Prevention and treatment of venous thromboembolism in cancer patients
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Martina-Elisabeth Spehlmann · Norbert Frey · Oliver J. Müller Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum Schleswig-Holstein, Kiel, Germany
Prevention and treatment of venous thromboembolism in cancer patients Low-molecular-weightheparin(LMWH) has been the standard treatment of venous thromboembolic events (VTE) in patients with malignancies in the past few years [1, 2]. This recommendation is based on several randomized clinical trials (RCTs) that have shown that LMWH is more effective than vitamin K antagonists in cancer patients with VTE [3–7]. However, according to recent study results, treatment of cancer-associated VTE withnovel oral anticoagulants (NOACs) is also possible [8–10]. These are administered orally, are cheaper than LMWH, and have a faster onset of action and more controllable pharmacodynamics than vitamin K antagonists (VKAs). It should also be noted that NOACs are also associated with a lower risk of food and drug interactions compared with VKAs. In addition to the prevention of recurrent thrombosis, there are also recent studies investigating a potential role of NOACs in primary prevention of VTE in ambulatory patients [11, 12]. In this article, we discuss the current RCTs that have investigated the efficacy and safety of NOACs in patients with malignancies regarding primary thrombosis prophylaxis as well as treatment and prevention of recurrent cancer-associated VTE [8–10].
a day (AVERT study [12]) versus placebo were performed to answer the question of whether these medications are beneficial for primary VTE prevention in high-risk ambulatory cancer patients. Both studies showed an advantage for rivaroxaban as well as for apixaban in the prevention of VTE, with a low incidence of major bleeding. However, the NOACs had no effect on mortality. Therefore, thromboprophylaxis may be prescribed in high-risk outpatients with cancer, e.g., patients with advanced pancreatic carcinoma after ruling out contraindications such as a high risk of bleeding and drug interactions. According to the current German guidelines, LMWH is still preferred over NOACs. However, according to the CASSINI and AVERT studies, rivaroxaban and apixaban are effective in the prevention of VTE in cancer patients [11, 12]. Thus, these NOACs could be considered in selected ambulatory cancer patients who have a high risk of VTE and in whom potential pharmacological interactions or a high risk of bleeding is absent. Potential application of this treatment should be discussed on an individual base since NOACs are not approved for this indication.
Thrombosis prophylaxis in cancer outpatients
The incidence of VTE in cancer patients is significantly increased to 4–20% compared with the normal population [13, 14]. In particular, patients undergoing surgery for malignancy have a higher risk of postoperative deep vein thrombosis (DVT) than patients who have undergone surgery for non-malignant diseases.
Prophylaxis with LMHW for outpatients with tumors is currently not routine
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