Evaluating the use of appropriate anticoagulation with lenalidomide and pomalidomide in patients with multiple myeloma

Abstract

Background Lenalidomide and pomalidomide are two immunomodulatory medications with the potential to improve outcomes for patients with multiple myeloma; however, a black box warning for venous thromboembolism exists. Purpose The purpose of this study was to assess overall adherence to guideline recommendations for anticoagulation therapy with lenalidomide and pomalidomide in multiple myeloma patients. Methods This retrospective study at an ambulatory oncology clinic utilized chart reviews from the calendar years 2013-2016. The primary endpoint was prescription of appropriate anticoagulation upon initiation of therapy based on a list of predetermined risk factors. Secondary endpoints included incidence of deep venous thromboembolism, pulmonary embolism, myocardial infarction, stroke, and major bleed; initial anticoagulant prescribed; and whether or not anticoagulation was prescribed for another disease state. Results A total of 130 patients met inclusion criteria: 70.8% (n = 92) and 29.2% (n = 38) were prescribed lenalidomide and pomalidomide, respectively. A total risk score of two was most common (n = 54, 41.5%). Aspirin 81 mg oral tablet was prescribed most often (n = 53, 40.8%), followed by no anticoagulation (n = 30, 23.1%). Overall, 27 patients (20.8%) were prescribed anticoagulation in accordance with National Comprehensive Cancer Network guidelines. Incidence of deep venous thromboembolism was the most common adverse event (n = 4, 3.1%), followed by major bleed (n = 1, 0.8%). No reports of pulmonary embolism, myocardial infarction, or stroke were documented. Conclusions Overall, a disparity exists between appropriate prescribing of prophylactic anticoagulation and current practice guidelines. However, documentation of thromboembolic events was lower than recorded in previously published literature.

A Real-Life Survey of Venous Thromboembolic Events Occurring in Myeloma Patients Treated in Third Line with Second-Generation Novel Agents

“…In particular, thrombosis occurred in about 10% of MM patients treated with chemotherapy [ 17 ], while up to 24% of patients treated with the immunomodulatory drug (IMiD) thalidomide experienced VTE complications, particularly when it is administrated in combination with other agents (dexamethasone and/or cytotoxic chemotherapy) [ 7 , 17 , 18 , 19 , 20 ]. Second generation IMiD lenalidomide may have similar effects on increasing VTE [ 7 , 18 , 19 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”

“…These recommendations were then taken up and confirmed by the 2015 European Myeloma Network (EMN) [ 38 ] and 2017 ESMO guidelines [ 39 ]. Limited data are available about thrombotic risk in patients on treatment with pomalidomie but, as with the other IMiDs, it seems to determine an increased risk of thrombosis [ 17 , 25 , 40 , 41 , 42 , 43 , 44 ]. With regard to the second-generation proteasome inhibitor Carfilzomib, phase III trial ASPIRE, which compares the efficacy of lenalidomide-dexamethasone versus carfilzomib-lenalidomide-dexamethasone, shows a higher incidence of VTE in the three-drugs arm (13% vs. 6%), despite the mandatory use of thromboprophylaxis [ 45 ].…”