Rivaroxaban vs Dalteparin in Cancer-Associated Thromboembolism

Venous Thromboembolism and Cancer: A Comprehensive Review from Pathophysiology to Novel Treatment

“…Recurrent VTE occurred in four patients in the rivaroxaban arm and in six patients in the dalteparin arm (HR, 0.75; 95% CI, 0.21–2.66; p = 0.13 for noninferiority). Regarding safety profiles, major bleeding or CRNMB occurred in nine and eight patients in the rivaroxaban and dalteparin groups, respectively (HR, 1.27; 95% CI, 0.49–3.26) [ 49 ].…”

Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus

“…A meta-analysis of the results of all RCTs comparing LMWH with VKA for the management of CAT reported a 44% reduction in the risk of recurrent VTE (relative risk (RR): 0.56; 95% confidence interval (CI): 0.43 to 0.74), without a significant increase in the risk of major bleeding (RR: 1.07; 95% CI: 0.66 to 1.79) in patients treated with LMWH [ 29 ]. A similar meta-analysis of the results of all RCTs comparing DOACs with LMWH for the treatment of acute CAT reported a significantly lower risk of recurrent VTE (hazard ratio (HR): 0.63; 95% CI: 0.47 to 0.86) and a non-significantly higher risk of major bleeding (HR: 1.26; 95% CI: 0.84 to 1.90) with DOACs as compared to LMWH [ 28 ]. An analysis of 29 studies including a total of 8000 patients with cancer found that case fatality rates were higher for recurrent VTE than those for major bleeding at 15.0% (95% CI 6.6 to 30.1%) and 8.9% (95% CI 3.5 to 21.1%), respectively [ 30 ].…”

“…Even though catheter-related VTE is a common complication in patients with cancer, there is limited evidence to guide the management of upper extremity and catheter-related VTE as these patients were excluded from all RCTs of LMWH vs. VKA and DOAC vs. LMWH except for the ADAM-VTE trial [ 8 , 9 , 16 , 17 , 18 , 24 , 25 , 26 , 27 , 28 ]. Two studies of cancer patients with upper extremity catheter-related DVT suggested that LMWH and VKA are safe and effective, with no recurrent VTE events reported in either study and major bleeding event rates of 4% and 2% at 3 months [ 34 , 35 ].…”

“…The risk of major bleeding was higher with DOACs than LMWH in both the Hokusai-VTE Cancer and SELECT-D trials, although rates of major bleeding were similar in the CARAVAGGIO, ADAM-VTE, and CASTA-DIVA trials ( Table 1 ) [ 16 , 17 , 18 , 27 , 28 ]. Overall, pooled estimates from meta-analyses have reported a non-significantly higher rate of major bleeding complications among patients with CAT receiving a DOAC as compared to LMWH (HR:1.26; 95% CI 0.84–1.90 and RR: 1.36; 95% CI 0.55 to 3.35) [ 28 , 38 ]. Hence, identifying patients at higher risk of bleeding complications might be helpful to tailor anticoagulation in this patient population.…”

“…Limited data are available regarding the effects of the burden of cancer and burden of VTE on the efficacy and safety of anticoagulation. Cross-study comparison is limited by differences between clinical trials in baseline characteristics reflecting cancer burden ( Table 4 ), as well as in overall mortality rates ( Table 1 ), which suggest the overall burden of cancer may have been higher in the LMWH vs. VKA trials than in the DOAC vs. LMWH trials [ 8 , 9 , 16 , 17 , 18 , 24 , 25 , 26 , 27 , 28 ]. It is also important to note that patients who required thrombolysis or who underwent inferior vena cava filter insertion were excluded from the trials.…”