When a patient develops pulmonary embolism (PE) while on Avastin (bevacizumab), can Avastin be restarted after holding for 6 weeks with anticoagulation therapy?

From the Guidelines

For a patient who develops pulmonary embolism (PE) while on Avastin (bevacizumab) and is stable on anticoagulation, the general recommendation is to hold Avastin for at least 6 weeks after starting full-dose anticoagulation. This approach is based on the need to stabilize the patient on anticoagulation therapy before reintroducing Avastin, which may increase bleeding risk due to its anti-angiogenic properties that impair vascular integrity 1. When restarting Avastin, it is essential to ensure the patient has achieved therapeutic anticoagulation levels and is clinically stable, with close monitoring after restarting, particularly for signs of bleeding 1. The decision to restart Avastin should be individualized based on the patient's cancer status, thrombosis risk, and bleeding risk. Key considerations include:

• The patient's bleeding risk should be assessed to identify and treat modifiable bleeding risk factors, which may influence decision-making on the duration and regimen/dose of anticoagulant treatment 1.
• Therapeutic anticoagulation for more than 3 months is recommended for all patients with PE, with the duration of anticoagulation depending on the presence of transient or reversible risk factors and the patient's cancer status 1.
• Regular follow-up examinations are crucial to monitor for possible signs of VTE recurrence, cancer, or bleeding complications of anticoagulation, and to assess for persisting or new-onset dyspnoea or functional limitation 1.

From the FDA Drug Label

Discontinue Avzivi in patients with a Grade 4 VTE, including pulmonary embolism. The FDA drug label does not answer the question.

From the Research

Management of Pulmonary Embolism (PE) on Avastin

• The management of PE, including in patients on Avastin, primarily involves anticoagulation therapy 2, 3, 4, 5, 6.
• In patients who develop PE while on Avastin, the decision to hold or restart Avastin depends on various factors, including the severity of PE and the patient's overall clinical condition.

Anticoagulation Therapy

• Direct oral anticoagulants (DOACs) such as apixaban, edoxaban, rivaroxaban, or dabigatran are commonly used for treating PE and have been shown to be noninferior to traditional anticoagulants like heparin and warfarin 2, 4.
• The choice of anticoagulant therapy may depend on the patient's risk profile, with completely oral anticoagulation being effective and safe in patients at intermediate-high risk of death 4.

Holding or Restarting Avastin

• There is no specific guidance on holding or restarting Avastin in patients who develop PE while on the medication.
• However, in general, the management of PE involves holding any medications that may increase the risk of bleeding, such as anticoagulants, until the patient is stabilized 5, 6.
• The decision to restart Avastin should be made on a case-by-case basis, taking into account the patient's overall clinical condition and the risk-benefit ratio of continuing the medication.

Duration of Holding Avastin

• There is no specific recommendation on the duration of holding Avastin in patients who develop PE.
• However, in general, anticoagulation therapy is typically continued for at least 6 weeks in patients with PE, and the decision to restart Avastin should be made after the patient has completed the initial course of anticoagulation therapy 2, 4.