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Yang C, Khan F, MacDonald C, Guglielmo J, Lo M, Young R, Banez MT, Huang L, Nguyen R, Kang S, Saunders IM. Characterization of direct oral anticoagulants use in adult hematopoietic stem cell transplant recipients. J Thromb Thrombolysis 2024; 57:293-301. [PMID: 37932590 PMCID: PMC10869366 DOI: 10.1007/s11239-023-02902-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 11/08/2023]
Abstract
Direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) treatment are of interest in oncology due to ease of administration and lack of need for therapeutic monitoring compared to other anticoagulants. Data supporting their use in patients with hematologic malignancies post-hematopoietic stem cell transplant (HCT) are limited. The purpose of the study is to characterize DOAC use in HCT patients. This multicenter, retrospective cohort analysis included allogeneic and autologous HCT recipients. The primary outcome was major bleeding. Secondary outcomes included clinically relevant non-major bleeding (CRNMB)/minor bleeding and VTE recurrence. Of 126 patients, 91 (72.2%) patients received an autologous HCT, and 35 (27.8%) patients received an allo-HCT. No major bleeding occurred in either transplant recipient groups. In autologous HCT recipients, CRNMB/minor bleeding occurred in four (4.4%) patients and VTE recurrence occurred in one (1.1%) patient. For allogeneic HCT recipients, CRNMB/minor bleeding occurred in five (14.3%) patients and VTE recurrence occurred in two (5.7%) patients. For patients that experienced a CRNMB, five (100%) of the allogeneic HCT and two (50%) of the autologous HCT recipients were thrombocytopenic at the time of bleeding. Only 38.5% of patients who experienced a drug-drug interaction requiring DOAC dose adjustment received the appropriate dose adjustment. DOACs were associated with low rates of recurrent VTE and no major bleeding events, similar to published data on DOAC use in the general cancer patient population. This suggests that DOACs may be safe therapeutic options with proactive management of drug interactions and careful monitoring for bleeding events, especially in the allogeneic HCT population where minor bleeding rates were slightly higher.
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Affiliation(s)
- Claire Yang
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA.
| | | | | | - Julie Guglielmo
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA
| | - Mimi Lo
- UC San Francisco Medical Center, San Francisco, USA
| | | | | | - Lily Huang
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA
| | - Rosalyn Nguyen
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
| | - Stephen Kang
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
| | - Ila M Saunders
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
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Lee A, Badgley C, Lo M, Banez MT, Graff L, Damon L, Martin T, Dzundza J, Wong M, Olin R. Evaluation of venous thromboembolism prophylaxis protocol in hematopoietic cell transplant patients. Bone Marrow Transplant 2023; 58:1247-1253. [PMID: 37626267 PMCID: PMC10622316 DOI: 10.1038/s41409-023-02039-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/10/2023] [Accepted: 07/10/2023] [Indexed: 08/27/2023]
Abstract
Hematopoietic cell transplant (HCT) recipients are at risk for thromboembolic and bleeding complications. There is limited evidence regarding the optimal approach to managing venous thromboembolism (VTE) prophylaxis in hospitalized patients undergoing HCT. In this retrospective cohort study, we evaluated the incidence of bleeding and VTE events in hospitalized HCT patients who received VTE prophylaxis per our institution's VTE Prophylaxis Protocol (VPP), with either enoxaparin 40 mg subcutaneously daily or heparin 5 000 units subcutaneously twice daily, compared to historical controls who did not receive VTE prophylaxis. The primary outcome was a composite of major bleeding events, clinically relevant non-major bleeding (CRNMB), and minor bleeding. The secondary outcome was a composite of VTE events. A total of 614 patients were evaluated, including 278 prior to and 336 after implementation of VPP. VTE prophylaxis resulted in no difference in bleeding events (15.1% in the pre-VPP group vs. 14.6% in the post-VPP group, p = 0.86) or composite of major and CRNMB events (0.72% vs. 0.30%, p = 0.59). There was a trend toward lower incidence of VTE events in the post-VPP group which did not reach statistical significance (8.6% vs. 6.0%, p = 0.20). We conclude that VTE prophylaxis does not pose additional bleeding risk in HCT patients.
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Affiliation(s)
- Angela Lee
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA.
| | - Corinne Badgley
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Mimi Lo
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Marisela Tan Banez
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Larissa Graff
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA
| | - Lloyd Damon
- Division of Hematology-Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Thomas Martin
- Division of Hematology-Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - John Dzundza
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Melisa Wong
- Division of Hematology-Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca Olin
- Division of Hematology-Oncology, University of California, San Francisco, San Francisco, CA, USA
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Rath C, Yoo C, Cheplowitz H, Lo M, Young R, Guglielmo J, Saunders IM, Banerjee R, Young R, Kumar A, Chung A, Rosenberg AS, Costello C, Fine J, Wilson M, Patel N, Banez MT. Predictors of lenalidomide maintenance duration after autologous stem cell transplant in patients with multiple myeloma. J Oncol Pharm Pract 2023; 29:1715-1724. [PMID: 36731514 DOI: 10.1177/10781552221150935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND For patients with multiple myeloma (MM) who have undergone autologous stem cell transplant (auto-SCT), the immunomodulatory agent lenalidomide is a first-line option for maintenance therapy. Because longer durations of lenalidomide maintenance are associated with improved survival, identifying strategies to avoid premature cessation of maintenance is an important priority in the post-transplant setting. OBJECTIVES The primary objective of this analysis was to identify specific clinical predictors of lenalidomide treatment duration that could guide optimal medication management. Key secondary objectives included predictors of intolerable toxicity, rationale for lenalidomide dose reduction/discontinuation, and characterization of dose adjustments. STUDY DESIGN This retrospective, multi-center cohort study included adults with MM who underwent auto-SCT and initiated maintenance lenalidomide between 01/01/2012 and 02/28/2021. Variables assessed as potential predictors of maintenance duration or intolerable toxicity included age, body mass index (BMI), Eastern Cooperative Oncology Group (ECOG) performance status at time of auto-SCT, renal function, initial lenalidomide dose, use of combination maintenance therapy, and cytogenetic risk category. RESULTS Among 299 patients included, the median age at time of auto-SCT was 62 years (range 30-77). The majority of patients had standard-risk cytogenetics (64%) and an ECOG performance status of 0 or 1 (72%). In the overall population, the median duration of maintenance was 1.3 years (range 0.3-8.6 years). The median initial dose of lenalidomide was 10 mg daily (range 2.5-25 mg). During the study period, 35% of patients had a dose reduction due to toxicity, 21% stopped lenalidomide due to disease progression, and 19% stopped due to toxicity. Multivariate linear regression analyses did not identify any significant predictors of lenalidomide duration or discontinuation due to intolerable toxicity. The most frequently reported toxicities leading to discontinuation were cytopenias, rash, and fatigue. CONCLUSION This analysis did not identify any significant risk factors to predict the duration of lenalidomide maintenance or discontinuation for toxicity following auto-SCT in patients with MM. While limited by the retrospective design and relatively small sample size, our findings suggest that a priori lenalidomide dose reductions based on patient co-morbidities or performance status may not substantially affect the duration of lenalidomide maintenance.
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Affiliation(s)
- Carolyn Rath
- Department of Pharmaceutical Services, University of California, San Francisco, San Francisco, CA, USA
| | - Claude Yoo
- Department of Pharmacy Services, University of California, Davis, Sacramento, CA, USA
| | - Halle Cheplowitz
- Department of Pharmacy Services, University of California, San Diego, La Jolla, CA, USA
| | - Mimi Lo
- Department of Pharmaceutical Services, University of California, San Francisco, San Francisco, CA, USA
| | - Rebecca Young
- Department of Pharmaceutical Services, University of California, San Francisco, San Francisco, CA, USA
| | - Julie Guglielmo
- Department of Pharmacy Services, University of California, Davis, Sacramento, CA, USA
| | - Ila M Saunders
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Rahul Banerjee
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Division of Hematology and Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Richard Young
- Division of Hematology and Oncology, University of California, Davis, Sacramento, CA, USA
| | - Anupama Kumar
- Division of Hematology and Oncology and Bone Marrow Transplantation, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Alfred Chung
- Division of Hematology and Oncology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Aaron Seth Rosenberg
- Division of Hematology and Oncology, University of California, Davis, Sacramento, CA, USA
| | - Caitlin Costello
- Division of Hematology and Oncology and Bone Marrow Transplantation, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Jeffrey Fine
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Machelle Wilson
- Department of Public Health Sciences, School of Medicine, University of California, Davis, Sacramento, CA, USA
| | - Nimish Patel
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, CA, USA
| | - Marisela Tan Banez
- Department of Pharmaceutical Services, University of California, San Francisco, San Francisco, CA, USA
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