Treatment and Prophylaxis of Venous Thromboembolism in Patients with Cancer Including Patients with COVID-19
Publication Date: July 1, 2022
Last Updated: July 19, 2022
Treatment of incidental or symptomatic established VTE in patients with cancer
Initial treatment of established VTE (up to 10 days of anticoagulation)
Low-molecular-weight heparin (LMWH) is recommended for the initial treatment of established VTE in patients with cancer when creatinine clearance is ≥30 mL/min. (A, 1)
Values and preferences: LMWH is easier to use than unfractionated heparin. A regimen of LMWH, taken once per day, is recommended, unless a twice-per-day regimen is required because of patients’ characteristics (eg, risk of bleeding or moderate renal failure) or the need for technical intervention (eg, surgery or changing regimen). When a twice-per-day regimen is required, only enoxaparin (1 mg/kg, twice-daily) can be used.
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For patients who do not have a high risk of gastrointestinal or genitourinary bleeding, rivaroxaban or apixaban (in the first 10 days), or edoxaban (started after at least 5 days of parenteral anticoagulation) can also be used for the initial treatment of established VTE in patients with cancer when creatinine clearance is ≥30 mL/min. (A, 1)
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Unfractionated heparin can be also used for the initial treatment of established VTE for patients with cancer when LMWH or direct oral anticoagulants are contraindicated, or not available. (C, 2)
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Fondaparinux can be also used for the initial treatment of established VTE in patients with cancer. (D, 2)
Values and preferences: fondaparinux is easier to use than unfractionated heparin.
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Thrombolysis in patients with cancer and with established VTE can only be considered on a case-by-case basis, with specific attention paid to contraindications, especially bleeding risk—eg, brain metastasis. (U, G)
Values and preferences: an expert opinion is recommended before using thrombolytics, and the procedure should be done in centres with health-care practitioners who have appropriate expertise.
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In the initial treatment of VTE, inferior vena cava filters might be considered when anticoagulant treatment is contraindicated or, in the case of pulmonary embolism, when recurrence occurs under optimal anticoagulation. Periodic reassessment of contraindications for anticoagulation is recommended, and anticoagulation should be resumed when safe. (U, G)
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Prophylaxis of VTE in patients with cancer
Prophylaxis of VTE in surgically-treated patients with cancer
Use of low-molecular-weight-heparin (LMWH) once per day (when creatinine clearance is ≥30 mL/min) or low-dose unfractionated heparin three times per day is recommended to prevent postoperative VTE in patients with cancer; pharmacological prophylaxis should be started 2–12 h preoperatively and continued for at least 7–10 days; there are no data allowing conclusions regarding the superiority of one type of LMWH over another. (A, 1)
Values and preferences: LMWH once per day is more convenient.
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There is insufficient evidence to support
fondaparinux (C, 2)
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or direct oral anticoagulants (B, 2)
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as an alternative to LMWH for the prophylaxis of postoperative VTE in patients with cancer. Values and preferences: as per the first recommendation.
Use of the highest prophylactic dose of LMWH to prevent postoperative VTE in patients with cancer is recommended. (A, 1)
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Extended prophylaxis (4 weeks) with LMWH to prevent postoperative VTE after major abdominal or pelvic surgery (either laparotomy or laparoscopy) is recommended in patients with cancer who do not have a high risk of bleeding. (A, 1)
Values and preferences: longer duration of injections.
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Mechanical methods are not recommended as monotherapy except when pharmacological methods are contraindicated. (A, 2)
Values and preferences: no injection.
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Inferior vena cava filters are not recommended for routine prophylaxis. (A, 1)
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Overview
Title
Treatment and Prophylaxis of Venous Thromboembolism in Patients with Cancer Including Patients with COVID-19
Authoring Organization
International Initiative on Thrombosis and Cancer