prophylaxis in patients with multiple myeloma: where are we and where are we going? J Thromb Thrombolysis 2021; 52:584-589. [PMID: 33417149 DOI: 10.1007/s11239-020-02354-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2020] [Indexed: 10/22/2022]
Abstract
Venous thromboembolism is a common complication of patients with hematologic malignancies, due both to release of procoagulant factors by tumor cells and to external factors, such us drugs. In multiple myeloma patients, the risk is increased by use of immunomodulants, especially when associated to multidrug therapy, during the induction phase. Prevention of venous thromboembolism in myeloma patients is highly recommended but specific guidelines are still lacking. The most common approach is to stratify the thrombotic risk according to individual, myeloma-related and therapy-related risk factors and to use aspirin for all patients, except those with two or more thrombotic risk factors who should be treated with traditional oral or parenteral anticoagulant. A more controversial approach indicates for prophylaxis either anticoagulant or aspirin, regardless of risk stratification. Recent trials investigate prophylaxis in myeloma patients with direct oral anticoagulants, based on studies showing efficacy and safety of this new class of drugs in the treatment and prophylaxis of thrombosis in patients with any malignancy. The results of these trials are encouraging but they need to be confirmed by larger studies. An international consensus about best prophylaxis to prevent venous thromboembolism in patients with multiple myeloma on treatment is still missing. Therefore, thrombosis in multiple myeloma remains an ongoing issue.
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Affiliation(s)
- Gianfranco Lapietra
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Via Benevento, 6, 00161, Rome, Italy
| | - Alessandra Serrao
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Via Benevento, 6, 00161, Rome, Italy
| | - Francesca Fazio
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Via Benevento, 6, 00161, Rome, Italy
| | - Maria Teresa Petrucci
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Via Benevento, 6, 00161, Rome, Italy
| | - Antonio Chistolini
- Hematology, Department of Translational and Precision Medicine, Sapienza University, Via Benevento, 6, 00161, Rome, Italy.
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12
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Gupta K, Gandhi S, Mebane A, Singh A, Vishnuvardhan N, Patel E. Cancer patients and COVID-19: Mortality, serious complications, biomarkers, and ways forward. Cancer Treat Res Commun 2020; 26:100285. [PMID: 33360669 PMCID: PMC7832265 DOI: 10.1016/j.ctarc.2020.100285] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 02/06/2023]
Abstract
The SARS-CoV-2 (COVID-19) pandemic has particularly serious consequences for cancer patients, as they are at high risk for severe complications and mortality due to the virus since cancer patients are immunocompromised. Preliminary evidence suggests that patients with hematological, and metastatic malignancies are particularly susceptible to developing severe COVID-19 illness, which leads to poor prognosis. Biomarkers including C-reactive protein and interleukin-6 may be predictors of outcome and, therefore, crucial in assessing COVID-19 illness severity in cancer patients. A patient-specific risk and benefit inventory should be completed, and expert guidelines consulted when deciding to continue or postpone therapeutic interventions. This review presents preliminary evidence of COVID-19 infection and its impact on cancer, as well as discussion of general guidelines for the treatment and management of cancer patients with COVID-19.
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Affiliation(s)
- Kush Gupta
- Kasturba Medical College, Light House Hill Road, Mangalore, KA 575001, India.
| | - Shipra Gandhi
- Roswell Park Comprehensive Cancer Center, Buffalo, NY 14203, USA.
| | - Alexander Mebane
- Heart, Vascular & Leg Center, 5020 Commerce Dr, Bakersfield, CA, 93309, USA.
| | - Angelica Singh
- NewYork-Presbyterian/Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, New York, 11215 USA.
| | - Nivetha Vishnuvardhan
- NewYork-Presbyterian/Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, New York, 11215 USA.
| | - Eshan Patel
- NewYork-Presbyterian/Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, New York, 11215 USA.
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13
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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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14
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Yassine D, Brown EN, Putney D, Fasoranti O. Evaluation of the efficacy and safety of apixaban and rivaroxaban in cancer patients receiving concomitant active anti-neoplastic therapy at an outpatient cancer setting. J Oncol Pharm Pract 2020; 26:1650-1656. [DOI: 10.1177/1078155220901777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Venous thromboembolism is a common complication among cancer patients with an estimated risk of 20%. American Society of Clinical Oncology guidelines recommend direct oral anticoagulants for long-term anticoagulation but caution the use of direct oral anticoagulants because of drug–drug interactions with antineoplastic therapies. The clinical impact of these drug–drug interactions is yet to be studied in clinical trials. This study aims to evaluate the effect of the drug–drug interactions on venous thromboembolism recurrence and bleeding. Methods This is a retrospective cohort study that included cancer patients with venous thromboembolism receiving apixaban or rivaroxaban with antineoplastic therapy. The impact of the drug–drug interaction was determined by its effect on the rates of venous thromboembolism recurrence and bleeding in patients with a drug–drug interaction compared to patients with no drug–drug interaction. Results The primary composite endpoint of venous thromboembolism recurrence and bleeding events occurred in 65% versus 62% of patients in drug–drug interaction and non-drug–drug interaction groups accordingly. There was a higher rate of venous thromboembolism recurrence and minor bleeding events with anti-mitotic microtubule inhibitors and a higher rate of minor bleeding events with hormonal therapy and alkylating agents. Among the drug–drug interaction group, there were no major bleeding events reported with mild drug–drug interactions when compared to moderate-to-severe drug–drug interactions. There was no difference in time to venous thromboembolism recurrence between rivaroxaban and apixaban. Conclusion Due to small sample size, our study results could not confirm a higher risk of bleeding or venous thromboembolism recurrence with the drug–drug interactions. Further prospective study is warranted, but clinicians should be aware of these drug–drug interactions and identify them using available literature.
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Affiliation(s)
- Darin Yassine
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Erika N Brown
- Department of Pharmacy, Houston Methodist Willowbrook Hospital, Houston, TX, USA
| | - David Putney
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Oyejoke Fasoranti
- Department of Pharmacy, Houston Methodist Willowbrook Hospital, Houston, TX, USA
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15
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Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy. Blood Adv 2020; 3:3770-3779. [PMID: 31770442 DOI: 10.1182/bloodadvances.2019000369] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/18/2019] [Indexed: 01/19/2023] Open
Abstract
The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. 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 known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.
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16
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Dawwas GK, Dietrich E, Smith SM, Davis K, Park H. Comparative Effectiveness and Safety of Direct-acting Oral Anticoagulants and Warfarin in Patients with Venous Thromboembolism and Active Cancer: An Observational Analysis. Clin Ther 2020; 42:e161-e176. [PMID: 32768247 DOI: 10.1016/j.clinthera.2020.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 03/18/2020] [Accepted: 06/29/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE There is limited evidence to support the use of direct-acting oral anticoagulants (DOACs) in patients with venous thromboembolism (VTE) and active cancer. This study aimed to assess the effectiveness of DOACs versus warfarin for the prevention of recurrent VTE and major bleeding events in patients with VTE and active cancer. METHODS We identified patients with incident VTE and active cancer who newly initiated treatment with DOACs or warfarin from Truven Health MarketScan Commercial Claims and Medicare supplemental databases. Patients were followed up from treatment initiation (index date) until the occurrence of >7-day gap in treatment, the start of the study comparator, an outcome of interest (recurrent VTE or major bleeding), inpatient death, disenrollment, or end of the study period, whichever occurred first. We controlled for confounders via propensity score matching and estimated the hazard ratios (HRs) using Cox proportional hazards regression models. FINDINGS A total of 9952 patients were included in the matched cohort (4976 DOACs users and 4976 warfarin users). Patient characteristics were well balanced after matching. We observed a lower incidence of recurrent VTE (3 vs 5 per 100 person-years) and major bleeding events (2 vs 3 per 100 person-years) in the DOAC group compared to warfarin group, respectively. In Cox regression models, use of DOACs (vs warfarin) was associated with a lower risk of recurrent VTE (hazard ratio (HR), 0.59; 95% CI, 0.42-0.82) and major bleeding events (HR, 0.64; 95% CI, 0.44-0.94). IMPLICATIONS On the basis of our findings, among patients with VTE and active cancer, DOACs offer superior effectiveness with a lower risk of bleeding when compared with warfarin for the secondary prevention of VTE.
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Affiliation(s)
- Ghadeer K Dawwas
- Department of Biostatistics Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eric Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Steven M Smith
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA; Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Kyle Davis
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA.
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17
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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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18
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Tsoukalas N, Papakotoulas P, Christopoulou A, Ardavanis A, Koumakis G, Papandreou C, Papatsimpas G, Papakostas P, Samelis G, Andreadis C, Aravantinos G, Ziras N, Kalofonos C, Samantas E, Souggleri M, Makrantonakis P, Pentheroudakis G, Athanasiadis A, Stergiou H, Tripodaki ES, Bokas A, Grivas A, Timotheadou E, Bournakis E, Varthalitis I, Boukovinas I. Real-World Data on Thromboprophylaxis in Active Cancer Patients: Where Are We? Are We Getting There? Cancers (Basel) 2020; 12:cancers12071907. [PMID: 32679747 PMCID: PMC7409213 DOI: 10.3390/cancers12071907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/29/2020] [Accepted: 07/03/2020] [Indexed: 12/21/2022] Open
Abstract
Background: Cancer patients are at high risk for cancer-associated thrombosis (CAT). CAT is the second leading cause of death in these patients but it can be preventable with thromboprophylaxis. Patients and Methods: An observational, prospective, multicenter study aiming to record CAT management in clinical practice was conducted by the Hellenic Society of Medical Oncology (HeSMO). Results: A total of 426 active cancer patients (mean age 65.3 years, mean BMI: 26.1 kg/m2) who received thromboprophylaxis, were included from 18 oncology units. Tumor types were lung 25.1%, pancreas 13.9%, breast 8.7%, stomach 8.5%, ovarian 7.8%, and others 36%, while 69% had metastases. A total of 71% had a Khorana score ≤2 and 61% received High Thrombotic Risk Chemotherapy Agents (HTRCAs, e.g., platinum). For thromboprophylaxis patients received mainly Low Molecular Weight Heparins (LMWHs), on higher than prophylactic doses in 50% of cases. Overall, 16 (3.8%) thrombotic events and 6 (1.4%) bleeding events were recorded. Notably, patients on higher doses of LMWHs compared to patients who received standard prophylactic doses had 70% lower odds to develop thrombotic events (OR: 0.3, 95% CI: 0.10–1.0, p = 0.04). Conclusion: CAT is an important issue in oncology. Along with the Khorana score, factors as metastases and use of HTRCAs should also be taken into consideration. Thromboprophylaxis for active cancer patients with LMWHs, even on higher doses is safe and efficient.
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Affiliation(s)
- Nikolaos Tsoukalas
- 401 General Military Hospital, 11525 Athens, Greece
- Correspondence: ; Tel.: +30-6977366056
| | - Pavlos Papakotoulas
- “Theagenio” Anticancer Hospital, 54639 Thessaloniki, Greece; (P.P.); (C.A.); (A.B.)
| | | | - Alexandros Ardavanis
- “Agios Savvas” Anticancer Hospital, 11522 Athens, Greece; (A.A.); (G.K.); (E.-S.T.); (A.G.)
| | - Georgios Koumakis
- “Agios Savvas” Anticancer Hospital, 11522 Athens, Greece; (A.A.); (G.K.); (E.-S.T.); (A.G.)
| | | | | | | | | | | | | | | | | | | | - Maria Souggleri
- ‘‘Saint Andrew’’ General Hospital, 26335 Patras, Greece; (A.C.); (M.S.)
| | | | | | | | - Helen Stergiou
- “Bioclinic” Hospital, 54622 Thessaloniki, Greece; (H.S.); (I.B.)
| | - Elli-Sofia Tripodaki
- “Agios Savvas” Anticancer Hospital, 11522 Athens, Greece; (A.A.); (G.K.); (E.-S.T.); (A.G.)
| | - Alexandros Bokas
- “Theagenio” Anticancer Hospital, 54639 Thessaloniki, Greece; (P.P.); (C.A.); (A.B.)
| | - Anastasios Grivas
- “Agios Savvas” Anticancer Hospital, 11522 Athens, Greece; (A.A.); (G.K.); (E.-S.T.); (A.G.)
| | - Eleni Timotheadou
- “Papageorgiou” General Hospital, 56429 Thessaloniki, Greece; (C.P.); (E.T.)
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19
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Nimblette C, Seecheran R, Kawall J, Seecheran V, Persad S, Ramsaroop K, Seecheran NA. Dissolution of metastatic thymic carcinoma-associated right atrial thrombus with rivaroxaban. SAGE Open Med Case Rep 2020; 8:2050313X20927596. [PMID: 32551115 PMCID: PMC7278298 DOI: 10.1177/2050313x20927596] [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: 07/14/2019] [Accepted: 04/27/2020] [Indexed: 11/15/2022] Open
Abstract
Thymic carcinoma typically exhibits more clinically aggressive behavior and portends a worse prognosis as compared to thymoma. Venous thromboembolism is a significant cause of morbidity and mortality in oncologic patients. Traditionally, the standard-of-care management of cancer-associated venous thromboembolism has been therapeutic anticoagulation with low molecular weight heparins; however, with the advent of direct oral anticoagulants, there is an ongoing paradigm shift to transition to these novel agents in an attempt to attenuate cancer-associated venous thromboembolism events. We describe an exceedingly rare case of metastatic thymic carcinoma–associated right atrial thrombus with high-risk embolic features, which subsequently underwent near-complete dissolution with rivaroxaban after 3 months.
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Affiliation(s)
- Curlene Nimblette
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | - Rajeev Seecheran
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | - Jessica Kawall
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | - Valmiki Seecheran
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | - Sangeeta Persad
- North Central Regional Health Authority, Mt. Hope, Trinidad and Tobago
| | | | - Naveen Anand Seecheran
- Department of Clinical Medical Sciences, The University of the West Indies, St. Augustine, Trinidad and Tobago
- Naveen Anand Seecheran, Department of Clinical Medical Sciences, The University of the West Indies, 2nd Floor, Building #67, Eric Williams Medical Sciences Complex, Mt. Hope, Trinidad and Tobago. Emails: ;
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20
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Brown LB, Streiff MB, Haut ER. Venous Thromboembolism Prevention and Treatment in Cancer Surgery. Adv Surg 2020; 54:17-30. [PMID: 32713428 DOI: 10.1016/j.yasu.2020.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Lawrence B Brown
- Department of Surgery, The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, 1800 Orleans Street - Tower 110, Baltimore, MD 21287, USA. https://twitter.com/lawrenceb_brown
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7300, Baltimore, MD 21205, USA; Department of Pathology, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7300, Baltimore, MD 21205, USA; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA. https://twitter.com/mstreif1
| | - Elliott R Haut
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD, USA; Anesthesiology and Critical Care Medicine (ACCM), Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7300, Baltimore, MD 21205, USA; Emergency Medicine, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Health Policy & Management, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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21
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Therapeutic strategies for thrombosis: new targets and approaches. Nat Rev Drug Discov 2020; 19:333-352. [PMID: 32132678 DOI: 10.1038/s41573-020-0061-0] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2020] [Indexed: 12/19/2022]
Abstract
Antiplatelet agents and anticoagulants are a mainstay for the prevention and treatment of thrombosis. However, despite advances in antithrombotic therapy, a fundamental challenge is the side effect of bleeding. Improved understanding of the mechanisms of haemostasis and thrombosis has revealed new targets for attenuating thrombosis with the potential for less bleeding, including glycoprotein VI on platelets and factor XIa of the coagulation system. The efficacy and safety of new agents are currently being evaluated in phase III trials. This Review provides an overview of haemostasis and thrombosis, details the current landscape of antithrombotic agents, addresses challenges with preventing thromboembolic events in patients at high risk and describes the emerging therapeutic strategies that may break the inexorable link between antithrombotic therapy and bleeding risk.
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22
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Aspberg S, Yu L, Gigante B, Smedby KE, Singer DE. Risk of Ischemic Stroke and Major Bleeding in Patients with Atrial Fibrillation and Cancer. J Stroke Cerebrovasc Dis 2020; 29:104560. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.104560] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 11/21/2019] [Indexed: 12/21/2022] Open
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23
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Fatunde OA, Brown SA. The Role of CYP450 Drug Metabolism in Precision Cardio-Oncology. Int J Mol Sci 2020; 21:E604. [PMID: 31963461 PMCID: PMC7014347 DOI: 10.3390/ijms21020604] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 01/09/2020] [Accepted: 01/13/2020] [Indexed: 12/13/2022] Open
Abstract
As many novel cancer therapies continue to emerge, the field of Cardio-Oncology (or onco-cardiology) has become crucial to prevent, monitor and treat cancer therapy-related cardiovascular toxicity. Furthermore, given the narrow therapeutic window of most cancer therapies, drug-drug interactions are prevalent in the cancer population. Consequently, there is an increased risk of affecting drug efficacy or predisposing individual patients to adverse side effects. Here we review the role of cytochrome P450 (CYP450) enzymes in the field of Cardio-Oncology. We highlight the importance of cardiac medications in preventive Cardio-Oncology for high-risk patients or in the management of cardiotoxicities during or following cancer treatment. Common interactions between Oncology and Cardiology drugs are catalogued, emphasizing the impact of differential metabolism of each substrate drug on unpredictable drug bioavailability and consequent inter-individual variability in treatment response or development of cardiovascular toxicity. This inter-individual variability in bioavailability and subsequent response can be further enhanced by genomic variants in CYP450, or by modifications of CYP450 gene, RNA or protein expression or function in various 'omics' related to precision medicine. Thus, we advocate for an individualized approach to each patient by a multidisciplinary team with clinical pharmacists evaluating a treatment plan tailored to a practice of precision Cardio-Oncology. This review may increase awareness of these key concepts in the rapidly evolving field of Cardio-Oncology.
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Affiliation(s)
- Olubadewa A. Fatunde
- Department of Medicine, University of Texas Health Science Center at Tyler–CHRISTUS Good Shepherd Medical Center, Longview, TX 75601, USA
| | - Sherry-Ann Brown
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA
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24
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Shiba PTG, Sharma V. The impact of venous thromboembolism on the outcomes of patients with cervical carcinoma, a retrospective analysis at a single institution. SOUTHERN AFRICAN JOURNAL OF GYNAECOLOGICAL ONCOLOGY 2019. [DOI: 10.1080/20742835.2019.1701257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Preyesh T Goven Shiba
- Department of Radiation Oncology, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - Vinay Sharma
- Department of Radiation Oncology, University of the Witwatersrand and Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
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25
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Al-Samkari H, Connors JM. Managing the competing risks of thrombosis, bleeding, and anticoagulation in patients with malignancy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:71-79. [PMID: 31808892 PMCID: PMC6913483 DOI: 10.1182/hematology.2019000369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
The association between malignancy and thrombosis has been recognized for over a century and a half. Patients with cancer have an elevated risk of both initial and recurrent venous thromboembolism (VTE) compared with patients without cancer owing to cancer- and patient-specific factors. Recurrent VTE is common despite anticoagulation, presenting additional management challenges. Patients with cancer also have an increased risk of bleeding when on anticoagulants compared with patients without cancer. This bleeding risk is heightened by the thrombocytopenia common in patients with hematologic malignancies and those treated with intensive myelosuppressive chemotherapy regimens. Despite the advancements in cancer-directed therapy made over the past 15 years, numerous large studies have confirmed that bleeding and VTE recurrence rates remain high in cancer patients. 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 known increased risks for bleeding. In the context of challenging illustrative cases, this review will describe management approaches to clinical scenarios in which data are sparse: cancer patients with recurrent VTE despite anticoagulation and cancer patients with a new VTE in the setting of severe thrombocytopenia.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA; and
| | - Jean M Connors
- Harvard Medical School, Boston, MA; and
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
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26
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Al‐Samkari H, Song AB, Connors JM. Cancer‐associated thrombosis: Where do we stand? ACTA ACUST UNITED AC 2019. [DOI: 10.1002/acg2.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Hanny Al‐Samkari
- Division of Hematology Massachusetts General Hospital, Harvard Medical School Boston MA USA
| | - Andrew B. Song
- Division of Hematology Massachusetts General Hospital, Harvard Medical School Boston MA USA
| | - Jean M. Connors
- Division of Hematology Brigham and Women’s Hospital, Harvard Medical School Boston MA USA
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27
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Franco-Moreno A, Cabezón-Gutiérrez L, Palka-Kotlowsa M, Villamayor-Delgado M, García-Navarro M. Evaluation of direct oral anticoagulants for the treatment of cancer-associated thrombosis: an update. J Thromb Thrombolysis 2019; 47:409-419. [PMID: 30467760 DOI: 10.1007/s11239-018-1783-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Cancer is associated with an increased risk of venous thromboembolism of four to sixfold. Cancer-related interventions such as chemotherapy, hormonal therapy and indwelling central venous catheters also increase the risk of venous thromboembolism. Low molecular weight heparin for at least 3-6 months is the current standard of care for the treatment of cancer associated venous thromboembolism. Anticoagulation should be continued as long as the cancer is active. Over the past few years, direct oral anticoagulants have emerged, including one direct thrombin inhibitor (dabigatran etexilate) and three factor Xa inhibitors (apixaban, edoxaban and rivaroxaban). In the randomized controlled trials comparing direct oral anticoagulants with vitamin K antagonists, the direct oral anticoagulants all provide non-inferior in prevention of thromboembolic events in patients with atrial fibrillation, for the prevention and treatment of venous thromboembolism and in acute coronary syndrome. In people with cancer, these drugs have emerged as attractive alternatives for the treatment of venous thromboembolism with the potential to overcome the limitations of low molecular weight heparin. Randomized controlled studies comparing direct oral anticoagulants to low molecular weight heparin in cancer patients are still limited and direct oral anticoagulants are not recommended for the treatment of cancer associated venous thromboembolism yet. However, new emerging data are supporting the use of direct oral anticoagulants in cancer-associated thrombosis. Here, we review recent data on the evidence related to the efficacy and safety of direct oral anticoagulants for the treatment of venous thromboembolism in patients with cancer.
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Affiliation(s)
- A Franco-Moreno
- Department of Internal Medicine, Torrejón University Hospital, Mateo Inurria, s/n (Soto del Henares), 28850, Torrejón de Ardoz, Madrid, Spain.
| | - L Cabezón-Gutiérrez
- Department of Medical Oncology, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain
| | - M Palka-Kotlowsa
- Department of Medical Oncology, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain
| | - M Villamayor-Delgado
- Department of Medical Oncology, Torrejón University Hospital, Torrejón de Ardoz, Madrid, Spain
| | - M García-Navarro
- Department of Internal Medicine, Torrejón University Hospital, Mateo Inurria, s/n (Soto del Henares), 28850, Torrejón de Ardoz, Madrid, Spain
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Lai E, Alishetti S, Wong JM, Delic L, Egrie G, Rosenblatt A. Right Ventricular Thrombus in Transit: Raising the Stakes in the Management of Pulmonary Embolism. ACTA ACUST UNITED AC 2019; 3:272-276. [PMID: 32002483 PMCID: PMC6984981 DOI: 10.1016/j.case.2019.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Right heart thrombi are rare and associated with significant mortality. RV thrombus was complicated by recurrent pulmonary emboli and managed surgically. Recurrent pulmonary emboli in anticoagulated patients may suggest malignancy. The optimal treatment for right heart thrombi remains uncertain. Surgical thrombectomy is an option, but treatment should be individualized.
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Affiliation(s)
- Everett Lai
- California Pacific Medical Center, San Francisco, California
| | | | - Jonathan M Wong
- California Pacific Medical Center, San Francisco, California
| | - Lejla Delic
- Department of Gynecologic Oncology, California Pacific Medical Center, San Francisco, California
| | - Glenn Egrie
- Department of Cardiothoracic Surgery, California Pacific Medical Center, San Francisco, California
| | - Andrew Rosenblatt
- Department of Cardiology, California Pacific Medical Center, San Francisco, California
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29
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Chatterjee S, Dubey S, Lahiri D, Ray BK. Non vitamin K oral anticoagulants versus antiplatelets in embolic stroke of undetermined source: most updated evidence. Minerva Cardioangiol 2019; 67:340-347. [PMID: 31220915 DOI: 10.23736/s0026-4725.19.04967-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Recent trial data have expanded the horizons of newer indications of non-vitamin K oral anticoagulants (NOAC). Most recently they are being evaluated for use in embolic stroke of undetermined source (ESUS). ESUS are particularly known for their recurrences. So, identifying the causes and treating those etiological factors are the keys to secondary prevention of ESUS. Although traditional experts still opine for the use of antiplatelets for secondary prevention of ESUS as for other causes of embolic stroke, there are still room for improvement in delivery of optimal treatment strategy. So, NOAC is being tried as an alternative to traditional atiplatelet therapy in head-to-head trials. Unfortunately, recent trial data (from NAVIGATE-ESUS and RESPECT-ESUS) have not shown any added benefits (with comparable bleeding risk) of NOAC compared to aspirin in prevention of ESUS. This review intends to highlight the concept of ESUS, its varied etiologies, discuss the published and ongoing trials and tries to dig the reasons why the overall trial data have been disappointing. It also discusses the arenas where NOAC may be proved to be better than antiplatelets. Overall, we have stressed on the personalized case-to-case basis decision making while choosing the appropriate therapy in secondary prevention of ESUS.
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Affiliation(s)
- Subhankar Chatterjee
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, India -
| | - Souvik Dubey
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Postgraduate Medical Education and Research and SSKM Hospital, Kolkata, India
| | - Durjoy Lahiri
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Postgraduate Medical Education and Research and SSKM Hospital, Kolkata, India
| | - Biman K Ray
- Department of Neurology, Bangur Institute of Neurosciences, Institute of Postgraduate Medical Education and Research and SSKM Hospital, Kolkata, India
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30
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Song AB, Rosovsky RP, Connors JM, Al-Samkari H. Direct oral anticoagulants for treatment and prevention of venous thromboembolism in cancer patients. Vasc Health Risk Manag 2019; 15:175-186. [PMID: 31417269 PMCID: PMC6593743 DOI: 10.2147/vhrm.s132556] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/05/2019] [Indexed: 12/12/2022] Open
Abstract
Venous thromboembolism (VTE) is a common cause of morbidity and mortality in patients with cancer. Compared with the general population, cancer patients with VTE have higher rates of both VTE recurrence and bleeding. While low molecular weight heparin (LMWH) has been the mainstay of treatment for cancer-associated VTE for over a decade, direct oral anticoagulants (DOACs) have recently emerged as a new therapeutic option due to their ease of administration and because they do not require laboratory monitoring. Several large randomized clinical trials have been performed or are ongoing at the time of writing, comparing DOACs with LMWH in this population. Three of these trials have thus far been published and suggest that DOACs are a reasonable alternative to LMWH for management of cancer-associated VTE. Despite the advantages offered by DOACs, these agents may not be appropriate for certain patient groups owing to increased risk of bleeding, organ compromise, extremes of weight, and other issues. Finally, data are emerging suggesting that DOACs may be useful for primary thromboprophylaxis in cancer patients in conjunction with validated risk assessment scores. In this evidence-based review, data for the use of DOACs to treat cancer-associated VTE will be examined, focusing on efficacy, safety, and timing of treatment. Guidance on choosing the optimal anticoagulant for a given patient is also offered.
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Affiliation(s)
- Andrew B Song
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rachel P Rosovsky
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jean M Connors
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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32
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Metharom P, Falasca M, Berndt MC. The History of Armand Trousseau and Cancer-Associated Thrombosis. Cancers (Basel) 2019; 11:cancers11020158. [PMID: 30708967 PMCID: PMC6406548 DOI: 10.3390/cancers11020158] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/30/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- Pat Metharom
- Platelet Research Laboratory, Curtin Health Innovation Research Institute, Curtin University, Perth 6100, Australia.
| | - Marco Falasca
- Metabolic Signalling Group, School of Biomedical Sciences, Curtin Health Innovation Research Institute, Curtin University, Perth 6102, Australia.
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