Recommendations for the acute treatment of cancer-associated thrombosis
| ISTH SSC 201826 . | ASCO 201925 . | ITAC 201937 . | NCCN 202038 . | ESC 201939 . |
|---|---|---|---|---|
| DOACs (edoxaban and rivaroxaban) and LMWH are the preferred agents Choice dependent on the risk of bleeding (LMWH preferred in patients with a high risk of bleeding) and potential for DDIs High risk of bleeding was defined as patients with luminal GI cancers with an intact primary, patients with cancers at risk of bleeding from the GU tract, bladder, or nephrostomy tubes, or patients with active GI mucosal abnormalities such as duodenal ulcers, gastritis, esophagitis, or colitis | Initial anticoagulation (first 5-10 d): LMWH or rivaroxaban preferred Long-term (<6 mo): LMWH, edoxaban, or rivaroxaban (VKAs are acceptable alternatives for long-term therapy if LMWH/DOACs are not available) There is an increase in major bleeding risk with DOACs, particularly observed in GI and potentially GU malignancies. Caution with DOACs is also warranted in other settings with high risk for mucosal bleeding Consider DDI | Initial anticoagulation (first 5-10 d): LMWH, rivaroxaban, or edoxaban following ≥5 d of parenteral anticoagulation Long-term (<6 mo): LMWH or DOACs (to date evidence is only available for edoxaban and rivaroxaban) DOACs should be used with caution in patients with GI cancers, especially upper GI cancers DOACs are recommended for patients with cancer when creatinine clearance is ≥30 mL/min in the absence of strong DDI or GI absorption impairment | Appropriate monotherapy/combined therapy options include: LMWH, edoxaban, apixaban, and rivaroxaban LMWH is preferred for patients with gastric or gastroesophageal lesions because these patients are at increased risk for hemorrhage with DOACs Consider DDI Use anticoagulation with caution in patients with compromised renal or liver function | Long-term for patients with PE and cancer (<6 mo): LMWH are preferred over VKAs Edoxaban or rivaroxaban should be considered as an alternative to LMWH Caution for patients with GI cancer because of the increased risk of bleeding with DOACs |
| ISTH SSC 201826 . | ASCO 201925 . | ITAC 201937 . | NCCN 202038 . | ESC 201939 . |
|---|---|---|---|---|
| DOACs (edoxaban and rivaroxaban) and LMWH are the preferred agents Choice dependent on the risk of bleeding (LMWH preferred in patients with a high risk of bleeding) and potential for DDIs High risk of bleeding was defined as patients with luminal GI cancers with an intact primary, patients with cancers at risk of bleeding from the GU tract, bladder, or nephrostomy tubes, or patients with active GI mucosal abnormalities such as duodenal ulcers, gastritis, esophagitis, or colitis | Initial anticoagulation (first 5-10 d): LMWH or rivaroxaban preferred Long-term (<6 mo): LMWH, edoxaban, or rivaroxaban (VKAs are acceptable alternatives for long-term therapy if LMWH/DOACs are not available) There is an increase in major bleeding risk with DOACs, particularly observed in GI and potentially GU malignancies. Caution with DOACs is also warranted in other settings with high risk for mucosal bleeding Consider DDI | Initial anticoagulation (first 5-10 d): LMWH, rivaroxaban, or edoxaban following ≥5 d of parenteral anticoagulation Long-term (<6 mo): LMWH or DOACs (to date evidence is only available for edoxaban and rivaroxaban) DOACs should be used with caution in patients with GI cancers, especially upper GI cancers DOACs are recommended for patients with cancer when creatinine clearance is ≥30 mL/min in the absence of strong DDI or GI absorption impairment | Appropriate monotherapy/combined therapy options include: LMWH, edoxaban, apixaban, and rivaroxaban LMWH is preferred for patients with gastric or gastroesophageal lesions because these patients are at increased risk for hemorrhage with DOACs Consider DDI Use anticoagulation with caution in patients with compromised renal or liver function | Long-term for patients with PE and cancer (<6 mo): LMWH are preferred over VKAs Edoxaban or rivaroxaban should be considered as an alternative to LMWH Caution for patients with GI cancer because of the increased risk of bleeding with DOACs |
ASCO, American Society of Clinical Oncology; DDI, drug-to-drug interactions; ESC, European Society of Cardiology; GU, genitourinary; ISTH, International Society on Thrombosis and Haemostasis; ITAC, International Initiative on Thrombosis and Cancer; NCCN, National Comprehensive Cancer Network; PE, pulmonary embolism.