Abstract
The development of thrombocytopenia in the setting of therapeutic anticoagulation for venous thromboembolic disease (VTE) is common in cancer patients, but guidelines for management are based on limited past data and have not been validated. In 2011, Memorial Sloan Kettering Cancer Center (MSKCC) implemented the following guidelines in this setting: administer full dose enoxaparin for a platelet count > 50,000/mcL, half-dose enoxaparin for a platelet count of 25,000–50,000/mcL, and hold anticoagulation for a platelet count < 25,000/mcL. We now report validation of safety and efficacy of these guidelines. As a Quality Assessment Initiative, we evaluated our guidelines for adult cancer patients at MSKCC who were on therapeutic-dose enoxaparin for VTE during the years 2011 through 2013 and experienced at least one 7-day period of thrombocytopenia (platelet count ≤ 50,000/mcL). We assessed adherence to the enoxaparin dose modification guidelines, major bleeding, clinically relevant non-major bleeding, recurrent VTE, and mortality during the thrombocytopenic episodes. We identified 99 patients with 140 episodes of thrombocytopenia of 7 or more days. The median duration of these thrombocytopenic episodes was 12 days. The enoxaparin dose was modified in 133 of the 140 episodes (95%), reflecting satisfactory adherence to our institutional guidelines. There were no recurrent VTE events or major bleeding episodes when the anticoagulant dose was reduced or held. In this cohort, there was only one major bleeding episode, a trauma-associated retroperitoneal hemorrhage that occurred on the third day of a thrombocytopenic episode, prior to enoxaparin dose modification. There were 13 clinically relevant non-major bleeding episodes. Lastly, 10 patients died of cancer-related causes during an episode of thrombocytopenia. This Quality Assessment Initiative supports the safety and efficacy of our guidelines for therapeutic enoxaparin dose modification.
Highlights
Management of venous thromboembolism (VTE) is a common and challenging problem in cancer patients, with incidence rates ranging up to approximately 19% of patients, depending on the tumor type and therapy [1, 2]
The rate of recurrent thrombosis and major bleeding is higher in the cancer population with VTE, compared with the general medical population [6]
We queried the clinical information systems for a list of all individuals treated at Memorial Sloan Kettering Cancer Center and meeting the following criteria: aged 18+ years, were prescribed therapeutic-dose enoxaparin, had at least one ICD9 code for VTE, and subsequently had at least one platelet count measurement below 50,000/mcL during the years 2011–2013
Summary
Management of venous thromboembolism (VTE) is a common and challenging problem in cancer patients, with incidence rates ranging up to approximately 19% of patients, depending on the tumor type and therapy [1, 2]. Arterial and venous thrombosis remain a significant cause of cancer associated morbidity and mortality [3]. Low-molecular weight heparin (LMWH), such as enoxaparin or dalteparin, has been the recommended treatment of thrombosis in cancer [4, 5]. The rate of recurrent thrombosis and major bleeding is higher in the cancer population with VTE, compared with the general medical population [6]. In two studies of dalteparin for cancer-associated thrombosis, the 6-month rate of major bleeding was approximately 6–9% [7, 8]
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