Intracranial hemorrhage with direct oral anticoagulants in patients with brain tumors

Abstract

Summary Intracranial hemorrhage (ICH) is common in patients with brain tumors. We compared rates of ICH with DOACs and low molecular weight heparin. DOACs were associated with a lower incidence of ICH in primary brain tumors. DOACs appear safe to administer to patients with brain tumors. Summary BackgroundDirect oral anticoagulants (DOACs) are efficacious in the treatment of cancer‐associated thrombosis but are associated with an increased risk of hemorrhage compared with low‐molecular‐weight heparin in certain malignancies. Whether the DOACs increase the incidence of intracranial hemorrhage (ICH) in patients with brain tumors is not established. ObjectivesTo determine the cumulative incidence of ICH in DOACs compared with Low‐molecular‐weight heparin (LMWH) in patients with brain tumors and venous thromboembolism. Patients and methodsA retrospective comparative cohort study was performed. Radiographic images for all ICH events were reviewed and the primary endpoint was cumulative incidence of ICH at 12 months following initiation of anticoagulation. Results and conclusionsA total of 172 patients with brain tumors were evaluated (42 DOAC and 131 LMWH). In the primary brain tumor cohort (n = 67), the cumulative incidence of any ICH was 0% in patients receiving DOACs vs. 36.8% (95% confidence interval [CI], 22.3–51.3%) in those treated with LMWH, with a major ICH incidence of 18.2% (95% CI, 8.4–31.0). In the brain metastases cohort (n = 105), DOACs did not increase the risk of any ICH relative to enoxaparin, with an incidence of 27.8% (95% CI, 5.5–56.7%) compared with 52.9% (95% CI, 37.4–66.2%). Similarly, DOAC did not increase the incidence of major ICH in brain metastases, with a cumulative incidence 11.1% (95% CI, 0.5–40.6%) vs. 17.8% (95% CI, 10.2–27.2%). We conclude that DOACs are not associated with an increased incidence of ICH relative to LMWH in patients with brain metastases or primary brain tumors.

Rivaroxaban treatment of cancer‐associated venous thromboembolism: Memorial Sloan Kettering Cancer Center institutional experience

“…At the time, there were no data addressing the relative safety of rivaroxaban vs. LMWH in those patients. However, more recent reports support the use of a DOAC in patients with primary or metastatic cancer of the brain …”

The use of direct oral anticoagulants for primary thromboprophylaxis in ambulatory cancer patients: Guidance from the SSC of the ISTH

“…In patients with brain tumors and CAT, a previous study has shown that therapeutic doses of DOACs were not associated with increased risk of intracranial bleeding relative to LMWH. 18 Although both studies used Khorana score to identify high-risk patients, the included types of malignancies remained heterogeneous and could carry different thrombotic and bleeding risks. However, data from AVERT and CASSINI studies are the highest level of evidence to date regarding using DOACs as primary thromboprophylaxis for ambulatory cancer patients, and it is likely not feasible to conduct dedicated studies in each tumor type.…”

“…In addition, patients with malignancy involving the brain are at high risks of both bleeding and thrombosis, but this population was underrepresented (24 patients in AVERT and excluded in CASSINI), and whether this high‐risk population could have similar outcomes remains unclear. In patients with brain tumors and CAT, a previous study has shown that therapeutic doses of DOACs were not associated with increased risk of intracranial bleeding relative to LMWH . Although both studies used Khorana score to identify high‐risk patients, the included types of malignancies remained heterogeneous and could carry different thrombotic and bleeding risks.…”

Prophylaxis of Venous Thromboembolic Complications in Patients With Active Oncological Disease, Receiving Medical Anti-Cancer Chemotherapy in Outpatient Conditions. Role of Apixaban

“…Риск развития ВТЭО у пациентов с первичным или метастатическим поражением головного мозга в 15 раз выше, чем в общей популяции онкологических пациентов [38]. Лечение и медикаментозная профилактика ВТЭО у этой категории пациентов сопряжены с высоким риском внутричерепных кровоизлияний.…”