- David Green, MD, PhD
A summary of guidelines to help clinicians manage difficult clinical issues
- David Green, MD, PhD
Sponsoring Organization: The International Society of Thrombosis and Haemostasis Subcommittee on Haemostasis and Malignancy
Target Population: Oncologists, hematologists, primary-care providers
Background and Objective
Venous thromboembolism (VTE) is a common complication of malignant disease, and VTE treatment for patients with cancer is similar to that for patients without cancer. Occasionally, however, thrombi extend or recur in cancer patients despite anticoagulant therapy, or patients experience chemotherapy-induced thrombocytopenia or develop bleeding because a tumor has eroded blood vessels. Here are key recommendations to help clinicians manage difficult issues in patients with cancer-associated thrombosis.
Key Points or Recommendations
For recurrent VTE despite therapeutic anticoagulation with warfarin, switch to full-dose, low-molecular-weight heparin (LMWH). If thrombosis recurs despite LMWH, increase the dose by 25% and reassess 5 to 7 days after dose escalation. If symptoms do not improve, use the peak anti–factor-Xa level to estimate the next dose escalation.
For thrombocytopenia and acute VTE, give full-dose anticoagulation if the platelet count is ≥50,000 per μL. If the platelet count is lower, infuse platelets to raise the count to ≥50,000 per μL. For persistent VTE and a platelet count of 25,000 to 50,000 per μL, decrease the dose of LMWH by 50%; for a platelet count of <25,000 per μL, discontinue LMWH.
In patients with major or life-threatening bleeding, withhold anticoagulation and insert a retrievable vena caval filter; when bleeding has resolved, resume anticoagulation and remove the filter. Filters are not recommended for patients with chronic thrombosis, but might be considered in those with contraindications to anticoagulation and high risk for potentially fatal pulmonary embolism.
These guidelines are based on the best available evidence. However, they might change if future randomized trials indicate better alternatives. The new oral anticoagulants are still untested in the cancer setting, and the current guidelines recommend that they not be used until there is evidence to the contrary. More-effective cancer treatments and drugs with less thrombogenicity are anticipated to decrease the incidence of cancer-associated thrombosis.
Editor Disclosures at Time of Publication
Disclosures for David Green, MD, PhD at time of publication Consultant / Advisory board Altor Bioscience Grant / research support NIH