ASH Guidelines Do Not Recommend Any Specific DOAC Over Another for Cancer-Associated Thrombosis
The American Society of Hematology (ASH) 2021 guidelines for management of venous thromboembolism in patients with cancer do not recommend any specific DOAC over another in any particular context. The guidelines suggest DOACs as a class (specifically mentioning apixaban, edoxaban, or rivaroxaban) for treatment of cancer-associated thrombosis 1.
ASH Recommendations for DOACs in Cancer Patients
For the initial treatment of VTE in patients with cancer, ASH suggests either DOAC (specifically mentioning apixaban or rivaroxaban) or LMWH (conditional recommendation, very low certainty in evidence) 1
For short-term treatment of VTE (3-6 months) in patients with active cancer, ASH suggests DOAC (apixaban, edoxaban, or rivaroxaban) over LMWH (conditional recommendation, low certainty in evidence) 1
For short-term treatment of VTE (3-6 months) in patients with active cancer, ASH suggests DOAC (apixaban, edoxaban, or rivaroxaban) over VKA (conditional recommendation, very low certainty in evidence) 1
For patients with active cancer and VTE requiring long-term anticoagulation (>6 months), ASH suggests using either DOACs or LMWH without specifying preference for any particular DOAC (conditional recommendation, very low certainty in evidence) 1
Clinical Considerations When Choosing Between DOACs
While ASH guidelines do not recommend one DOAC over another, they do acknowledge factors that may influence DOAC selection:
Drug-drug interactions with anticancer therapies should be carefully evaluated when selecting a DOAC 1
Patient-specific factors such as renal function, hepatic function, and concomitant medications should be considered when choosing between DOACs 1
Factors such as once-daily versus twice-daily dosing and out-of-pocket costs may drive selection of specific DOACs 1
For patients with gastrointestinal cancers, special consideration is needed as some DOACs may have increased risk of GI bleeding 1
Practical Guidance for DOAC Selection
Recent research indicates that for nearly all antineoplastic agents, at least one DOAC can be considered compatible, allowing for individualized selection based on potential drug interactions 2
When evaluating potential drug-drug interactions, consider that apixaban and rivaroxaban are metabolized primarily through CYP3A4, while edoxaban relies less on this pathway 2, 3
P-glycoprotein (P-gp) interactions are relevant for all DOACs but vary in importance (dabigatran and edoxaban are more dependent on P-gp than apixaban and rivaroxaban) 1, 2
For patients with luminal gastrointestinal cancers with an intact primary or active gastrointestinal mucosal abnormalities, DOACs should be used with caution 1
Important Caveats
The ASH guidelines specifically state that the choice of anticoagulant must be based on the specific clinical setting to minimize risk, after careful consideration of bleeding risk, drug-drug interactions, and patient preference 1
For patients with cancer undergoing surgical procedures, ASH makes no recommendation on the use of DOACs for thromboprophylaxis due to lack of available studies 1
When patients are unable to tolerate oral medications (e.g., due to nausea and vomiting), parenteral anticoagulation with LMWH is suggested until oral anticoagulation can be resumed 1