Multiple Myeloma is Not a Contraindication to Rivaroxaban
Multiple myeloma is not a contraindication to rivaroxaban, and rivaroxaban may actually be an appropriate thromboprophylaxis option for certain multiple myeloma patients. 1
Evidence-Based Recommendations for Multiple Myeloma Patients
The American Society of Clinical Oncology (ASCO) guidelines specifically address thromboprophylaxis in multiple myeloma patients:
For patients with multiple myeloma receiving thalidomide or lenalidomide-based regimens with chemotherapy and/or dexamethasone:
- Lower-risk patients: Either aspirin or LMWH is recommended
- Higher-risk patients: LMWH is recommended 1
For high-risk outpatients with cancer (Khorana score ≥2) starting systemic chemotherapy:
- Rivaroxaban may be offered as thromboprophylaxis provided there are no significant bleeding risk factors or drug interactions 1
Rivaroxaban Use in Multiple Myeloma
Recent evidence supports the use of rivaroxaban in multiple myeloma patients:
A 2022 study comparing thromboprophylaxis options in newly diagnosed multiple myeloma patients found that low-dose rivaroxaban was effective in reducing VTE risk without increasing bleeding rates in patients receiving carfilzomib, lenalidomide, and dexamethasone (KRD) 2
The VTE rate with rivaroxaban thromboprophylaxis was 4.8%, comparable to the rate with aspirin in bortezomib-based regimens, and significantly lower than the 16.1% VTE rate observed with aspirin in carfilzomib-based regimens 2
Important Considerations When Using Rivaroxaban
While not contraindicated, several factors should be considered when using rivaroxaban in multiple myeloma patients:
Renal Function
- Rivaroxaban should be used with caution in patients with moderate renal impairment (CrCl 30-50 mL/min) 3
- Rivaroxaban should be avoided in patients with severe renal impairment (CrCl <30 mL/min) 3
- Multiple myeloma patients often have renal dysfunction, requiring careful monitoring
Drug Interactions
- Avoid concomitant use with strong inhibitors of both CYP3A4 and P-glycoprotein (e.g., azole antimycotics, HIV protease inhibitors) 1
- Use caution with drugs that strongly inhibit only CYP3A4 or only P-glycoprotein 1
Bleeding Risk
- Assess for bleeding risk factors before initiating rivaroxaban 1
- Consider patient age, weight, and comorbidities 3, 4
- Patients >75 years with renal dysfunction or weighing <50 kg should use rivaroxaban with caution 3
Alternative Thromboprophylaxis Options
For multiple myeloma patients where rivaroxaban may not be appropriate:
- Low-risk patients receiving immunomodulatory drugs: Aspirin (81-325 mg daily) 1
- Higher-risk patients or those receiving thalidomide/lenalidomide with high-dose dexamethasone, doxorubicin, or multi-agent chemotherapy: LMWH or warfarin (INR 2-3) 1
- Apixaban (2.5 mg twice daily) has also shown promise in a phase 2 pilot study of myeloma patients on immunomodulatory therapy 5
Conclusion
Multiple myeloma itself is not a contraindication to rivaroxaban use. The decision to use rivaroxaban should be based on the patient's specific treatment regimen, thrombotic risk factors, bleeding risk, renal function, and potential drug interactions. For multiple myeloma patients receiving immunomodulatory drugs, ASCO guidelines provide specific recommendations based on risk stratification, with rivaroxaban being an appropriate option for certain patients.