From the Guidelines
Direct oral anticoagulants (DOACs) are recommended for the treatment of venous thromboembolism (VTE) in cancer patients, with the preferred DOACs including apixaban, rivaroxaban, and edoxaban, as stated in the most recent guidelines 1. The treatment should continue for at least 3 months or as long as active cancer or cancer therapy, with consideration for extended therapy in patients with active cancer. Key factors to consider when selecting a regimen include:
- Renal failure (CrCl <30 mL/min)
- Hepatic disease (elevated transaminases or bilirubin, Child-Pugh B and C liver impairment, or cirrhosis)
- Inpatient/outpatient status
- U.S. FDA approval
- Cost
- Patient preference
- Ease of administration
- Monitoring
- Bleeding risk assessment
- Ability to reverse anticoagulation Before starting DOACs, clinicians should assess drug interactions with cancer therapies, renal function (adjusting doses for impairment), and bleeding risk, as highlighted in the guidelines 1. Regular monitoring of renal function, complete blood counts, and clinical assessment for bleeding or recurrent thrombosis is essential, with follow-up every 2 to 3 days for the first 14 days while in the inpatient setting and every 2 weeks thereafter or as clinically indicated 1. DOACs are preferred over vitamin K antagonists in cancer patients because they have demonstrated similar or superior efficacy with comparable safety profiles, require no routine laboratory monitoring, and offer more convenient fixed dosing without dietary restrictions, improving quality of life for cancer patients already managing complex treatment regimens, as supported by recent studies 1. Low molecular weight heparin (LMWH) remains an alternative, particularly for patients with gastrointestinal or genitourinary cancers due to potentially higher bleeding risk with DOACs in these populations, as noted in previous guidelines 1. However, the most recent guidelines 1 suggest that DOACs can be used for long-term treatment of cancer-associated VTE in appropriate candidates, with results appearing to be comparable to LMWH and warfarin. In patients with cancer, DOACs and LMWH are preferable to warfarin, as stated in the guidelines 1. Overall, the use of DOACs in cancer-associated VTE should be guided by the most recent guidelines and individual patient factors, with a focus on minimizing morbidity, mortality, and improving quality of life.
From the Research
Role of Direct Oral Anticoagulants (DOACs) in Cancer-Associated Venous Thromboembolism (VTE)
- The treatment of VTE in patients with cancer is challenging due to increased risks of both recurrent VTE and major bleeding 2.
- DOACs, such as apixaban, edoxaban, or rivaroxaban, are preferred for patients without gastric or gastroesophageal lesions, according to the National Comprehensive Cancer Network (NCCN) guidelines 2.
- DOACs have been associated with an increased risk of major bleeding in patients with gastrointestinal and possibly genitourinary cancers, and should be used with caution in these patients 2.
Efficacy and Safety of DOACs Compared to Low-Molecular-Weight Heparin (LMWH)
- Studies have shown that DOACs may be as safe and effective as LMWH and warfarin for the treatment of VTE in patients with cancer 3, 4.
- A network meta-analysis found that LMWH emerged as significantly superior to vitamin K antagonists (VKA) with respect to risk reduction of recurrent VTE, and its safety was comparable to VKA 4.
- The efficacy and safety of LMWH and DOACs for the treatment of VTE in cancer patients may be comparable, with some studies suggesting that DOACs may have a reduced risk of recurrent VTE compared to LMWH 5.
Patient Selection and Treatment Considerations
- Patient selection for treatment with DOACs should consider factors such as the type of cancer, risk of bleeding, and patient preference 2.
- The patient's willingness and ability to comply with LMWH injections, and their treatment preference, should also be considered 2.
- Anticoagulation should be continued indefinitely while cancer is active or under treatment, or if there are persistent risk factors for recurrent VTE 2.