Effectiveness and safety of rivaroxaban compared with low-molecular-weight heparin in cancer-associated thromboembolism

Abstract

Guidelines provide differing recommendations regarding direct-acting oral anticoagulants vs low-molecular-weight heparin (LMWH) for treatment of cancer-associated thrombosis (CAT). This study was undertaken to evaluate the effectiveness and safety of rivaroxaban vs LMWH for treatment of CAT. Using US Surveillance, Epidemiology and End Results-Medicare–linked data from 2013 through 2016, we evaluated adults with active breast, lung, ovarian, or pancreatic cancer, who were admitted to the hospital or treated in the emergency department for CAT and were prescribed rivaroxaban or LMWH for outpatient anticoagulation. Patients with luminal gastrointestinal or genitourinary cancers were excluded. Rivaroxaban and LMWH users were 1:1 propensity score matched. Outcomes included the composite of recurrent thrombosis or major bleeding, each outcome separately, and mortality at 6 months, using an intent-to-treat approach. On-treatment analysis after 12 months was also performed. Proportional hazards models for the subdistribution of competing risk were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). We included 529 rivaroxaban- and 529 LMWH-treated patients with CAT. Rivaroxaban was not associated with differences in risk of the composite outcome (HR, 0.71; 95% CI, 0.41-1.22), major bleeding (HR, 1.01; 95% CI, 0.50-2.01), or mortality (HR, 0.87; 95% CI, 0.70-1.07) vs LMWH, but it reduced recurrent thrombosis (HR, 0.37; 95% CI, 0.15-0.95). On-treatment analysis at 12 months showed similar results. Rivaroxaban may be a reasonable alternative to LMWH for patients with CAT without gastrointestinal or genitourinary cancer.

Comparison of the efficacy and safety of rivaroxaban and low-molecular-weight heparin in Chinese lung cancer patients with nonhigh-risk pulmonary embolism

“…Unexpectedly, the mortality was signi cantly higher in LMWH group compared to rivaroxaban group. The trend of all-cause mortality in the present study was similar to an Asian-based retrospective study and two prospective trials, but the other trials with cancer-associated VTE did not show distinct comparisons among vitamin K antagonist, LMWH and DOACs [30][31][32][33][34]. Indeed, LMWH group had high proportion of central PE, intermediate-risk PE, CCI score ≥ 3, and receiving palliative oncotherapy during the study period, which suggested that the more advanced cancer stage and heavier thrombotic burden might contributed to the increased risks of VTE recurrence and mortality.…”

Efficacy and safety of catheter ablation for atrial fibrillation in patients with history of cancer

“…A potential reason for the excess bleeding risk observed by Giustozzi et al includes their practice of bridging with low molecular weight heparin after the procedure rather than continuing anticoagulation without interruption, as is the usual practice at the institutions included in our study. Furthermore, more than half the patients included in the study by Giustozzi et al had a history of gastrointestinal and genitourinary malignancies that are more prone to bleeding with anticoagulation than other cancers [ 22 ].…”

Efficacy and Safety of Catheter Ablation for Atrial Fibrillation in Patients with History of Cancer

“…includes their practice of bridging with low molecular weight heparin after the procedure rather than continuing anticoagulation without interruption, as is the usual practice at the institutions included in our study. Furthermore, more than half the patients included in the study by Giustozzi et al had a history of gastrointestinal and genitourinary malignancies that are more prone to bleeding with anticoagulation than other cancers 23 .…”