Venous Thromboembolic Disease

Abstract

OverviewVenous thromboembolism (VTE) is a common and life-threatening condition in patients with cancer.1,2 Results from a retrospective study of hospitalized adult patients with cancer with neutropenia (N=66,106) showed that approximately 3% to 12% of these patients, depending on the type of malignancy, experienced VTE during their first hospitalization.1 In a recent health claims database analysis of patients undergoing chemotherapy for solid tumors in the ambulatory setting (N=17,284), VTE NCCN Venous Thromboembolic Disease Clinical Practice Guidelines in Oncology AbstractVenous thromboembolism (VTE) remains a common and life-threatening complication among patients with cancer. Thromboprophylaxis can be used to prevent the occurrence of VTE in patients with cancer who are considered at high risk for developing this complication. Therefore, it is critical to recognize the various risk factors for VTE in patients with cancer. Risk assessment tools are available to help identify patients for whom discussions regarding the potential benefits and risks of thromboprophylaxis would be appropriate. The NCCN Clinical Practice Guidelines in Oncology for VTE provide recommendations on risk evaluation, diagnosis, prevention, and treatment of VTE in patients with cancer. (JNCCN 2013;11:1402-1429 NCCN Categories of Evidence and ConsensusCategory 1: Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate. Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate. Category 2B: Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate. Category 3: Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate. These guidelines are also available on the Internet. For the latest update, visit NCCN.org.

Venous thromboembolism in hematopoietic stem cell transplant recipients

“…50,51 The American Society of Clinical Oncology (ASCO) and National Comprehensive Cancer Network (NCCN) guidelines advise against the use of routine prophylactic anticoagulation in ambulatory patients with cancer. 47,52 An exception is made for patients with MM receiving treatment with thalidomide, lenalidomide or pomalidomide. Hospitalized patients and those with CVCs are also at higher risk of thrombosis.…”

“…The International Myeloma Working group and ASCO recommend prophylaxis with either aspirin or LMWH for lower risk patients, and LMWH for higher risk patients receiving thalidomide or lenalidomide. 47,61 Hospitalized patients Based on randomized clinical trials of thromboprophylaxis in medically ill hospitalized patients, 62,63 and a meta-analysis that demonstrated 40% lower rates of VTE with pharmacologic prophylaxis versus placebo, 64 the current ACCP 52 and ASCO guidelines 47 strongly recommend thromboprophylaxis in hospitalized medically ill and cancer patients, respectively. However, trials of thromboprophylaxis did not include HSCT patients who are not specifically included in these recommendations.…”

Multiple Myeloma: Supportive Care Requirements and Coordination of Patient-Centered Care

“…37 Risk factors for VTE not specific to multiple myeloma include older age, obesity, tobacco use, infection, history of prior venous thromboembolism, use of ESAs, use of hormone replacement therapy, presence of a central venous catheter, and inactivity/immobility. 38 Disease-specific risk factors include monoclonal protein level greater than 1.6 g/dL, other signs of progressive disease such as increased production of inflammatory cytokines, and hyperviscosity. 38 Treatment with both thalidomide and lenalidomide further increase the risk of venous thromboembolism, particularly in newly diagnosed patients.…”

“…38 Disease-specific risk factors include monoclonal protein level greater than 1.6 g/dL, other signs of progressive disease such as increased production of inflammatory cytokines, and hyperviscosity. 38 Treatment with both thalidomide and lenalidomide further increase the risk of venous thromboembolism, particularly in newly diagnosed patients. 13 When thalidomide and lenalidomide are used as a single agent in newly diagnosed patients, an estimated 3%-4% experience VTE.…”

“…37 LMWH (equivalent to enoxaparin 40 mg/day) is recommended for those with 2 or more individual/myeloma-related risk factors. 38 LMWH is also recommended for all patients receiving concurrent high-dose dexamethasone or doxorubicin. Full-dose warfarin targeting a therapeutic international normalized ratio of 2-3 is an alternative to LMWH, although there are limited data in the literature with this strategy.…”