EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer

Abstract

In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.

Predictors of Early Thrombotic Events in Adult Patients with Acute Myeloid Leukemia: A Real-World Experience

“…The dose of LMWH was reduced by 50% if PLTc was between 30 and 50 × 10 9 /L and discontinued or not initiated when PLTc was <30 × 10 9 /L. Patients with a previous history of MI were prophylactically treated with antiplatelet drugs if PLTc >50 × 10 9 /L [ 30 ].…”

Early‐onset venous thromboembolisms in newly diagnosed non‐promyelocytic acute myeloid leukemia patients undergoing intensive induction chemotherapy

“…47 Although we did not observe major bleeding complications 23 in these patients, literature and current guidelines both clearly indicate a non-negligible risk of hemorrhage. 16,[47][48][49][50] In contrast, patients with solid cancers suffer higher mortality due to VTE than due to major bleeding. 11 Since we and others have failed to clearly detect an adverse impact of VTE on OS, whereas the adverse impact of hemorrhage in AML patients is clear, 16 a conservative approach toward the treatment of VTE may be warranted.…”

“…Most of our AML patients with VTE were treated therapeutically with low molecular weight heparin adjusted to platelet levels. However, patients were treated on an individual basis and we cannot provide systematized treatment recommendations based on our current data 47 . Although we did not observe major bleeding complications 23 in these patients, literature and current guidelines both clearly indicate a non‐negligible risk of hemorrhage 16,47–50 .…”

The prevalence of thrombocytopenia in patients with acute cancer-associated thrombosis

“…[3][4][5][6][7][8][9] Recently released European Hematology Association clinical guidelines in the management of these complex scenarios further emphasizes the everyday challenges faced by clinicians in this population. [10] Data on the true prevalence of thrombocytopenia in patients with cancer and concomitant thrombosis are extremely limited. [11] Thrombocytopenia is common in hematologic malignancies and often observed following certain cytotoxic chemotherapies in patients with solid tumors.…”