Management of cancer‐associated thrombosis in patients with thrombocytopenia: guidance from the SSC of the ISTH

Bannow, Bethany Samuelson; Lee, A.; Khorana, Alok A.; Zwicker, Jeffrey I.; Noble, Simon; Ay, Cihan; Carrier, Marc

doi:10.1111/jth.14015

Cited by 158 publications

(107 citation statements)

References 33 publications

(40 reference statements)

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“…Whether this directly contributed to increased bleeding is unclear. Finally, complicating thrombocytopenia is a frequent concern in patients with cancer‐associated thrombosis . Thrombocytopenia was present in a small minority of patients in our cohort (7.6%), and only one of the major bleeding events was associated with thrombocytopenia.…”

Section: Discussionmentioning

confidence: 72%

Periprocedural interruption of anticoagulation in patients with cancer‐associated venous thromboembolism: An analysis of thrombotic and bleeding outcomes

Shaw

Douketis

Gal

et al. 2019

Journal of Thrombosis and Haemostasis

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Background: Patients with cancer are at high risk for venous thromboembolic events.Venous thromboembolism (VTE) can lead to significant morbidity among patients with cancer, and is estimated to be one of the leading causes of death among cancer patients. Patients with cancer often require invasive procedures for biopsy or therapeutic purposes. There is a lack of data on postoperative outcomes following interruption of anticoagulation in this population.Objective: To assess 30-day postoperative thromboembolic and major bleeding complication rates following the perioperative interruption of anticoagulation in patients with cancer-associated VTE. Methods:We conducted a retrospective self-controlled case series study with patients with cancer-associated VTE undergoing perioperative interruption of anticoagulation at a dedicated tertiary-care anticoagulation clinic for invasive procedures between January 2013 and March 2018. The primary efficacy and safety outcomes were the 30-day postoperative rates of VTE and major bleeding, respectively. The secondary outcomes included the 30-day rates of clinically relevant non-major bleeding (CRNMB) and overall mortality. Patients undergoing multiple perioperative anticoagulation interruptions were included. Results:One hundred and forty-six patients undergoing 171 periprocedural interruptions were included in our cohort. The 30-day rates of VTE and major bleeding were both 4.1% (95% confidence interval [CI] 2.0-8.2). The 30-day rate of CRNMB was 2.9% (95% CI 1.3-6.7) and the 30-day overall mortality rate was 0.6% (95% CI 0.1-3.4).There were no fatal postoperative VTE or major bleeding events. Conclusions: The periprocedural interruption of anticoagulation in patients with cancer-associated VTE is associated with high postoperative rates of VTE and major bleeding. Patients with cancer-associated VTE may require closer follow-up for VTE and bleeding complications after invasive procedures. K E Y W O R D S anticoagulants, hemorrhage, neoplasms, perioperative period, venous thromboembolism S U PP O RTI N G I N FO R M ATI O N Additional supporting information may be found online in the Supporting Information section at the end of the article. How to cite this article: Shaw JR, Douketis J, Le Gal G, Carrier M. Periprocedural interruption of anticoagulation in patients with cancer-associated venous thromboembolism: An analysis of thrombotic and bleeding outcomes. J Thromb Haemost.

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Section: Discussionmentioning

confidence: 72%

Periprocedural interruption of anticoagulation in patients with cancer‐associated venous thromboembolism: An analysis of thrombotic and bleeding outcomes

Shaw

Douketis

Gal

et al. 2019

Journal of Thrombosis and Haemostasis

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“… We suggest LMWH for the acute management of VTE related to asparaginase therapy if severe thrombocytopenia (ie, platelet count < 50 x 10 9 /L) is anticipated. Following resolution of severe thrombocytopenia, DOAC may be considered in the absence of other relative contraindications such as major drug interactions. We recommend therapeutic dosing of LMWH and suggest monitoring of anti‐Xa levels due to increased variability in the setting of decreased plasma antithrombin concentrations (see Management of anticoagulation with severe thrombocytopenia per ISTH SSC Hemostasis and Malignancy guidance). For life‐threatening VTE such as cerebral venous thrombosis or central PE, we suggest short‐term concurrent administration of antithrombin concentrate until therapeutic anticoagulation and clinical stability is established. We recommend therapeutic anticoagulation for a catheter‐related deep vein thrombosis (DVT) and nonremoval of a functioning catheter in accordance with prior ISTH guidance For high‐risk thrombotic events such as cerebral venous or sinus thrombosis, central PE, proximal DVT, or arterial thrombosis we recommend holding asparaginase therapy, at least temporarily. We suggest the consideration to resume asparaginase following successful stabilization of the acute thrombotic event (approximately 4 weeks).…”

Section: Management Of Vte During Asparaginase Therapymentioning

confidence: 99%

The prevention and management of asparaginase‐related venous thromboembolism in adults: Guidance from the SSC on Hemostasis and Malignancy of the ISTH

Zwicker

Wang

DeAngelo

et al. 2020

Journal of Thrombosis and Haemostasis

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Venous thromboembolism is a common complication of asparaginase-based chemotherapy regimens for the treatment of acute lymphoblastic leukemia. Thrombosis associated with asparaginase administration poses a number of specific and often clinically challenging management decisions. This review provides guidance on the prevention and treatment of thrombosis associated with asparaginase in adults including discussions on antithrombin repletion, pharmacologic thromboprophylaxis, cerebral venous thrombosis, and therapeutic anticoagulation. K E Y W O R D S acute lymphoblastic leukemia, anticoagulation, antithrombin, asparaginase, cerebral venous thrombosis, venous thromboembolism The guidance statements included in this document are similar to those in other guidance documents and are predicated on the following premises: For each of the clinical situations, our guidance statements are applicable to an average adult patient with venous thromboembolism (VTE) associated with asparaginase therapy during the course of therapy for acute lymphoblastic leukemia (ALL).We anticipate that there will be clinical circumstances for which our guidance statements do not apply. As for all cases, our statements may provide guidance but do not replace clinical judgement for the management of individual patients.• The wording "we recommend" reflects a strong guidance statement with strong consensus among the authors, whereby the clinician should consider adopting the practice in a majority of cases.

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“…As warfarin operates via vitamin K inhibition, oncologic patients with numerous reasons for vitamin K deficiency, such as diarrhea from chemotherapy or radiation or antibiotics for infections due to immunosuppression, face an additionally increased risk of bleeding [43]. The current standard of care for management of cancer-associated venous thromboembolism (VTE) is low molecular weight heparin [51][52][53][54][55]. Direct oral anticoagulants (DOACs) are emerging as potentially equally efficacious alternatives to low molecular weight heparin, with ideal bioavailability and mode of administration (orally) [29].…”

Section: Drug-drug Interactionsmentioning

confidence: 99%

The Role of CYP450 Drug Metabolism in Precision Cardio-Oncology

Fatunde

Brown

2020

IJMS

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As many novel cancer therapies continue to emerge, the field of Cardio-Oncology (or onco-cardiology) has become crucial to prevent, monitor and treat cancer therapy-related cardiovascular toxicity. Furthermore, given the narrow therapeutic window of most cancer therapies, drug-drug interactions are prevalent in the cancer population. Consequently, there is an increased risk of affecting drug efficacy or predisposing individual patients to adverse side effects. Here we review the role of cytochrome P450 (CYP450) enzymes in the field of Cardio-Oncology. We highlight the importance of cardiac medications in preventive Cardio-Oncology for high-risk patients or in the management of cardiotoxicities during or following cancer treatment. Common interactions between Oncology and Cardiology drugs are catalogued, emphasizing the impact of differential metabolism of each substrate drug on unpredictable drug bioavailability and consequent inter-individual variability in treatment response or development of cardiovascular toxicity. This inter-individual variability in bioavailability and subsequent response can be further enhanced by genomic variants in CYP450, or by modifications of CYP450 gene, RNA or protein expression or function in various ‘omics’ related to precision medicine. Thus, we advocate for an individualized approach to each patient by a multidisciplinary team with clinical pharmacists evaluating a treatment plan tailored to a practice of precision Cardio-Oncology. This review may increase awareness of these key concepts in the rapidly evolving field of Cardio-Oncology.

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Management of cancer‐associated thrombosis in patients with thrombocytopenia: guidance from the SSC of the ISTH

Cited by 158 publications

References 33 publications

Periprocedural interruption of anticoagulation in patients with cancer‐associated venous thromboembolism: An analysis of thrombotic and bleeding outcomes

Periprocedural interruption of anticoagulation in patients with cancer‐associated venous thromboembolism: An analysis of thrombotic and bleeding outcomes

The prevention and management of asparaginase‐related venous thromboembolism in adults: Guidance from the SSC on Hemostasis and Malignancy of the ISTH

The Role of CYP450 Drug Metabolism in Precision Cardio-Oncology

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