2019 International Clinical Practice Guidelines for the Treatment And Prophylaxis Of Venous Thromboembolism In Patients With Cancer

2019 International Clinical Practice Guidelines for the Treatment and Prophylaxis Of Venous Thromboembolism In Patients With Cancer

• Initial treatment of established VTE – International Advisory Panel ranking (8.18 out of 9)
  • Low-molecular-weight heparin (LMWH):
    • Is recommended for the initial treatment of established VTE in patients with cancer:
      • When creatinine clearance is ≥ 30 mL per min (grade 1B)
    • LMWH:
      • Is easier to use than unfractionated heparin
    • A regimen of LMWH:
      • Taken once per day:
        • Is recommended, unless a twice-per-day regimen is required:
          • Because of patient characteristics (eg, fragile patients who are at risk of hemorrhage)
  • For patients who do not have a high risk of gastrointestinal or genitourinary bleeding:
    • A regimen of rivaroxaban (in the first 10 days) or edoxaban (started after at least 5 days of parenteral anticoagulation):
      • Can also be used for the initial treatment of established VTE:
        • In patients with cancer when creatinine clearance is ≥ 30 mL/min (grade 1B)
  • Unfractionated heparin:
    • Can also be used for the initial treatment of established VTE in patients with cancer:
      • When LMWH or direct oral anticoagulants are contraindicated, or not available (grade 2C)
  • Fondaparinux can also be used for the initial treatment of established VTE:
    • For patients with cancer (grade 2D)
    • Fondaparinux is easier to use than unfractionated heparin
  • Thrombolysis in patients with cancer with established VTE can only be considered on a case-by-case basis:
    • With specific attention paid to contraindications, especially bleeding risk eg, brain metastasis (guidance, based on evidence of very low quality and the high bleeding risk of thrombolytic therapy)
    • An expert opinion is recommended before using thrombolytics, and the procedure should be done in centers with health-care practitioners who have appropriate expertise
  • In the initial treatment of VTE:
    • Inferior vena cava filters may be considered when:
      • Anticoagulant treatment is contraindicated or
      • In the case of pulmonary embolism
      • When recurrence occurs under optimal anticoagulation
    • Periodic reassessment of contraindications for anticoagulation is recommended, and anticoagulation should be resumed when safe (guidance, based on evidence of very low quality and an unknown balance between desirable and undesirable effects)
• Early maintenance (up to 6 months) and long term (beyond 6 months) – International Advisory Panel ranking (8.09 out of 9):
  • LMWHs are preferred over vitamin K antagonists:
    • For the treatment of VTE in patients with cancer:
      • When creatinine clearance is ≥ 30 mL/min (grade 1A)
    • Daily subcutaneous injection can represent a burden for patients
  • Direct oral anticoagulants:
    • Are recommended for patients with cancer:
      • When creatinine clearance is ≥ 30 mL/min in the absence of strong drug-to-drug interactions or gastrointestinal absorption impairment (grade 1A)
    • Use caution in patients with:
      • Gastrointestinal tract malignancies, especially upper gastrointestinal tract malignancies:
        • As the available data show increased risk of gastrointestinal tract bleeding with:
          • Edoxaban and rivaroxaban
    • Data for other direct oral anticoagulants are needed as it is not clear whether other direct oral anticoagulants will have the same risk profile
  • LMWH or direct oral anticoagulants should be used for:
    • A minimum of 6 months to treat established VTE in patients with cancer (grade 1A)
    • After 6 months:
      • Termination or continuation of anticoagulation (LMWH, direct oral anticoagulants, or vitamin K antagonists):
        • Should be based on individual evaluation of the benefit–risk ratio, tolerability, drug availability, patient preference, and cancer activity (guidance in the absence of data)
• Treatment of VTE recurrence in patients with cancer under anticoagulation – International Advisory Panel ranking (8.0 out of 9):
  • In the event of VTE recurrence, three options can be considered:
    • Increase LMWH by 20% to 25%
    • Switch to direct oral anticoagulants:
      • For direct oral anticoagulants:
        • Switch to LMWH
    • For vitamin K antagonists:
      • Switch to LMWH or direct oral anticoagulants (guidance based on evidence of very low quality and an unknown balance between desirable and undesirable effects)
  • Effect of therapy should be monitored:
    • By improvement of symptoms
• Treatment of established catheter-related thrombosis – International Advisory Panel ranking (8.19 out of 9):
  • For the treatment of symptomatic catheter-related thrombosis in patients with cancer:
    • Anticoagulant treatment is recommended for a minimum of 3 months and as long as the central venous catheter is in place
    • In this setting:
      • LMWHs are suggested and direct comparisons between LMWHs, direct oral anticoagulants, and vitamin K antagonists have not been made (guidance)
  • In patients with cancer with catheter-related thrombosis:
    • The central venous catheter can be kept in place:
      • If it is functional, well positioned, and not infected:
        • With a good resolution of symptoms under close surveillance while anticoagulation therapy is administered
  • No standard approach in terms of duration of anticoagulation is established (guidance)
• Reference:
  • 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Crossref DOI link: https://doi.org/10.1016/S1470-2045(19)30336-5. Published: 2019-10. Update policy: https://doi.org/10.1016/ELSEVIER_CM_POLICY

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