The use of direct oral anticoagulants for thromboprophylaxis or treatment of cancer-associated venous thromboembolism: a meta-analysis and review of the guidelines

Background Cancer is a well-known risk factor of preventable thromboembolic disease. This study aims to provide guidance on the prevention and management of cancer-associated thrombosis (CT) that tailors prophylactic and therapeutic options for medical and surgical oncology patients presenting to health care settings in Saudi Arabia. Methods The present consensus was developed in concordance with the modified Delphi-based approach, which incorporates a face-to-face meeting between two voting rounds to gain experts' feedback on the proposed statements. All experts were either oncologists, hematologists, or hemato-oncologist with an active clinical and research profile in hemato-oncology. Results The experts highlighted that the comparatively high incidence of inherited thrombophilia among the Saudi population may account for a higher CT burden in the Kingdom than in other parts of the world. However, due to the lack of literature that assesses CT in Saudi Arabia, primary venous thromboembolism prophylaxis should be tailored according to a valid risk assessment of cancer patients and should be implemented in routine practice. For hospitalized medical oncology patients, the experts agreed that prophylaxis with low-molecular-weight heparin (LMWH) should be offered, regardless of the presence of acute illness. For ambulatory medical oncology patients, LMWH or direct oral anticoagulants (DOACs) prophylaxis should be offered for high-risk patients. Concerning surgical patients, they agreed that all oncology patients undergoing surgery should be offered thromboprophylaxis. In terms of secondary prophylaxis, the experts recommended continuing a prophylactic dose of anticoagulant (LMWH or DOAC), for an appropriate period depending on the cancer type and stage. Finally, they also provided a set of statements on management of CT in Saudi Arabia. Conclusion The present modified Delphi-based study combined the best available evidence and clinical experience with the current health care policies and settings in Saudi Arabia to build a consensus statement on the epidemiology, prevention, and management of CT.

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“…Another meta-analysis showed that DOACs were linked with a significant reduction in VTE recurrence but with an incremental risk of CRNM. 96 …”

Section: Resultsmentioning

confidence: 99%

The Saudi Consensus for the Management of Cancer-Associated Thromboembolism: A Modified Delphi-Based Study

AlSheef

Bazarbashi

Warsi

et al. 2023

TH Open

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“…In Table 1, we described the baseline characteristics of patients that were on DOAC therapy prior to index hospitalization. The median age for patients on DOAC therapy was 69 years [IQR 59-78] years, with a median APACHE III score at 24 hours of 64 [51-78] and Charlson's comorbidity score 4 [5][6][7][8][9][10][11]. Commonest comorbidities included any cancer (N = 291, 52.2%), Diabetes mellitus (N = 189, 33.9%), congestive heart failure (CHF) (N = 183, 32.8%), and chronic pulmonary disease (including COPD, asthma, pulmonary hypertension, interstitial lung diseases) (N = 172, 30.8%).…”

Section: Baseline Characteristicsmentioning

confidence: 99%

“…8,9 DOACs also benefit the cancer population by reducing the risk of symptomatic VTE and VTE recurrence. 10 Overall, apixaban and dabigatran (but not rivaroxaban) are associated with lower bleeding risk and death when compared to warfarin in patients with heart failure and atrial fibrillation. 11 The doses often need adjustment due to changes in renal function.…”

Section: Introductionmentioning

confidence: 99%

Anticoagulation Prescribing Patterns in Intensive Care Unit Patients Admitted with Prehospital Direct Oral Anticoagulant Therapy: A Single Academic Center Experience

et al. 2022

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Objective:To describe the current prescribing practices of direct oral anticoagulants (DOACs) in intensive care unit (ICU) patients and the associated clinical outcomes, including the incidence of major bleeding episodes and the need for intervention (endoscopic, surgical, or interventional radiology guided). Design:Observational, retrospective chart review. Setting and Participants:Single large academic center study. Participants included patients with critical illness who were admitted to the intensive care units (ICU) at Mayo Clinic from January 1st, 2012, until May 4th, 2018. Adult ICU patients with a DOAC (apixaban, rivaroxaban, dabigatran, or edoxaban) listed as one of the active medications at the time of hospital admission were included. Results:37 249 patients in medical and surgical intensive care units were screened for the study period. After excluding patients who did not qualify, 558 unique encounters were included. The median age was 69 (IQR 59-78) years; most patients were male, white Caucasians, and had a median SOFA score of 4. After excluding the patients who had major bleeding episodes in the first 24 hours, 188 (39%) were continued on the same DOAC therapy, 204 (42%) were discontinued without transitioning to another agent, and 95 (20%) were transitioned to another agent. Finally, 410 (84%) were dismissed on DOAC therapy at the end of hospitalization. The difference in the continuation rate of the same DOAC agent beyond 24 hours, discontinuation without transition to an alternate agent, or discontinuation of DOAC with a transition to an alternate anticoagulation agent was not statistically significant ( P = .60). A total of 52 major bleeding events were identified. Gastrointestinal bleeding was the most common bleeding complication [n (%): 34 (65)], followed by intra-abdominal and peri-procedural bleeding [7 (13.5) and 7 (13.5)]. Thirty-three (65%) patients had a major bleeding complication requiring intervention. Conclusions:Our single-center retrospective study describes the current prescribing practices and preliminary outcomes in ICU patients with prehospital use of DOACs. Up to 20% of the patients were transitioned to a different agent within 24 hours of ICU admission, whereas a significant proportion of patients (42%) had anticoagulation discontinued altogether. Most patients who suffered a major bleeding episode required either endoscopic or surgical intervention to control bleeding.

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“…Due to the proven efficacy, convenience and patient preference of DOACs compared to LMWHs and VKAs [10][11][12], recommendations for the use of DOACs in cancer patients have also been included in guidelines. DOACs are recommended in cancer patients without renal and/or hepatic impairment, with low risk of bleeding and without genitourinary or gastro-intestinal tumours [13,14]. However, guidelines also acknowledge that the use of DOACs is not without caveats when in combination with anticancer drugs as there are still concerns about the risk of bleeding and drug-drug interactions (DDIs) may occur [13,14].…”

Section: Introductionmentioning

confidence: 99%

“…DOACs are recommended in cancer patients without renal and/or hepatic impairment, with low risk of bleeding and without genitourinary or gastro-intestinal tumours [13,14]. However, guidelines also acknowledge that the use of DOACs is not without caveats when in combination with anticancer drugs as there are still concerns about the risk of bleeding and drug-drug interactions (DDIs) may occur [13,14].…”

Section: Introductionmentioning

confidence: 99%

Practical recommendations to combine small-molecule inhibitors and direct oral anticoagulants in patients with nonsmall cell lung cancer

Otten¹,

Piet

Heuvel

et al. 2022

Eur Respir Rev

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BackgroundThe risk for thromboembolisms in nonsmall cell lung cancer (NSCLC) patients is increased and often requires treatment or prophylaxis with direct oral anticoagulants (DOACs). Small-molecule inhibitors (SMIs) to treat NSCLC may cause relevant drug–drug interactions (DDIs) with DOACs. Guidance on how to combine these drugs is lacking, leaving patients at risk of clotting or bleeding. Here, we give practical recommendations to manage these DDIs.MethodsFor all DOACs and SMIs approved in Europe and the USA up to December 2021, a literature review was executed and reviews by the US Food and Drug Administration and European Medicines Agency were analysed for information on DDIs. A DDI potency classification for DOACs was composed and brought together with DDI characteristics of each SMI, resulting in recommendations for each combination.ResultsHalf of the combinations result in relevant DDIs, requiring an intervention to prevent ineffective or toxic treatment with DOACs. These actions include dose adjustments, separation of administration or switching between anticoagulant therapies. Combinations of SMIs with edoxaban never cause relevant DDIs, compared to more than half of combinations with other DOACs and even increasing to almost all combinations with rivaroxaban.ConclusionsCombinations of SMIs and DOACs often result in relevant DDIs that can be prevented by adjusting the DOAC dosage, separation of administration or switching between anticoagulants.

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The use of direct oral anticoagulants for thromboprophylaxis or treatment of cancer-associated venous thromboembolism: a meta-analysis and review of the guidelines

Cited by 6 publications

References 38 publications

The Saudi Consensus for the Management of Cancer-Associated Thromboembolism: A Modified Delphi-Based Study

The Saudi Consensus for the Management of Cancer-Associated Thromboembolism: A Modified Delphi-Based Study

Anticoagulation Prescribing Patterns in Intensive Care Unit Patients Admitted with Prehospital Direct Oral Anticoagulant Therapy: A Single Academic Center Experience

Practical recommendations to combine small-molecule inhibitors and direct oral anticoagulants in patients with nonsmall cell lung cancer

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