Venous thromboembolism (VTE), a life-threatening complication of active malignancy, is among the foremost causes of death in patients with cancer. Recent evidence has shown the incidence of cancer-related thrombosis is on the rise, which is likely the result of several factors, including anticancer therapy, surgical treatment, and type of cancer. As a result, updated clinical practice guidelines for the treatment of VTE in patients with cancer are essential to ensure optimal patient care.
In a review published in The Lancet Oncology, Dominique Farge, MD, PhD, of Paris Diderot University, Hôpital Saint-Louis in France, and coauthors reported on the 2019 international clinical practice guidelines for the treatment and prophylaxis of VTE in patients with cancer. The guidelines represent a global consensus of international experts within the International Initiative on Thrombosis and Cancer (ITAC).
Prior to the update, the guidelines were last revised in 2016. The new recommendations were made based on literature published up to December 31, 2018, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to establish levels of recommendation. The ITAC working group systematically reviewed the body of literature and included new data related to both treatment and prophylaxis of VTE in patients with cancer. In addition, the group included new evidence on risk stratification to help determine optimal primary prophylaxis treatment.
Overall, the guidelines include 3 main sections:
- Treatment of established VTE
- VTE prophylaxis in patients with cancer
- VTE treatment in special situations
Treatment of Established VTE
The recommendations in this section focused on 4 key areas: initial treatment of established VTE, early (up to 6 months) and long-term (past 6 months) maintenance, treatment of VTE recurrence in patients under anticoagulation, and treatment of established catheter-related thrombosis.
The panel recommended use of low-molecular-weight heparin (LMWH) for initial anticoagulation treatment of established VTE in patients with a creatinine clearance of 30 mL/min or higher. With respect to regimen, they stated that once-daily dosing is sufficient for most patients, though some patients, such as those at high risk for hemorrhage, may require a twice-daily regimen. In addition, for patients at low risk for gastrointestinal or genitourinary bleeding and with a creatinine clearance of 30 mL/min or greater, edoxaban or rivaroxaban can be used as initial therapy.