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Wojtukiewicz MZ, Tesarova P, Karetová D, Windyga J. In Search of the Perfect Thrombosis and Bleeding-Associated Cancer Scale. Semin Thromb Hemost 2024; 50:443-454. [PMID: 37852295 DOI: 10.1055/s-0043-1776003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Thrombosis and bleeding are commonly observed in cancer patients, and their management is crucial for positive patient outcomes. A comprehensive, prophylactic, and therapeutic management of venous thrombosis should focus on identifying the patients who would benefit most from treatment to reduce mortality and minimize the risk of thrombosis recurrence without significantly increasing the risk of bleeding. Existing cancer scales provide valuable information for assessing the overall burden of cancer and guiding treatment decisions, but their ability to predict thrombotic and bleeding events remains limited. With increasing knowledge of the pathophysiology of cancer and the availability of advanced anticancer therapies, new risk factors for cancer-associated thrombosis and bleeding are being identified. In this report, we analyze the current literature and identify new risk factors for venous thrombosis and bleeding which are not included in routinely used risk scores. While some existing cancer scales partially capture the risk of thrombosis and bleeding, there is a need for more specific and accurate scales tailored to these complications. The development of such scales could improve risk stratification, aid in treatment selection, and enhance patient care. Therefore, further research and development of novel cancer scales focused on thrombosis and bleeding are warranted to optimize patient management and outcomes.
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Affiliation(s)
- Marek Z Wojtukiewicz
- Department of Oncology, Medical University of Bialystok, Bialystok, Poland
- Comprehensive Cancer Center, Bialystok, Poland
| | - Petra Tesarova
- Department of Oncology, Institute of Radiation Oncology, First Faculty of Medicine, Charles University and Bulovka University Hospital, Prague, Czech Republic
| | - Debora Karetová
- Second Department of Medicine-Department of Cardiovascular Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine in Warsaw, Warsaw, Poland
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2
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Wang Z, Li Y, He X, Fu Y, Li Y, Zhou X, Dong Z. In vivo evaluation of the pharmacokinetic interactions between almonertinib and rivaroxaban, almonertinib and apixaban. Front Pharmacol 2023; 14:1263975. [PMID: 37860116 PMCID: PMC10582335 DOI: 10.3389/fphar.2023.1263975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/22/2023] [Indexed: 10/21/2023] Open
Abstract
Background: Almonertinib, a third-generation epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), is commonly used as a first-line treatment for non-small cell lung cancer (NSCLC) patients with EGFR T790M mutations. Rivaroxaban and apixaban are a selective, direct factor Xa inhibitor used to treat venous thromboembolism (VTE), which is a frequent complication of NSCLC. Rivaroxaban and apixaban are substrates of CYP3A4, P-gp and BCRP, whereas almonertinib is an inhibitor of P-gp and BCRP. Rivaroxaban or apixaban are often prescribed together with almonertinib in NSCLC patients, but clear information on pharmacokinetic drug interaction is lacking. Therefore, this study aimed to unravel the extent of interactions between almonertinib-rivaroxaban and almonertinib apixaban in rats, and whether the pharmacokinetic interaction can be mitigated by rivaroxaban and apixaban dose adjustment. Methods: Rats were divided into ten groups (n = 6) that received rivaroxaban (2 mg/kg) (group 1), apixaban (0.5 mg/kg) (group 2), almonertinib (15 mg/kg) (group 3, group 4), almonertinib with rivaroxaban (2 mg/kg) (group 5), almonertinib with rivaroxaban (1 mg/kg) (group 6), almonertinib with apixaban (0.5 mg/kg) (group 7), almonertinib with apixaban (0.25 mg/kg) (group 8), rivaroxaban (2 mg/kg) with almonertinib (group 9), apixaban (0.5 mg/kg) with almonertinib (group 10). The concentrations of drugs were determined by an ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS). The levels of messenger RNA were determined using quantitative real-time polymerase chain reaction (qRT-PCR). Results and Discussion: The results indicate that almonertinib increased the Cmax and AUC0-t of 2 mg/kg rivaroxaban by 3.30 and 3.60-fold, 1 mg/kg rivaroxaban by 1.28 and 1.90-fold. Almonertinib increased the Cmax and AUC0-t of 0.5 mg/kg apixaban by 2.69 and 2.87-fold, 0.25 mg/kg apixaban by 2.19 and 2.06-fold. In addition, rivaroxaban also increased systemic exposure to almonertinib. The results of qRT-PCR showed that almonertinib reduced the expression of Cyp3a1 in liver and intestine, and Abcb1a, Abcg2 in intestine and kidney. The pharmacokinetic results suggest that it is important to take special care of the interactions of these drugs in clinical applications.
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Affiliation(s)
- Zhi Wang
- Graduate School of Hebei Medical University, Shijiazhuang, China
| | - Ying Li
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang, China
| | - Xueru He
- Graduate School of Hebei Medical University, Shijiazhuang, China
| | - Yuhao Fu
- Graduate School of Hebei Medical University, Shijiazhuang, China
| | - Yajing Li
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang, China
| | - Xin Zhou
- Graduate School of Hebei Medical University, Shijiazhuang, China
| | - Zhanjun Dong
- Department of Pharmacy, Hebei General Hospital, Shijiazhuang, China
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3
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Cominacini M, Suardi S, Ferrari G, Ciresa R, Tosi F, De Marchi S, Valenti MT, Dalle Carbonare L. DOAC in the treatment of cancer-associated venous thromboembolism: a retrospective cohort study beyond the guidelines. J Cancer Res Clin Oncol 2023; 149:5773-5779. [PMID: 36577902 PMCID: PMC10356843 DOI: 10.1007/s00432-022-04535-8] [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: 09/01/2022] [Accepted: 12/16/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The emerging use of direct oral anticoagulants (DOAC) in the management of cancer-associated venous thromboembolism (CAT) is significantly improving therapeutic adherence and quality of life. Despite this, many conditions can restrict the therapeutic index of these drugs. For all these reasons the latest guidelines recommend the use of heparins in the treatment of CAT as the preferred treatment in some clinical settings. OBJECTIVES We evaluated the efficacy and the safety of DOAC, in terms of recurrent venous thromboembolism (VTE) and major bleeding (MB), as a composite primary outcome. Mortality and clinically relevant non-major bleeding (CRNMB) were evaluated as secondary outcomes. METHODS We performed a retrospective study on 209 patients to compare the effects of DOAC versus heparins for the treatment of CAT. 127 patients with a high bleeding risk neoplasia were enrolled. RESULTS A primary-outcome event occurred in 11.3% of patients treated with heparins and in 10.5% treated with DOAC (Relative Risk 0.92; 95% CI 0.42-2.01, p = 0.84). Recurrent VTE occurred in 6.1% in the heparins group and in 8.4% in the DOAC group (RR 1.37; 95% CI 0.51-3.64, p = 0.52). MB occurred in 5.2% in the heparins group and in 2.1% in the DOAC group (RR 0.40; 95% CI 0.08-1.93, p = 0.25). CONCLUSIONS DOAC seem to be as effective and safe as heparins in the treatment of CAT. Most bleeding events occurred in patients with high-risk bleeding neoplasms regardless of the type of anticoagulant. Considering the characteristics and satisfaction of patients using DOAC in this setting, this approach should be considered as a first choice.
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Affiliation(s)
- Mattia Cominacini
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale Scuro, 10, Policlinico G.B. Rossi, 37134, Verona, Italy
| | - Silvia Suardi
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale Scuro, 10, Policlinico G.B. Rossi, 37134, Verona, Italy
| | - Giulia Ferrari
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale Scuro, 10, Policlinico G.B. Rossi, 37134, Verona, Italy
| | - Roberto Ciresa
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale Scuro, 10, Policlinico G.B. Rossi, 37134, Verona, Italy
| | - Federica Tosi
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale Scuro, 10, Policlinico G.B. Rossi, 37134, Verona, Italy
| | - Sergio De Marchi
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale Scuro, 10, Policlinico G.B. Rossi, 37134, Verona, Italy
| | - Maria Teresa Valenti
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, 37134, Verona, Italy
| | - Luca Dalle Carbonare
- Department of Medicine, Section of Internal Medicine, University of Verona, Piazzale Scuro, 10, Policlinico G.B. Rossi, 37134, Verona, Italy.
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4
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Cohen AT, Benson G, Bradbury CA, Choudhuri S, Hutchinson Jones N, Maraveyas A, Venugopal B, Young AM, Chapman C, McIntyre S, Burney D, Pollock KG, Morgan AR, Gabb PD, Alikhan R. A consensus viewpoint on the role of direct factor Xa inhibitors in the management of cancer-associated venous thromboembolism in the UK. Curr Med Res Opin 2023; 39:483-495. [PMID: 36629478 DOI: 10.1080/03007995.2023.2167441] [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] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Cancer patients are at high risk of venous thromboembolism (VTE), a significant cause of cancer-related death. Historically, low molecular weight heparins (LMWH) were the gold standard therapy for cancer-associated VTE, but recent evidence supports the use of direct factor Xa inhibitors in cancer-associated VTE and this is now reflected in many guidelines. However, uptake of direct factor Xa inhibitors varies and guidance on the use of direct factor Xa inhibitors in specific cancer sub-populations and clinical situations is lacking. This review presents consensus expert opinion alongside evaluation of evidence to support healthcare professionals in the use of direct factor Xa inhibitors in cancer-associated VTE. METHODS Recent guidelines, meta-analyses, reviews and clinical studies on anticoagulation therapy for cancer-associated VTE were used to direct clinically relevant topics and evidence to be systematically discussed using nominal group technique. The consensus manuscript and recommendations were developed based on these discussions. RESULTS Considerations when prescribing anticoagulant therapy for cancer-associated VTE include cancer site and stage, systemic anti-cancer therapy (including vascular access), drug-drug interactions, length of anticoagulation, quality of life and needs during palliative care. Treatment of patients with kidney or liver impairment, gastrointestinal disorders, extremes of bodyweight, elevated bleeding or recurrence risk, VTE recurrence and COVID-19 is discussed. CONCLUSION Anticoagulant therapy for cancer-associated VTE patients should be carefully selected with consideration given to the relative benefits of specific drugs when individualizing care. Direct factor Xa inhibitors are typically the treatment of choice for preventing VTE recurrence in non-cancer patients and should also be considered as such for cancer-associated VTE in most situations.
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Affiliation(s)
- Alexander T Cohen
- Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Gary Benson
- Northern Ireland Haemophilia Comprehensive Care Centre and Thrombosis Unit, Belfast, UK
| | | | | | | | | | - Balaji Venugopal
- The Beatson West of Scotland Cancer Centre, Glasgow, UK
- Institute of Cancer Sciences, University of Glasgow, Glasgow, UK
| | - Annie M Young
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | | | | | | | | | | | - Peter D Gabb
- Health Economics and Outcomes Research Ltd., Cardiff, UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre, University Hospital of Wales, Cardiff, UK
- Cardiff University School of Medicine, Cardiff, UK
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5
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Lee LH, Danchaivijitr P, Uaprasert N, Gill H, Sacdalan DL, Ho GF, Parakh R, Pai P, Lee JK, Rey N, Cohen AT. Safe and effective treatment of venous Thromboembolism associated with Cancer: focus on direct Oral Anticoagulants in Asian patients. Exp Hematol Oncol 2022; 11:79. [PMID: 36303259 PMCID: PMC9615183 DOI: 10.1186/s40164-022-00331-9] [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: 10/05/2022] [Accepted: 10/06/2022] [Indexed: 11/10/2022] Open
Abstract
Cancer-associated thrombosis (CAT) poses a significant disease burden and the incidence in Asian populations is increasing. Anticoagulation is the cornerstone of treatment, but can be challenging due to the high bleeding risk in some cancers and the high risk of recurrent venous thromboembolism (VTE) in patients with malignancies. Direct oral anticoagulants (DOACs) are well established as first-choice treatments for VTE in non-cancer patients, offering a more convenient and less invasive treatment option than low-molecular-weight heparin (LMWH). Asian patients have exhibited comparable efficacy and safety outcomes with other races in trials of DOACs for VTE in the general population. Although no specific data are available in Asian patients with CAT, results from randomized controlled trials of apixaban, edoxaban, or rivaroxaban versus the LMWH, dalteparin, indicate that DOACs are a reasonable alternative to LMWH for anticoagulation in Asian patients with CAT. This is further supported by analyses of real-world data in Asian populations demonstrating the efficacy and safety of DOACs in Asian patients with CAT. Apixaban, edoxaban, or rivaroxaban are recommended in the most recently updated international guidelines as first-line therapy for CAT in patients without gastrointestinal or genitourinary cancers and at low risk of bleeding. An increased risk of major gastrointestinal bleeding was evident with edoxaban or rivaroxaban, but not apixaban, versus dalteparin in the clinical trials, suggesting that apixaban could be a safe alternative to LMWH in patients with gastrointestinal malignancies. Determining the optimal anticoagulant therapy for patients with CAT requires careful consideration of bleeding risk, tumor type, renal function, drug-drug interactions, financial costs, and patients' needs and preferences.
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Affiliation(s)
- Lai Heng Lee
- Haematology Department, Singapore General Hospital, Bukit Merah, Singapore
| | - Pongwut Danchaivijitr
- Division of Medical Oncology, Department of Internal Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Noppacharn Uaprasert
- Research Unit in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Harinder Gill
- Department of Medicine, The University of Hong Kong, 102 Pokfulam Road, Pokfulam Hong Kong, Pokfulam, Hong Kong, China.
| | | | - Gwo Fuang Ho
- Clinical Oncology, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Rajiv Parakh
- Division of Peripheral Vascular & Endovascular Service, Medanta-Medicity, Gurgaon, Haryana, India
| | - Paresh Pai
- Vascular and Endovascular Surgery, The Vascular Clinic, Mumbai, India
| | - Jen-Kuang Lee
- Cardiology Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Nannette Rey
- de La Salle Medical and Health Sciences Institute, Dasmarinas Cavite, Philippines
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' Hospitals, NHS Trust, King's College, London, UK
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6
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Escobar A, Salem AM, Dickson K, Johnson TN, Burk KJ, Bashoura L, Faiz SA. Anticoagulation and bleeding in the cancer patient. Support Care Cancer 2022; 30:8547-8557. [PMID: 35579752 PMCID: PMC9529787 DOI: 10.1007/s00520-022-07136-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/09/2022] [Indexed: 11/29/2022]
Abstract
Cancer patients have an increased risk of bleeding compared to non-cancer patients with anticoagulant therapy. A bleeding risk assessment before initiation of anticoagulation is recommended. Currently low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) are the mainstays of treatment for cancer-associated venous thromboembolism (VTE). Since DOACs are administered orally, they offer some convenience and ease of administration; however, LMWH may be preferred in certain cancers. Given the prevalence of anticoagulant therapies in cancer patients, clinical providers must be able to recognize potentially critical bleeding sites and modalities to reverse major hemorrhage. Reversal agents or antidotes to bleeding may be required when bleeding is persistent or life-threatening. These include vitamin K, fresh frozen plasma (FFP), protamine, prothrombin complex concentrate (PCC) or andexanet alfa, and idarucizumab. Inferior vena cava (IVC) filter insertion can be also considered in those with major bleeding. Evidence for timing and need for re-initiation of anticoagulant therapy after a major bleeding remains sparse, but a multi-disciplinary approach and shared decision-making can be implemented in the interim.
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Affiliation(s)
- Andres Escobar
- Divisions of Critical Care, Pulmonary and Sleep Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Ahmed M Salem
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Kodwo Dickson
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tami N Johnson
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kathyrn J Burk
- Department of Emergency Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lara Bashoura
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA
| | - Saadia A Faiz
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Unit 1462, P.O. Box 301402, Houston, TX, 77030-1402, USA.
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7
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Parrini I, Lucà F, Rao CM, Parise G, Micali LR, Musumeci G, La Meir M, Colivicchi F, Gulizia MM, Gelsomino S. Superiority of Direct Oral Anticoagulants over Vitamin K Antagonists in Oncological Patients with Atrial Fibrillation: Analysis of Efficacy and Safety Outcomes. J Clin Med 2022; 11:jcm11195712. [PMID: 36233581 PMCID: PMC9572823 DOI: 10.3390/jcm11195712] [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: 07/11/2022] [Revised: 08/31/2022] [Accepted: 09/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background and aim. Cancer and atrial fibrillation (AF) may be associated, and anticoagulation, either with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), is necessary to prevent thromboembolic events by reducing the risk of bleeding. The log incidence rate ratio (IRR) and 95% confidence interval were used as index statistics. Higgin’s I2 test was adopted to assess statistical inconsistencies by considering interstudy variations, defined by values ranging from 0 to 100%. I2 values of less than 40% are associated with very low heterogeneity among the studies; values between 40% and 75% indicate moderate heterogeneity, and those greater than 75% suggest severe heterogeneity. The aim of this meta-analysis was to compare the safety and efficacy of VKAs and DOACs in oncologic patients with AF. Methods. A meta-analysis was conducted comparing VKAs to DOACs in terms of thromboembolic events and bleeding. A meta-regression was conducted to investigate the differences in efficacy and safety between four different DOACs. Moreover, a sub-analysis on active-cancer-only patients was conducted. Results. A total of eight papers were included. The log incidence rate ratio (IRR) for thromboembolic events between the two groups was −0.69 (p < 0.005). The meta-regression did not reveal significant differences between the types of DOACs (p > 0.9). The Log IRR was −0.38 (p = 0.008) for ischemic stroke, −0.43 (p = 0.02) for myocardial infarction, −0.39 (p = 0.45) for arterial embolism, and −1.04 (p = 0.003) for venous thromboembolism. The log IRR for bleeding events was −0.43 (p < 0.005), and the meta-regression revealed no statistical difference (p = 0.7). The log IRR of hemorrhagic stroke, major bleeding, and clinically relevant non-major bleeding between the VKA and DOAC groups was −0.51 (p < 0.0001), −0.45 (p = 0.03), and 0.0045 (p = 0.97), respectively. Similar results were found in active-cancer patients for all the endpoints except for clinically-relevant non-major bleedings. Conclusions. DOACs showed better efficacy and safety outcomes than VKAs. No difference was found between types of DOACs.
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Affiliation(s)
- Iris Parrini
- Division of Cardiology, Mauriziano Hospital, 10128 Turin, Italy
- Correspondence:
| | - Fabiana Lucà
- Grande Ospedale Metropolitano, 89124 Reggio Calabria, Italy
| | | | - Gianmarco Parise
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Linda Renata Micali
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | | | - Mark La Meir
- University Hospital Brussels, 1050 Brussels, Belgium
| | | | - Michele Massimo Gulizia
- Cardiology Division, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi”, 95126 Catania, Italy
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
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8
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Otten LS, Piet B, van den Heuvel MM, Marzolini C, van Geel RMJM, Gulikers JL, Burger DM, Leentjens J, Ter Heine R. Practical recommendations to combine small-molecule inhibitors and direct oral anticoagulants in patients with nonsmall cell lung cancer. Eur Respir Rev 2022; 31:31/164/220004. [PMID: 35705208 DOI: 10.1183/16000617.0004-2022] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 04/07/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The risk for thromboembolisms in nonsmall cell lung cancer (NSCLC) patients is increased and often requires treatment or prophylaxis with direct oral anticoagulants (DOACs). Small-molecule inhibitors (SMIs) to treat NSCLC may cause relevant drug-drug interactions (DDIs) with DOACs. Guidance on how to combine these drugs is lacking, leaving patients at risk of clotting or bleeding. Here, we give practical recommendations to manage these DDIs. METHODS For all DOACs and SMIs approved in Europe and the USA up to December 2021, a literature review was executed and reviews by the US Food and Drug Administration and European Medicines Agency were analysed for information on DDIs. A DDI potency classification for DOACs was composed and brought together with DDI characteristics of each SMI, resulting in recommendations for each combination. RESULTS Half of the combinations result in relevant DDIs, requiring an intervention to prevent ineffective or toxic treatment with DOACs. These actions include dose adjustments, separation of administration or switching between anticoagulant therapies. Combinations of SMIs with edoxaban never cause relevant DDIs, compared to more than half of combinations with other DOACs and even increasing to almost all combinations with rivaroxaban. CONCLUSIONS Combinations of SMIs and DOACs often result in relevant DDIs that can be prevented by adjusting the DOAC dosage, separation of administration or switching between anticoagulants.
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Affiliation(s)
- Leila S Otten
- Dept of Pharmacy and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Berber Piet
- Dept of Pulmonology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Catia Marzolini
- Dept of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Division of Infectious Diseases and Hospital Epidemiology, Depts of Medicine and Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Robin M J M van Geel
- Dept of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Dept of Internal Medicine and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Judith L Gulikers
- Dept of Clinical Pharmacy and Toxicology, Maastricht University Medical Center+, Maastricht, The Netherlands.,Dept of Internal Medicine and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David M Burger
- Dept of Pharmacy and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jenneke Leentjens
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, The Netherlands
| | - Rob Ter Heine
- Dept of Pharmacy and Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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9
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Biomarkers of Venous Thromboembolism Recurrence after Discontinuation of Low Molecular Weight Heparin Treatment for Cancer-Associated Thrombosis (HISPALIS-Study). Cancers (Basel) 2022; 14:cancers14112771. [PMID: 35681751 PMCID: PMC9179374 DOI: 10.3390/cancers14112771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 05/26/2022] [Accepted: 05/30/2022] [Indexed: 01/08/2023] Open
Abstract
The most appropriate duration of anticoagulant treatment for cancer-associated venous thromboembolism (CAT) remains unclear. We have conducted a prospective multicenter study in CAT patients with more than 6 months of anticoagulant treatment to predict the risk of venous thromboembolism (VTE) recurrence after anticoagulation discontinuation. Blood samples were obtained when patients stopped the anticoagulation, at 21 days and at 90 days. In each sample we assessed different coagulation-related biomarkers: D-dimer (DD), high-sensitivity C-reactive protein (hs-CRP), P-selectin (PS), phospholipids, soluble tissue factor, factor VIII and the thrombin generation test. It was evaluated 325 CAT patients and 166 patients were included in the study, mean age 64 ± 17 years. VTE recurrence until 6 months after stopping anticoagulation treatment was 9.87% [95% confidence interval (CI): 6−15]. The biomarkers sub-distribution hazard ratios were 6.32 for ratio DD basal/DD 21 days > 2 (95% CI: 1.82−21.90), 6.36 for hs-CRP > 4.5 (95% CI: 1.73−23.40) and 5.58 for PS > 40 (95% CI: 1.46−21.30) after 21 days of stopping anticoagulation. This is the first study that has identified the DD ratio, hs-CRP and PS as potential biomarkers of VTE recurrence in cancer patients after the discontinuation of anticoagulation treatment. A risk-adapted strategy may allow the identification of the optimal time to withdraw the anticoagulation in each CAT patient.
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10
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Venous Thromboembolism and Cancer: A Comprehensive Review from Pathophysiology to Novel Treatment. Biomolecules 2022; 12:biom12020259. [PMID: 35204760 PMCID: PMC8961522 DOI: 10.3390/biom12020259] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/20/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022] Open
Abstract
Acute thrombotic events can unveil occult cancer, as they are its first manifestation in about 20 to 30% of all cases. Malignancy interacts in an intricate way with the hemostatic system, promoting both thrombosis and bleeding. The main pathway involved in these reactions involves the activation of tumor-associated procoagulant factors, which eventually results in clot formation. The clinical manifestation of cancer-related thrombotic events mainly involves the venous side, and manifests in a broad spectrum of conditions, including unusual sites of venous thrombosis. The selection of patients who have a balanced risk–benefit profile for management of anticoagulation is complex, given individual patient goals and preferences, different prognosis of specific cancers, common comorbidities, potential drug–drug interactions, underweight states, and the competing risks of morbidity and mortality. Anticoagulant treatment in cancer settings is broadly debated, considering the potential application of direct oral anticoagulants in both thromboprophylaxis and secondary prevention, having demonstrated its efficacy and safety compared to conventional treatment. This review aims to provide a brief overview of the pathophysiology and management of cancer-related thrombosis, summarizing the results obtained in recent clinical trials.
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Lee CL, Chen WS, Wee Y, Wang CS, Chen WC, Chiu TJ, Wang YM, Wu CN, Yang YH, Luo SD, Wu SC. Direct Oral Anticoagulants Are Associated with Superior Survival Outcomes than Warfarin in Patients with Head and Neck Cancers. Cancers (Basel) 2022; 14:cancers14030703. [PMID: 35158969 PMCID: PMC8833638 DOI: 10.3390/cancers14030703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Patients with head and neck cancers may suffer from cancer-associated thromboembolism and direct oral anticoagulants (DOACs) are a potential new therapeutic option. We aimed to determine the clinical impact of DOACs compared with traditional anticoagulants on the survival of patients with head and neck cancers. In our study, DOAC users had significantly better disease-specific survival (DSS) and higher overall survival (OS) rates than warfarin users and those who did not use any anticoagulant. Further, there were no significant differences in the occurrence rate of bleeding or ischemic events between DOAC and warfarin users. Our study suggested that DOACs can be a treatment choice or prophylaxis for tumor emboli in head and neck cancer patients and that they might be a better choice than traditional anticoagulants. Abstract Increasing clinical evidence supports the use of direct oral anticoagulants (DOACs) as a potential new therapeutic option for patients suffering from cancer-associated thromboembolism. However, the clinical impact of DOACs compared with traditional anticoagulants on the survival of patients with head and neck cancer has not been well studied. A total of 1025 patients diagnosed as having head and neck cancer, including 92 DOAC users, 113 warfarin users, and 820 nonusers of anticoagulants, were selected from the Chang Gung Research Database between January 2001 and December 2019. The patients were matched using the propensity-score method. The survival rates were estimated among the three groups using the Kaplan–Meier method. The protective effects and side effects of the two anticoagulants were compared using the chi-square test. The death rate (18 patients, 19.57%) in patients using DOACs was significantly lower than that in patients using warfarin (68 patients, 60.18%) and those not using any anticoagulant (403 patients, 49.15%). DOAC users had significantly better disease-specific survival (DSS) than warfarin users (p = 0.019) and those who did not use any anticoagulant (p = 0.03). Further, DOAC users had significantly higher overall survival (OS) rates than warfarin users and those who did not use any anticoagulant (p = 0.003). Patients with oropharyngeal and laryngeal cancer and DOAC users had a significantly lower hazard ratio for survival, whereas patients with American Joint Committee on Cancer stage IV disease and those receiving multidisciplinary treatment (e.g., surgery with radiotherapy or concurrent radiochemotherapy) had a significantly higher hazard ratio for survival. Among them, patients with laryngeal cancer (HR = 0.47, 95% CI = 0.26–0.86, p = 0.0134) and DOAC users (HR = 0.53, 95% CI = 0.29–0.98, p = 0.042) had the lowest hazard ratio from DSS analysis. Similarly, patients with laryngeal cancer (HR = 0.48, 95% CI = 0.30–0.76, p = 0.0018) and DOAC users (HR = 0.58, 95% CI = 0.36–0.93, p = 0.0251) had the lowest hazard ratio from OS analysis. As for the protective effects or side effects of anticoagulants, there were no significant differences in the occurrence rate of bleeding or ischemic events between DOAC and warfarin users. In our study, DOACs were found to be better than warfarin in terms of survival in patients with head and neck cancer. As regards thromboembolism prevention and side effects, DOACs were comparable to warfarin in our patients. DOACs can be a treatment choice or prophylaxis for tumor emboli in head and neck cancer patients and they might be a better choice than traditional anticoagulants according to the results of our study.
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Affiliation(s)
- Chien-Lin Lee
- Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
| | - Wei-Shan Chen
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (W.-S.C.); (W.-C.C.); (C.-N.W.)
| | - Yinshen Wee
- Department of Pathology, University of Utah, Salt Lake City, UT 84112, USA;
| | - Ching-Shuen Wang
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 110, Taiwan;
| | - Wei-Chih Chen
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (W.-S.C.); (W.-C.C.); (C.-N.W.)
| | - Tai-Jan Chiu
- Department of Hematology-Oncology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Yu-Ming Wang
- Department of Radiation Oncology and Proton & Radiation Therapy Center, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan;
| | - Ching-Nung Wu
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (W.-S.C.); (W.-C.C.); (C.-N.W.)
| | - Yao-Hsu Yang
- Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi 613, Taiwan;
- Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi 613, Taiwan
- School of Traditional Chinese Medicine, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Sheng-Dean Luo
- Department of Otolaryngology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan; (W.-S.C.); (W.-C.C.); (C.-N.W.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Correspondence: (S.-D.L.); (S.-C.W.); Tel.: +886-7-7317123 (ext. 2533) (S.-D.L. & S.-C.W.)
| | - Shao-Chun Wu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan
- Correspondence: (S.-D.L.); (S.-C.W.); Tel.: +886-7-7317123 (ext. 2533) (S.-D.L. & S.-C.W.)
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12
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Dubinski D, Won SY, Behmanesh B, Dosch M, Puchinin V, Baumgarten P, Bernstock JD, Voss M, Schuss P, Konczalla J, Czabanka M, Freiman TM, Gessler F. Therapeutic Anticoagulation Impacts MR Morphologic Recurrence Patterns in Glioblastoma-A Matched-Pair Analysis. J Clin Med 2022; 11:422. [PMID: 35054114 PMCID: PMC8778000 DOI: 10.3390/jcm11020422] [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: 12/10/2021] [Revised: 01/03/2022] [Accepted: 01/10/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Glioblastoma (GBM) patients are at particularly high risk for thrombotic complications. In the event of a postoperative pulmonary embolism, therapeutic anticoagulation (tAC) is indispensable. The impact of therapeutic anticoagulation on recurrence pattern in GBM is currently unknown. METHODS We conducted a matched-pair cohort analysis of 57 GBM patients with or without tAC that were matched for age, sex, gross total resection and MGMT methylation status in a ratio of 1:2. Patients' characteristics and clinical course were evaluated using medical charts. MRI characteristics were evaluated by two independent authors blinded to the AC status. RESULTS The morphologic MRI appearance in first GBM recurrence showed a significantly higher presence of multifocal, midline crossing and sharp demarcated GBM recurrence patterns in patients with therapeutic tAC compared to the matched control group. Although statistically non-significant, the therapeutic tAC cohort showed increased survival. CONCLUSION Therapeutic anticoagulation induced significant morphologic changes in GBM recurrences. The underlying pathophysiology is discussed in this article but remains to be further elucidated.
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Affiliation(s)
- Daniel Dubinski
- Department of Neurosurgery, University Hospital, Goethe University, 60528 Frankfurt, Germany; (S.-Y.W.); (B.B.); (M.D.); (V.P.); (P.B.); (J.K.); (M.C.)
- Department of Neurosurgery, University Medicine Rostock, 18055 Rostock, Germany; (T.M.F.); (F.G.)
| | - Sae-Yeon Won
- Department of Neurosurgery, University Hospital, Goethe University, 60528 Frankfurt, Germany; (S.-Y.W.); (B.B.); (M.D.); (V.P.); (P.B.); (J.K.); (M.C.)
- Department of Neurosurgery, University Medicine Rostock, 18055 Rostock, Germany; (T.M.F.); (F.G.)
| | - Bedjan Behmanesh
- Department of Neurosurgery, University Hospital, Goethe University, 60528 Frankfurt, Germany; (S.-Y.W.); (B.B.); (M.D.); (V.P.); (P.B.); (J.K.); (M.C.)
- Department of Neurosurgery, University Medicine Rostock, 18055 Rostock, Germany; (T.M.F.); (F.G.)
| | - Max Dosch
- Department of Neurosurgery, University Hospital, Goethe University, 60528 Frankfurt, Germany; (S.-Y.W.); (B.B.); (M.D.); (V.P.); (P.B.); (J.K.); (M.C.)
| | - Viktoria Puchinin
- Department of Neurosurgery, University Hospital, Goethe University, 60528 Frankfurt, Germany; (S.-Y.W.); (B.B.); (M.D.); (V.P.); (P.B.); (J.K.); (M.C.)
| | - Peter Baumgarten
- Department of Neurosurgery, University Hospital, Goethe University, 60528 Frankfurt, Germany; (S.-Y.W.); (B.B.); (M.D.); (V.P.); (P.B.); (J.K.); (M.C.)
| | - Joshua D. Bernstock
- Department of Neurosurgery, Birgham and Women’s, Harvard Medical School, Boston, MA 02115, USA;
| | - Martin Voss
- Dr. Senckenberg Institute of Neurooncology, Goethe University Hospital, 18055 Frankfurt, Germany;
| | - Patrick Schuss
- Department of Neurosurgery, Unfallkrankenhaus Berlin, 12683 Berlin, Germany;
| | - Jürgen Konczalla
- Department of Neurosurgery, University Hospital, Goethe University, 60528 Frankfurt, Germany; (S.-Y.W.); (B.B.); (M.D.); (V.P.); (P.B.); (J.K.); (M.C.)
| | - Marcus Czabanka
- Department of Neurosurgery, University Hospital, Goethe University, 60528 Frankfurt, Germany; (S.-Y.W.); (B.B.); (M.D.); (V.P.); (P.B.); (J.K.); (M.C.)
| | - Thomas M. Freiman
- Department of Neurosurgery, University Medicine Rostock, 18055 Rostock, Germany; (T.M.F.); (F.G.)
| | - Florian Gessler
- Department of Neurosurgery, University Medicine Rostock, 18055 Rostock, Germany; (T.M.F.); (F.G.)
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13
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Di W, Xu H, Xue T, Ling C. Advances in the Prediction and Risk Assessment of Lung Cancer-Associated Venous Thromboembolism. Cancer Manag Res 2021; 13:8317-8327. [PMID: 34764694 PMCID: PMC8575248 DOI: 10.2147/cmar.s328918] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022] Open
Abstract
According to the most recent data from the National Cancer Center, venous thromboembolism (VTE) has unsurprisingly become one of the most common complications in lung cancer. VTE not only interferes with the equilibrium of the clotting system but it also affects tumor progression and prognosis. For the identification of high-risk patients, many clinical risk assessment models have been developed and validated based on the risk factors found in previous studies. In this review, we will summarize advances in prediction and risk assessment of VTE, with a focus on early diagnosis and therapy, reduction of mortality, and the burden of medical costs in lung cancer patients.
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Affiliation(s)
- Wenjuan Di
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People's Republic of China
| | - Haotian Xu
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People's Republic of China
| | - Ting Xue
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People's Republic of China
| | - Chunhua Ling
- Department of Respiratory and Critical Care Medicine, The First Hospital Affiliated of Soochow University, Suzhou City, Jiangsu Province, People's Republic of China
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14
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Khan F, Sharma N, Ud Din M, Chetram R. Diagnostic and Therapeutic Challenges of Cerebral Venous Thrombosis in SARS-CoV-2 Infection: A Case Report and Review of Literature. Clin Pract 2021; 11:598-606. [PMID: 34563004 PMCID: PMC8482202 DOI: 10.3390/clinpract11030075] [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: 07/17/2021] [Revised: 08/17/2021] [Accepted: 08/27/2021] [Indexed: 11/30/2022] Open
Abstract
Headache, a common prodromal symptom of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, can also be a manifestation of cerebral venous thrombosis (CVT), secondary to COVID-19. CVT management continues to evolve, with direct oral anticoagulants (DOACs) emerging as an alternative to warfarin. A 44-year-old Asian female, with no past medical history, presented to the emergency room (ER) with complaints of nonproductive cough and left-sided headache. She denied a history of COVID-19 vaccination, and SARS-CoV-2 testing (with reverse transcriptase-polymerase chain reaction) was positive. Non-contrast computed tomography (CT) of the head revealed left transverse sinus hyperdensity, consistent with dense vein sign, and magnetic resonance venography (MRV) confirmed the presence of thrombus. The initial treatment included subcutaneous enoxaparin with headache resolution, and she was discharged on apixaban. Five weeks later, a non-contrast head CT showed resolution of the dense vein sign and recanalisation of left transverse sinus was seen on MRV. This report has highlighted the need for increased awareness of coagulopathy and thrombotic events, including cerebral venous thrombosis, in patients infected with SARS-CoV-2. Unremitting headache, in context of SARS-CoV-2 infection, should be evaluated with appropriate neurovascular imaging. Controlled studies are required to compare the safety and efficacy of DOACs with warfarin for management of cerebral venous thrombosis.
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Affiliation(s)
- Faisal Khan
- Neurology, College of Osteopathic Medicine, Sam Houston State University, Huntsville, TX 77340, USA
- Correspondence: ; Tel.: +713-234-7132; Fax: +281-249-5439
| | - Neha Sharma
- Neurology, Houston Medical Clerkship, Sugar Land, TX 77478, USA; (N.S.); (M.U.D.)
| | - Moin Ud Din
- Neurology, Houston Medical Clerkship, Sugar Land, TX 77478, USA; (N.S.); (M.U.D.)
| | - Ryan Chetram
- School of Medicine, Caribbean Medical University, 4797 Willemstad, Curaçao;
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15
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Risk Prediction and New Prophylaxis Strategies for Thromboembolism in Cancer. Cancers (Basel) 2021; 13:cancers13071556. [PMID: 33805252 PMCID: PMC8037773 DOI: 10.3390/cancers13071556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 11/17/2022] Open
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16
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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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