Evidence-Based Guidance on Venous Thromboembolism in Patients with Solid Tumours

Abstract

Venous thromboembolism (vte) is a serious, life-threatening complication of cancer. Anticoagulation therapy such as low molecular weight heparin (lmwh) has been shown to treat and prevent vte. Cancer therapy is often complex and ongoing, making the management of vte less straightforward in patients with cancer. There are no published Canadian guidelines available to suggest appropriate strategies for the management of vte in patients with solid tumours. We therefore aimed to develop a clear, evidence-based guideline on this topic. A systematic review of clinical trials and meta-analyses published between 2002 and 2013 in PubMed was conducted. Reference lists were handsearched for additional publications. The National Guidelines Clearinghouse was searched for relevant guidelines. Recommendations were developed based on the best available evidence. In patients with solid tumours, lmwh is recommended for those with established vte and for those without established vte but with a high risk for developing vte. Options for lmwh include dalteparin, enoxaparin, and tinzaparin. No one agent can be recommended over another, but in the setting of renal insufficiency, tinzaparin is preferred. Unfractionated heparin can be used under select circumstances only (that is, when rapid clearance of the anticoagulant is desired). The most common adverse event is bleeding, but major events are rare, and with appropriate follow-up care, bleeding can be monitored and appropriately managed.

Canadian consensus recommendations on the management of venous thromboembolism in patients with cancer. Part 2: treatment

“…The risk of recurrent vte is highest in the first 3 months after resolution of the thrombus 43 ; therefore, in patients whose cvc has been removed, anticoagulation therapy for at least 3 months is recommended [1][2][3][4] . Overall, there are no randomized data to guide management; however, based on the limited data available, the consensus was that, if a clot associated with a central line develops, and if the line is otherwise functional, it is reasonable to use anticoagulation to save the line.…”

“…Guidelines on the management of vte in the oncology setting have been developed by the American Society of Clinical Oncology 1 and CancerControl Alberta (part of Alberta Health Services) 2 , but fail to address several key issues concerning the monitoring of anticoagulation and the use of anticoagulants in specific subpopulations. Other guidelines are broader in scope, and their discussion of treatment for vte is therefore limited to a subsection [3][4][5] .…”

Canadian Consensus Recommendations on the Management of Venous Thromboembolism in Patients with Cancer. Part 1: Prophylaxis

“…Current guidelines recommend extending postoperative prophylaxis for up to 4 weeks in patients undergoing abdominal or pelvic cancer surgery [14][15][16][17][18] . A meta-analysis comparing the extended use of lmwh (3-4 weeks after surgery) with conventional in-hospital prophylaxis (for the period of time in hospital) evaluated data from patients undergoing major abdominal surgery.…”

“…Most hospitalized patients with cancer require thromboprophylaxis throughout hospitalization [14][15][16]18 . A systematic review comparing lmwh, unfractionated heparin (ufh), and placebo in medically ill patients (6.7% with current or previous cancer) demonstrated lower rates of dvt with lmwh than with placebo [odds ratio (or): 0.60; 95% ci: 0.47 to 0.75], but no difference when lmwh was compared with ufh (or: 0.92; 95% ci: 0.56 to 1.52).…”

“…Patients with cancer undergo complex treatment protocols and could have other comorbidities such as renal or hepatic insufficiency and thrombocytopenia that can affect the efficacy and safety of anticoagulation. Several groups have published guidelines on the management of vte in oncology patients-most recently, the American Society of Clinical Oncology 14 and CancerControl Alberta (part of Alberta Health Services) 15 . Other published guidelines include those from the U.S. National Comprehensive Cancer Network 16 , the European Society for Medical Oncology 17 , and the American College of Chest Physicians 18 .…”