What is the treatment for Deep Vein Thrombosis (DVT) secondary to malignancy?

From the Guidelines

The treatment for deep vein thrombosis (DVT) secondary to malignancy primarily involves anticoagulation therapy with low molecular weight heparin (LMWH) as the preferred first-line agent, with a recommendation for at least 6 months of treatment, as stated in the most recent guidelines 1. The choice of LMWH, such as enoxaparin, dalteparin, or tinzaparin, is crucial, and the dose should be adjusted according to the patient's renal function and body weight.

• Key considerations for treatment include:
  • Initial treatment with LMWH for 5-10 days, followed by long-term anticoagulation with LMWH, edoxaban, rivaroxaban, or apixaban for at least 6 months, as recommended by the latest guidelines 1.
  • Anticoagulation should continue beyond the initial 6 months in select patients with active cancer, such as those with metastatic disease or those receiving chemotherapy, as suggested by the updated guidelines 1.
  • The insertion of a vena cava filter may be considered as an adjunct to anticoagulation in patients with progression of thrombosis despite optimal anticoagulant therapy, although this is based on expert opinion and limited evidence 1.
  • Incidental PE and DVT should be treated in the same manner as symptomatic VTE, given their similar clinical outcomes compared with patients with cancer with symptomatic events, as stated in the latest guidelines 1. In addition to anticoagulation therapy, treatment should also include management of symptoms with leg elevation, compression stockings (20-30 mmHg pressure), and pain control, as well as regular monitoring for bleeding complications, thrombocytopenia, and recurrent thrombosis, with dose adjustments needed for patients with renal impairment or low body weight, as recommended by the guidelines 1. The higher risk of recurrent DVT in cancer patients is due to the hypercoagulable state created by tumor cells releasing procoagulant factors and inflammatory cytokines that activate the coagulation cascade, highlighting the importance of effective anticoagulation therapy in these patients, as discussed in the guidelines 1.

From the FDA Drug Label

Extended treatment of VTE in adult patients with cancer: Month 1: 200 units/kg subcutaneous once daily (2.3)Months 2 to 6: 150 units/kg subcutaneous once daily (2. 3) The treatment for Deep Vein Thrombosis (DVT) secondary to malignancy is dalteparin (SQ) at a dose of 200 units/kg subcutaneously once daily for the first month, followed by 150 units/kg subcutaneously once daily for months 2 to 6 2.

• Key points:
  • The dose is administered subcutaneously.
  • The treatment duration is six months.
  • The patient should be closely monitored for signs and symptoms of neurological impairment and bleeding. Note that rivaroxaban (PO) is also an option for the treatment of DVT, but the provided label does not specifically address DVT secondary to malignancy 3.

From the Research

Treatment for DVT Secondary to Malignancy

The treatment for Deep Vein Thrombosis (DVT) secondary to malignancy involves anticoagulation therapy. The following are key points to consider:

• Anticoagulant therapy with low-molecular-weight heparin (LMWH) has been the preferred approach recommended by practice guidelines 4, 5.
• LMWH is as effective as vitamin K antagonists (VKAs) in preventing recurrent venous thromboembolism (VTE) and has a similar incidence of bleeding complications 4.
• Direct oral anticoagulants (DOACs) such as apixaban, edoxaban, or rivaroxaban are preferred for patients without gastric or gastroesophageal lesions 5.
• DOACs have been associated with an increased risk of major bleeding in patients with gastrointestinal and possibly genitourinary cancers 5, 6.
• The National Comprehensive Cancer Network (NCCN) guidelines recommend LMWH or DOACs for the treatment of cancer-associated VTE 5.
• Patients with cancer who have VTE should be treated with anticoagulation for a minimum of 6 months, and anticoagulation should be continued indefinitely while cancer is active or under treatment 5, 7.

Anticoagulation Options

The following anticoagulation options are available for the treatment of DVT secondary to malignancy:

• Low-molecular-weight heparin (LMWH) 4, 5, 8
• Direct oral anticoagulants (DOACs) such as apixaban, edoxaban, or rivaroxaban 5, 6, 7, 8
• Vitamin K antagonists (VKAs) 4

Patient Selection and Considerations

When selecting an anticoagulation therapy, the following patient factors should be considered:

• Presence of gastric or gastroesophageal lesions 5
• Type of cancer and its treatment 5, 7
• Patient's willingness and ability to comply with LMWH injections 5
• Patient's treatment preference 5
• Risk of recurrent VTE and bleeding complications 4, 5, 7, 8