What is the preferred anticoagulant in patients with cancer (malignancy)?

From the Guidelines

Low molecular weight heparins (LMWHs) like enoxaparin are no longer the preferred anticoagulants for cancer-associated thrombosis, instead, an oral Xa inhibitor (apixaban) is recommended over LMWH for the initiation and treatment phases of therapy. The typical regimen for apixaban is 10 mg twice daily for 7 days, then 5 mg twice daily for at least 3-6 months, with consideration for extended therapy while cancer remains active. This recommendation is based on the most recent evidence from the Chest guideline and expert panel report 1. Some key points to consider when choosing an anticoagulant for cancer-associated thrombosis include:

• Cancer type and stage
• Bleeding risk
• Renal function
• Patient preference regarding injection versus oral administration
• Presence of luminal GI malignancy, in which case apixaban or LMWH may be the preferred option For patients with renal impairment (CrCl <30 mL/min), dose adjustment is necessary, or unfractionated heparin may be considered. Treatment decisions should be individualized based on these factors. It's worth noting that the previous guidelines recommended LMWHs as the preferred anticoagulants for cancer-associated thrombosis 1, however, the most recent evidence suggests that apixaban is a better option for most patients 1.

From the FDA Drug Label

Adult Patients with Cancer and Acute Symptomatic VTE Table 11 summarizes the number of patients with bleeding reactions that occurred in the clinical trial of adult patients with cancer and acute symptomatic VTE At the end of the six-month study, a total of 46 (13.6%) patients in the FRAGMIN arm and 62 (18. 5%) patients in the OAC arm experienced any bleeding event.

The preferred anticoagulant in cancer is dalteparin (FRAGMIN), as it has been directly compared to other anticoagulants, such as OAC (Oral Anticoagulant), in patients with cancer and acute symptomatic VTE, with a lower incidence of major bleeding reactions (5.6% vs 3.6%) and a similar incidence of any bleeding event (13.6% vs 18.5%) 2.

• Key points:
  • Dalteparin (FRAGMIN) has been studied in patients with cancer and acute symptomatic VTE.
  • The incidence of major bleeding reactions was 5.6% in the FRAGMIN arm and 3.6% in the OAC arm.
  • The incidence of any bleeding event was 13.6% in the FRAGMIN arm and 18.5% in the OAC arm.

From the Research

Preferred Anticoagulant in Cancer

The choice of anticoagulant for cancer-associated thrombosis depends on various factors, including the type of cancer, patient-specific factors, and the risk of bleeding.

• Low-molecular-weight heparin (LMWH) has been the traditional preferred anticoagulant for cancer-associated thrombosis, due to its efficacy in reducing the risk of recurrent venous thromboembolism (VTE) 3.
• However, recent studies have shown that direct oral anticoagulants (DOACs) such as apixaban, edoxaban, and rivaroxaban are effective and safe for the treatment of cancer-associated thrombosis, and may be preferred in patients without gastric or gastroesophageal lesions 4, 5, 6.
• The National Comprehensive Cancer Network (NCCN) guidelines recommend DOACs as the preferred anticoagulant for patients with cancer-associated thrombosis, except for those with gastric or gastroesophageal lesions, in whom LMWH is still the preferred choice 4, 5.
• The choice of anticoagulant should be individualized, taking into account the patient's risk of bleeding, cancer type, and other factors such as drug-drug interactions and the use of anticancer drugs associated with gastrointestinal toxicity 7.

Factors Influencing Anticoagulant Choice

Several factors influence the choice of anticoagulant in cancer patients, including:

• Cancer type: Patients with gastrointestinal cancers may be at higher risk of bleeding with DOACs, and LMWH may be preferred 5, 7.
• Bleeding risk: Patients at high risk of bleeding, such as those with urothelial cancer or taking anticancer drugs associated with gastrointestinal toxicity, may require caution with DOACs 7.
• Patient preferences: The patient's willingness and ability to comply with LMWH injections should be considered 4.
• Cost and accessibility: The cost and accessibility of anticoagulants may also influence the choice of anticoagulant.

Efficacy and Safety of Anticoagulants

Studies have shown that DOACs are effective in reducing the risk of recurrent VTE in cancer patients, with a similar safety profile to LMWH 6, 7.

• A systematic review and meta-analysis found that DOACs were associated with a lower risk of recurrent VTE compared to traditional anticoagulants, with no significant difference in bleeding risk 6.
• Another study found that the risk of major bleeding and clinically relevant non-major bleeding was higher with DOACs than with LMWH, although not significantly so 7.