The Role of Direct Oral Anticoagulants in Cancer-Associated Thrombosis According to the Current Literature

Eleni Arnaoutoglou,Nikos Rousas,Michail Peroulis,Petroula Nana,Konstantinos Spanos,George Kouvelos,Konstantinos Dakis,Miltos Matsagkas

doi:10.3390/medicina57090960

Eleni Arnaoutoglou, Nikos Rousas + Show 6 more

Open Access

https://doi.org/10.3390/medicina57090960

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Journal: Medicina	Publication Date: Sep 12, 2021
Citations: 1	License type: CC BY 4.0

Affiliation: University Hospital of Larissa, University of Thessaly

Abstract

Venous thromboembolism (VTE) is a common complication among patients suffering from malignancies, leading to an increased mortality rate. Novel randomized trials have added valuable information regarding cancer-associated thrombosis (CAT) management using direct oral anticoagulants (DOACs). The aim of this study is to present an overview of the current literature and recommendations in CAT treatment. A few randomized control trials (RCTs) have been integrated suggesting that DOACs may be effectively applied in CAT patients compared to low molecular weight heparins (LMWHs) with a decreased mortality and VTE recurrence rate. However, the risk of bleeding is higher, especially in patients with gastrointestinal malignancies. Real-world data are in accordance with these RCT findings, while in the currently available recommendations, DOACs are suggested as a reliable alternative to LMWH during the initial, long-term, and extended phase of treatment. Data retrieved from the current literature, including RCTs and “real-world” studies, aim to clarify the role of DOACs in CAT management, by highlighting their benefits and remarking upon the potential adverse outcomes. Current recommendations suggest the use of DOACs in well-selected patients with an increasing level of evidence through years.

Highlights

Venous thromboembolism (VTE) is a common complication among patients suffering from malignancies, while the risk of VTE varies during the progression of the disease [1]
The aim of this study is to present the current literature and recommendations regarding the role of direct oral anticoagulants (DOACs) in cancerassociated thrombosis (CAT) management
Regarding vitamin K antagonists (VKA)’ use in CAT, DOACs and low molecular weight heparins (LMWHs) seem to be more effective in VTE management, with reduced or equal bleeding risk compared to VKAs [38,39]

Summary

Introduction

Venous thromboembolism (VTE) is a common complication among patients suffering from malignancies, while the risk of VTE varies during the progression of the disease [1]. The apixaban and dalteparin in active malignancy associated venous thrombosis (ADAM) trial, which compared the efficacy and safety of apixaban to dalteparin in CAT by randomizing a total of 300 patients, demonstrated a decreased recurrent VTE rate with the use of DOAC compared to LMWH (0.7% in the apixaban group vs 6.3% in the dalteparin group, p = 0.0281). Venous Thromboembolism in Patients with Cancer (CARAVAGGIO) study, a prospective randomized, open label, blind endpoint evaluation, non-inferiority clinical trial This trial assessed the efficacy and safety of apixaban compared to dalteparin for the treatment of VTE in cancer patients [15,16]. It is of note that the CARAVAGGIO trial included a smaller proportion of patients with upper gastrointestinal cancer and hematologic malignancies compared to other studies (4% in the apixaban and 5.4% in the dalteparin group) [15,16]. DOAC selection should rely on a detailed patient-specific approach including the type and stage of cancer, patient history, bleeding risk, and concomitant medications

Real-World Data on CAT Patients

Current Recommendations on CAT Management

Aim & weighting the evidence

Considerations on the Current Literature

Findings

Conclusions