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Linder M, Ekbom A, Brobert G, Vogtländer K, Balabanova Y, Becattini C, Carrier M, Cohen AT, Coleman CI, Khorana AA, Lee AYY, Psaroudakis G, Abdelgawwad K, Rivera M, Schaefer B, Giunta DH. Comparison of rivaroxaban and low molecular weight heparin in the treatment of cancer-associated venous thromboembolism: a Swedish national population-based register study. J Thromb Thrombolysis 2024; 57:973-983. [PMID: 38735015 PMCID: PMC11315776 DOI: 10.1007/s11239-024-02992-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/26/2024] [Indexed: 05/13/2024]
Abstract
BACKGROUND Treating cancer-associated venous thromboembolism (CAT) with anticoagulation prevents recurrent venous thromboembolism (rVTE), but increases bleeding risk. OBJECTIVES To compare incidence of rVTE, major bleeding, and all-cause mortality for rivaroxaban versus low molecular weight heparin (LMWH) in patients with CAT. METHODS We developed a cohort study using Swedish national registers 2013-2019. Patients with CAT (venous thromboembolism within 6 months of cancer diagnosis) were included. Those with other indications or with high bleeding risk cancers were excluded (according to guidelines). Follow-up was from index-CAT until outcome, death, emigration, or end of study. Incidence rates (IR) per 1000 person-years with 95% confidence interval (CI) and propensity score overlap-weighted hazard ratios (HRs) for rivaroxaban versus LMWH were estimated. RESULTS We included 283 patients on rivaroxaban and 5181 on LMWH. The IR for rVTE was 68.7 (95% CI 40.0-109.9) for rivaroxaban, compared with 91.6 (95% CI 81.9-102.0) for LMWH, with adjusted HR 0.77 (95% CI 0.43-1.35). The IR for major bleeding was 23.5 (95% CI 8.6-51.1) for rivaroxaban versus 49.2 (95% CI 42.3-56.9) for LMWH, with adjusted HR 0.62 (95% CI 0.26-1.49). The IR for all-cause mortality was 146.8 (95% CI 103.9-201.5) for rivaroxaban and 565.6 (95% CI 541.8-590.2) for LMWH with adjusted HR 0.48 (95% CI 0.34-0.67). CONCLUSIONS Rivaroxaban performed similarly to LMWH for patients with CAT for rVTE and major bleeding. An all-cause mortality benefit was observed for rivaroxaban which potentially may be attributed to residual confounding. TRIAL REGISTRATION NUMBER NCT05150938 (Registered 9 December 2021).
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Affiliation(s)
- Marie Linder
- Department of Medicine Solna, Clinical Epidemiology/ Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Anders Ekbom
- Department of Medicine Solna, Clinical Epidemiology/ Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Cecilia Becattini
- Department of Internal and Emergency Medicine, Stroke Unit, University of Perugia, Perugia, Italy
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
| | - Alexander T Cohen
- Department of Haematological Medicine, Guy's and St Thomas' NHS Foundation Trust, King's College London, London, UK
| | - Craig I Coleman
- School of Pharmacy, University of Connecticut, Storrs, CT, USA
| | - Alok A Khorana
- Cleveland Clinic and Case Comprehensive Cancer Center, Cleveland, OH, USA
| | - Agnes Y Y Lee
- University of British Columbia and BC Cancer, Vancouver, Canada
| | | | | | - Marcela Rivera
- Consultant for Bayer AG, Berlin, Germany
- Janssen Research and Development, Barcelona, Spain
| | | | - Diego Hernan Giunta
- Department of Medicine Solna, Clinical Epidemiology/ Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Arce-Huamani MA, Barboza JJ, Martínez-Herrera JF, Torres-Roman JS, Maguiña JL. Efficacy and Safety of Apixaban versus Dalteparin as a Treatment for Cancer-Associated Venous Thromboembolism: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1867. [PMID: 37893585 PMCID: PMC10607997 DOI: 10.3390/medicina59101867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023]
Abstract
Background and Objectives: Venous thromboembolism (VTE) is common in cancer patients. Anticoagulant therapy with low-molecular-weight heparins (LMWHs) and direct oral anticoagulants (DOACs), such as dalteparin and apixaban, have demonstrated efficacy and safety. However, more comparative research of these drugs is still needed. This study aimed to synthesize evidence on the efficacy of apixaban compared to dalteparin in reducing recurrent VTE, major bleeding, and clinically relevant non-major bleeding associated with cancer. Materials and Methods: We systematically searched the PubMed, Scopus, Web of Science, Embase, Cochrane Library, and ClinicalTrials databases up to 5 January 2023, for randomized controlled trials comparing apixaban versus dalteparin as treatment for cancer-associated VTE. Five studies were included. Effects according to meta-analyses were reported as relative risks (RRs) and their 95% confidence intervals (CIs). Results: It was found that 33 of 734 (4.5%) patients treated with apixaban and 56 of 767 (7.3%) with dalteparin had recurrent VTE as the efficacy outcome (RR 0.49, 95% CI 0.15-1.58, I2 38%). Major bleeding occurred in 25 of 734 patients treated with apixaban (3.4%) and 27 of 767 with dalteparin (3.5%) (RR 1.29, 95% CI 0.31-5.27, I2 59%). Likewise, clinically relevant non-major bleeding occurred in 64 of 734 patients treated with apixaban (8.7%) and 46 of 767 (5.9%) with dalteparin (RR 1.52, 95% CI 1.05-2.19, I2 0%). Conclusions: Apixaban showed a lower risk of recurrent VTE than dalteparin in patients with cancer-associated VTE, albeit with no statistical difference. Statistical significance was observed for no major clinically relevant bleeding but not for major bleeding.
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Affiliation(s)
- Miguel A. Arce-Huamani
- Facultad de Ciencias de la Salud, Universidad Cientifica del Sur, Lima 15067, Peru;
- Cancer Research Networking, Universidad Cientifica del Sur, Lima 15067, Peru; (J.F.M.-H.); (J.S.T.-R.)
| | - Joshuan J. Barboza
- Centro de Investigación en Epidemiología y Medicina Basada en Evidencia, Universidad Norbert Wiener, Lima 13007, Peru;
| | - José Fabián Martínez-Herrera
- Cancer Research Networking, Universidad Cientifica del Sur, Lima 15067, Peru; (J.F.M.-H.); (J.S.T.-R.)
- Cancer Center, Medical Center American British Cowdray, Mexico City 01120, Mexico
| | - J. Smith Torres-Roman
- Cancer Research Networking, Universidad Cientifica del Sur, Lima 15067, Peru; (J.F.M.-H.); (J.S.T.-R.)
- Latin American Network for Cancer Research (LAN–CANCER), Lima 11702, Peru
| | - Jorge L. Maguiña
- Facultad de Ciencias de la Salud, Universidad Cientifica del Sur, Lima 15067, Peru;
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Odajima S, Seki T, Kato S, Tomita K, Shoburu Y, Suzuki E, Takenaka M, Saito M, Takano H, Yamada K, Okamoto A. Efficacy of edoxaban for the treatment of gynecological cancer-associated venous thromboembolism: analysis of Japanese real-world data. J Gynecol Oncol 2022; 33:e62. [PMID: 35712973 PMCID: PMC9428303 DOI: 10.3802/jgo.2022.33.e62] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/11/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Direct oral anticoagulants (DOACs) are increasingly being used for the treatment of cancer-associated venous thromboembolism (CAT). However, there is limited evidence of the efficacy of DOACs for the treatment of gynecological CAT. Thus, this study aimed to investigate the efficacy and safety of edoxaban for the treatment of gynecological CAT using Japanese real-world data. METHODS We reviewed the medical records of patients with 371 gynecological cancer who received edoxaban or vitamin K antagonist (VKA) between January 2011 and December 2018. RESULTS Altogether, 211 and 160 patients were treated with edoxaban and VKA, respectively. Fourteen patients (6.8%) in the edoxaban group and 22 (13.8%) in the VKA group showed recurrence of venous thromboembolism (VTE). Cumulative VTE recurrence was not significantly different between the 2 groups (p=0.340). Adverse events occurred in 15 (7.1%) and 11 (6.9%) patients in the edoxaban and VKA groups, respectively (p=0.697). Subgroup analysis of the edoxaban and VKA groups according to different tumor types, including ovarian, endometrial, and cervical cancer, showed equivalent outcomes in terms of VTE recurrence and adverse events. Patients without pulmonary embolism (PE) were mostly omitted from initial unfractionated heparin (UFH) therapy prior to administration of edoxaban. However, this did not increase the recurrence of VTE. CONCLUSION This study confirmed that edoxaban is effective and safe for the treatment of gynecological CAT. This finding was consistent for different types of gynecological cancer. Additionally, initial UFH therapy prior to the administration of edoxaban may be unnecessary for patients without PE.
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Affiliation(s)
- Suguru Odajima
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Toshiyuki Seki
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan.
| | - Sayako Kato
- Department of Obstetrics and Gynecology, Daisan Hospital, The Jikei University School of Medicine, Tokyo, Japan
| | - Keisuke Tomita
- Department of Obstetrics and Gynecology, Kashiwa Hospital, The Jikei University School of Medicine, Chiba, Japan
| | - Yuichi Shoburu
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Eitaro Suzuki
- Department of Obstetrics and Gynecology, Katsushika Medical Center, The Jikei University School of Medicine, Tokyo, Japan
| | - Masataka Takenaka
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Motoaki Saito
- Department of Obstetrics and Gynecology, Kashiwa Hospital, The Jikei University School of Medicine, Chiba, Japan
| | - Hirokuni Takano
- Department of Obstetrics and Gynecology, Katsushika Medical Center, The Jikei University School of Medicine, Tokyo, Japan
| | - Kyosuke Yamada
- Department of Obstetrics and Gynecology, Daisan Hospital, The Jikei University School of Medicine, Tokyo, Japan
| | - Aikou Okamoto
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
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Hussain MR, Ali FS, Verghese D, Myint PT, Ahmed M, Gong Z, Gerais Y, Siddiqui M, Lin JJ, Troy K. Factor Xa inhibitors versus low molecular weight heparin for the treatment of cancer associated venous thromboembolism; A meta-analysis of randomized controlled trials and non-randomized studies. Crit Rev Oncol Hematol 2021; 169:103526. [PMID: 34838704 DOI: 10.1016/j.critrevonc.2021.103526] [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: 05/12/2021] [Revised: 10/18/2021] [Accepted: 11/01/2021] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION We compared the safety and efficacy of Xa-inhibitors to LMWH for treatment of venous thromboembolism in mixed and gastrointestinal cancer cohorts (CA-VTE). METHODS A systematic search identified RCTs and non-randomized studies (NRS) comparing Xa-inhibitors to LMWH for treating CA-VTE. Relative risks were computed. Certainty was assessed using the GRADE approach. RESULTS Xa-inhibitors reduced the risk of recurrent VTE (RR0.64;0.49-0.84) and NRS (RR0.74;0.60-0.92;Moderate-Low Certainty). There was no significant difference in recurrent PE in RCTs (RR0.72;0.50-1.02) and NRS (1.43;0.65-3.12;Low-Very Low Certainty). Xa-inhibitors increased the risk of overall bleeding events in RCTs (RR1.45;1.05-2.01) and NRS (RR1.72;1.42-2.08;Moderate-Low Certainty), and the risk of major bleeding events in NRS (RR1.56;1.17-2.07), but not in RCTs (RR1.33;0.94-1.89; Low-Very Low Certainty). Similar results were detected in gastrointestinal cancer patients. CONCLUSION Xa-inhibitors may reduce the risk of recurrent VTE, but not recurrent PE compared to LMWH. A higher overall bleeding risk, and a questionably higher major bleeding risk was found with Xa-inhibitor use.
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Affiliation(s)
- Maryam R Hussain
- Department of Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Faisal S Ali
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, IL, USA; Division of Gastroenterology, Hepatology, and Nutrition, The University of Texas Health Science Center at Houston, TX, USA
| | - Dhiran Verghese
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, IL, USA
| | - Phyo Thazin Myint
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, IL, USA
| | - Mubashir Ahmed
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, IL, USA
| | - Zimu Gong
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, IL, USA
| | - Yasmin Gerais
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, IL, USA
| | - Mahrukh Siddiqui
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, IL, USA
| | - Jenny J Lin
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kevin Troy
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Extended thromboprophylaxis for medically ill patients with cancer: a systemic review and meta-analysis. Blood Adv 2021; 5:2055-2062. [PMID: 33861298 DOI: 10.1182/bloodadvances.2020004118] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/25/2021] [Indexed: 12/11/2022] Open
Abstract
Hospitalized medically ill patients with cancer are at increased risk of both venous thromboembolism and bleeding. The safety and efficacy of extended thromboprophylaxis in patients with cancer are unclear. We conducted a systematic review and meta-analysis of the literature using of MEDLINE, EMBASE, and the Cochrane CENTRAL databases to identify cancer subgroups enrolled in randomized controlled trials evaluating extended thromboprophylaxis following hospitalization. The primary outcomes were symptomatic and incidental venous thromboembolic events and hemorrhage (major hemorrhage and clinically relevant nonmajor bleeding). Four randomized controlled trials reported the outcomes of extended thromboprophylaxis in 3655 medically ill patients with active or history of cancer. The rates of venous thromboembolic events were similar between the extended-duration and standard-duration groups (odds ratio [OR], 0.85; 95% confidence interval [CI], 0.61-1.18; I2 = 0%). However, major and clinically relevant nonmajor bleeding occurred significantly more frequently in the extended-duration thromboprophylaxis group (OR, 2.10; 95% CI, 1.33-3.35; I2 = 8%). Extended thromboprophylaxis in hospitalized medically ill patients with cancer was not associated with a reduced rate of venous thromboembolic events but was associated with increased risk of hemorrhage. This study protocol was registered on PROSPERO as #CRD42020209333.
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Mohamed MFH, ElShafei MN, Ahmed MB, Abdalla LO, Ahmed I, Elzouki AN, Danjuma MIM. The Net Clinical Benefit of Rivaroxaban Compared to Low-Molecular-Weight Heparin in the Treatment of Cancer-Associated Thrombosis: Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2021; 27:1076029620940046. [PMID: 33651658 PMCID: PMC7930650 DOI: 10.1177/1076029620940046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Cancer-associated thrombosis (CAT) carries significant morbidity and mortality. Low-molecular-weight heparin (LMWH) remains the standard of care, with recent systematic studies suggesting the efficacy and safety of rivaroxaban in the treatment of CAT. Uncertainty, however, remains regarding rivaroxaban efficacy and safety in real-world settings. We performed a systematic review and meta-analysis of studies comparing rivaroxaban to LMWH. We searched PubMed, MEDLINE, and EMBASE. The primary outcome was the net clinical benefit (NCB), while rates of major bleeding (MB), venous thromboembolism (VTE), clinically relevant nonmajor bleeding (CRNMB), and all-cause mortality events were secondary outcomes. Seventeen studies were included in the final analysis. Rivaroxaban had a better NCB (relative risk [RR] = 0.82; 95% CI = 0.75-0.89, Q = 10.51, I 2 = 0%), less VTE events (RR = 0.73, 95% CI = 0.65-0.82, Q = 6.76, I 2 = 0%), and lower all-cause mortality (RR = 0.72, 95% CI = 0.57-0.91, Q = 32.8, I 2 = 79%) compared to LMWH. Additionally, comparable MB events (RR = 1.07, 95% CI = 0.85-1.33, Q = 16.9, I 2 = 11%). However, CRNMB events were higher in the rivaroxaban group (RR = 2.02, 95% CI = 1.46-2.80, Q = 9.9, I 2 = 19%). Additional analyses demonstrated consistency of results. Our review encompassing data from randomized and real-world data suggested rivaroxaban superiority compared to LMWH in terms of a better NCB, fewer VTE events, lower all-cause mortality, and comparable MB risk while carrying a higher risk of CRNMB. These findings support the use of rivaroxaban in the treatment of CAT. Additionally, it warrants a sizable randomized controlled study testing the superiority of rivaroxaban versus LMWH formulation and ascertaining bleeding outcomes according to cancer type and site.
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Affiliation(s)
- Mouhand F H Mohamed
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | | | | | - Lina O Abdalla
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | - Israa Ahmed
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar
| | - Abdel-Naser Elzouki
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar.,473226Qatar University, College of Medicine, QU Health, Doha, Qatar
| | - Mohammed Ibn-Mas'ud Danjuma
- Internal Medicine Department, Hamad General Hospital, 36977Hamad Medical Corporation, Doha, Qatar.,473226Qatar University, College of Medicine, QU Health, Doha, Qatar
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Park JY. The role of direct oral anticoagulants in venous thromboembolic disease in gynecologic cancer. J Gynecol Oncol 2019; 31:e40. [PMID: 31833262 PMCID: PMC6918893 DOI: 10.3802/jgo.2020.31.e40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/01/2019] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jeong Yeol Park
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea.
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