Network meta-analysis of anticoagulation strategies for venous thromboembolism in patients with cancer
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Network meta‑analysis of anticoagulation strategies for venous thromboembolism in patients with cancer Hiroki Ueyama1 · Hirotaka Miyashita1 · Hisato Takagi2 · Christina Cruz1 · Alfred Burger1 · Alexandros Briasoulis3 · Toshiki Kuno1
© Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Cancer-associated thrombosis (CAT) is a common complication in patients with malignancy. Although direct oral anticoagulants (DOACs) have emerged as a treatment option for CAT, there have not been head-to-head comparisons of these agents. We searched MEDLINE and EMBASE from inception to April 2020 for studies comparing the effect of different long-term anticoagulation strategies for venous thromboembolism (VTE) in patients with cancer. We performed a network meta-analysis comparing the antithrombotic strategies in the selected studies using random-effects model. We identified a total of 20 studies [9 randomized control trials (RCTs) and 11 subgroup analyses from other unique RCTs] with total of 6699 patients for inclusion in our analysis. There was no significant difference in recurrent VTE, all-cause death, major bleeding and clinically relevant non-major bleeding among DOACs. When DOACs were combined, recurrent VTE was significantly decreased in DOACs compared to low-molecular weight heparin (LMWH) and Vitamin K antagonist (VKA) [RR (95% CI) 0.75 (0.59–0.94); RR (95% CI) 0.51 (0.39–0.66), respectively] without significant increase in major bleeding or clinically relevant non-major bleeding. In patients with CAT, there was no significant difference in recurrent thrombotic event among different DOACs. Bleeding risk was comparable among all anticoagulation strategies. When DOACs were combined, DOACs were associated with a significant decrease in recurrent VTE with comparable bleeding risk to LMWH and VKA. Keywords Cancer associated thrombosis · Venous thromboembolism · Oral anticoagulant · Direct oral anticoagulant Abbreviations CAT Cancer associated thromboembolism CI Confidence intervals CRNMB Clinically relevant non-major bleeding DOACs Direct oral anticoagulants DVT Deep vein thrombosis LMWH Low-molecular weight heparin PE Pulmonary embolism Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11239-020-02151-2) contains supplementary material, which is available to authorized users. * Toshiki Kuno [email protected] 1
Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, First Avenue, 16th street, New York, NY 10003, USA
2
Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
3
Division of Cardiology, Heart Failure and Transplantation, University of Iowa, Iowa City, IA, USA
RCT Randomized controlled trials RR Risk ratio VKA Vitamin K antagonist VTE Venous thromboembolism
Highlights • DOACs showed significant reduction in recurrent VTE
compared to LMWH and VKA.
• There was no significant difference in recurrent VTE
among different DOACs.
• Bleeding risks we
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