From the Guidelines
Direct Oral Anticoagulants (DOACs) can be used for cancer-associated venous thromboembolism (VTE) and are now considered first-line therapy for many cancer patients. The most recent and highest quality study, published in 2024, supports the use of DOACs, such as apixaban and edoxaban, for the treatment of VTE in cancer patients 1. Specifically, apixaban (10 mg twice daily for 7 days, then 5 mg twice daily) and rivaroxaban (15 mg twice daily for 21 days, then 20 mg once daily) have the strongest evidence supporting their use in cancer patients. Edoxaban (60 mg once daily, or 30 mg once daily for patients with creatinine clearance 30-50 mL/min, body weight ≤60 kg, or on certain P-glycoprotein inhibitors) is also an option.
Some key points to consider when using DOACs for cancer-associated VTE include:
- Treatment duration is typically at least 6 months, with consideration for extended therapy in patients with active cancer
- DOACs should be used cautiously in patients with gastrointestinal or genitourinary cancers due to higher bleeding risk
- DOACs are not recommended for those with severe renal impairment (CrCl <30 mL/min), certain drug interactions, or high risk of gastrointestinal bleeding
- Low molecular weight heparin remains an alternative, particularly for patients with luminal gastrointestinal cancers, severe renal impairment, or drug interactions
The 2022 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer also support the use of DOACs, including apixaban, rivaroxaban, and edoxaban, as initial treatment options in patients with cancer-associated thrombosis who are not at high risk of gastrointestinal or genitourinary bleeding 1. Overall, the use of DOACs for cancer-associated VTE is supported by high-quality evidence and should be considered as a first-line treatment option for many cancer patients.
From the Research
Use of DOACs for Cancer-Associated VTE
- Direct Oral Anticoagulants (DOACs) can be used for the treatment of cancer-associated Venous Thromboembolism (VTE) 2, 3, 4, 5, 6.
- The efficacy and safety of DOACs in patients with cancer and VTE have been evaluated in several studies, with results showing that DOACs are an effective treatment option for these patients 2, 4, 5.
- However, the use of DOACs in patients with cancer and VTE requires consideration of bleeding risk, particularly in patients with gastrointestinal (GI) malignancies 5, 6.
- The choice of anticoagulant therapy, including DOACs or low-molecular-weight heparin (LMWH), should be individualized based on patient-specific and cancer-related factors 6.
Efficacy and Safety of DOACs
- Studies have shown that DOACs are associated with a reduced risk of recurrent VTE compared to LMWH or warfarin 4.
- However, the risk of major bleeding with DOACs is similar to or slightly higher than with LMWH 2, 4, 5.
- The risk of clinically relevant non-major bleeding (CRNMB) is also similar between DOACs and LMWH 2, 4.
Patient Selection and Controversies
- Patient selection for treatment with DOACs should consider factors such as bleeding risk, cancer type, and patient preference 5, 6.
- DOACs may be preferred for patients without GI malignancies, while LMWH may be preferred for patients with upper or unresected lower GI tumors 5, 6.
- The use of DOACs in patients with cancer and VTE requires careful consideration of the potential benefits and risks, as well as ongoing monitoring and management of bleeding risk 6.