Anticoagulation for the initial treatment of venous thromboembolism in patients with cancer

Abstract

BACKGROUND.The authors compared the relative efficacy and safety of low‐ molecular‐weight heparin (LMWH) and unfractionated heparin (UFH) for the initial treatment of venous thromboembolism (VTE) between patients with and without cancer.METHODS.By using Cochrane methodology for systematic reviews, separate meta‐analyses were conducted for subgroups of patients with and without cancer, and relative risks (RRs) were compared for statistical significance. The methodologic quality for each outcome was assessed by using the Grading of Recommendations Assessment, Development, and Evaluation approach.RESULTS.LMWH reduced mortality significantly compared with UFH in patients with cancer (RR of 0.71; 95% confidence interval [95% CI], 0.52‐0.98 [moderate‐quality evidence]) but not in patients without cancer (RR of 0.97; 95% CI, 0.65‐1.46 [low‐quality evidence]). However, the difference in the RR for the 2 subgroups did not reach statistical significance (P = .113). The difference between LMWH and UFH in the effect on recurrent VTE was not statistically significant in the subgroup with cancer (RR of 0.78; 95% CI, 0.29‐2.08 [low‐quality evidence]), in the subgroup without cancer (RR of 0.94; 95% CI, 0.60‐1.46 [low‐quality evidence]), or between the 2 subgroups (P = .367). No data were available for bleeding outcomes, thrombocytopenia, or postphlebitic syndrome.CONCLUSIONS.The current results indicated that LMWH most likely is superior to UFH in reducing mortality in the initial treatment of VTE for patients with cancer. There is a need for more and better designed trials to confirm these findings. Cancer 2008. © 2008 American Cancer Society.

Direct oral anticoagulants for the treatment of acute venous thromboembolism in patients with cancer: a meta-analysis of randomised controlled trials

“…Our results indicate that DOACs are associated with a significantly lower risk of recurrent VTE than VKAs in patients with active cancer, while the risk of bleeding and mortality is similar between the treatment groups. These findings show striking similarities with the results of two Cochrane reviews [5,13], reporting a significant reduction in the incidence of recurrent VTE in patients receiving LMWH compared with those receiving VKAs, with no differences in bleeding or survival. Accordingly, LMWH is the treatment of choice in cancer-associated VTE [4] because of fewer drug-drug interactions (especially with chemotherapeutic agents), a more predictable dose response, no need for laboratory monitoring, reliable delivery in patients with nausea/vomiting and a shorter half-life allowing a greater flexibility during invasive procedures and in cases where chemotherapy-induced thrombocytopenia develops.…”

Direct oral anticoagulants for the treatment of acute venous thromboembolism in patients with cancer: a meta-analysis of randomised controlled trials

“…Our results indicate that DOACs are associated with a significantly lower risk of recurrent VTE than VKAs in patients with active cancer, while the risk of bleeding and mortality is similar between the treatment groups. These findings show striking similarities with the results of two Cochrane reviews [5,13], reporting a significant reduction in the incidence of recurrent VTE in patients receiving LMWH compared with those receiving VKAs, with no differences in bleeding or survival. Accordingly, LMWH is the treatment of choice in cancer-associated VTE [4] because of fewer drug-drug interactions (especially with chemotherapeutic agents), a more predictable dose response, no need for laboratory monitoring, reliable delivery in patients with nausea/vomiting and a shorter half-life allowing a greater flexibility during invasive procedures and in cases where chemotherapy-induced thrombocytopenia develops.…”

Low-molecular-weight heparins are superior to vitamin K antagonists for the long term treatment of venous thromboembolism in patients with cancer: a cochrane systematic review

“…The reason for this differential effect in patients with cancer is not clear. A similar differential effect of anticoagulants has been found in the initial treatment of venous thromboembolism where LMWH was superior to UFH in patients with cancer but not in patients without cancer [ 36 ].…”

Clinical Outcomes of Venous Thromboembolism in Patients with and without Cancer: The SWIss Venous ThromboEmbolism Registry (SWIVTER)

“…2,8 In a systematic review and meta-analysis by the Cochrane collaboration group, the administration of long-term LMWH halved the risk of recurrent VTE in patients with cancer when compared with VKA. 11 In our study, two-thirds of patients with cancer-associated VTE did not receive LMWH for !3 months as recommended by current consensus guidelines. This proportion seems high, but it compares favorably with findings from the RIETE registry where only 18% of patients received long-term LMWH for at least the first 3 months, which indicates suboptimal adherence.…”

Direct oral anticoagulants for the treatment of acute venous thromboembolism in patients with cancer: a meta-analysis of randomised controlled trials

“…Our results indicate that DOACs are associated with a significantly lower risk of recurrent VTE than VKAs in patients with active cancer, while the risk of bleeding and mortality is similar between the treatment groups. These findings show striking similarities with the results of two Cochrane reviews [5,13], reporting a significant reduction in the incidence of recurrent VTE in patients receiving LMWH compared with those receiving VKAs, with no differences in bleeding or survival. Accordingly, LMWH is the treatment of choice in cancer-associated VTE [4] because of fewer drug-drug interactions (especially with chemotherapeutic agents), a more predictable dose response, no need for laboratory monitoring, reliable delivery in patients with nausea/vomiting and a shorter half-life allowing a greater flexibility during invasive procedures and in cases where chemotherapy-induced thrombocytopenia develops.…”

Low-molecular-weight heparins are superior to vitamin K antagonists for the long term treatment of venous thromboembolism in patients with cancer: a cochrane systematic review

“…The reason for this differential effect in patients with cancer is not clear. A similar differential effect of anticoagulants has been found in the initial treatment of venous thromboembolism where LMWH was superior to UFH in patients with cancer but not in patients without cancer [ 36 ].…”

Clinical Outcomes of Venous Thromboembolism in Patients with and without Cancer: The SWIss Venous ThromboEmbolism Registry (SWIVTER)

“…2,8 In a systematic review and meta-analysis by the Cochrane collaboration group, the administration of long-term LMWH halved the risk of recurrent VTE in patients with cancer when compared with VKA. 11 In our study, two-thirds of patients with cancer-associated VTE did not receive LMWH for !3 months as recommended by current consensus guidelines. This proportion seems high, but it compares favorably with findings from the RIETE registry where only 18% of patients received long-term LMWH for at least the first 3 months, which indicates suboptimal adherence.…”

Direct oral anticoagulants for the treatment of acute venous thromboembolism in patients with cancer: a meta-analysis of randomised controlled trials

“…Our results indicate that DOACs are associated with a significantly lower risk of recurrent VTE than VKAs in patients with active cancer, while the risk of bleeding and mortality is similar between the treatment groups. These findings show striking similarities with the results of two Cochrane reviews [5,13], reporting a significant reduction in the incidence of recurrent VTE in patients receiving LMWH compared with those receiving VKAs, with no differences in bleeding or survival. Accordingly, LMWH is the treatment of choice in cancer-associated VTE [4] because of fewer drug-drug interactions (especially with chemotherapeutic agents), a more predictable dose response, no need for laboratory monitoring, reliable delivery in patients with nausea/vomiting and a shorter half-life allowing a greater flexibility during invasive procedures and in cases where chemotherapy-induced thrombocytopenia develops.…”

Low-molecular-weight heparins are superior to vitamin K antagonists for the long term treatment of venous thromboembolism in patients with cancer: a cochrane systematic review

“…The reason for this differential effect in patients with cancer is not clear. A similar differential effect of anticoagulants has been found in the initial treatment of venous thromboembolism where LMWH was superior to UFH in patients with cancer but not in patients without cancer [ 36 ].…”

Clinical Outcomes of Venous Thromboembolism in Patients with and without Cancer: The SWIss Venous ThromboEmbolism Registry (SWIVTER)

“…2,8 In a systematic review and meta-analysis by the Cochrane collaboration group, the administration of long-term LMWH halved the risk of recurrent VTE in patients with cancer when compared with VKA. 11 In our study, two-thirds of patients with cancer-associated VTE did not receive LMWH for !3 months as recommended by current consensus guidelines. This proportion seems high, but it compares favorably with findings from the RIETE registry where only 18% of patients received long-term LMWH for at least the first 3 months, which indicates suboptimal adherence.…”