How to Choose An Appropriate Anticoagulant for Cancer-Associated Thrombosis
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Venous thromboembolic disease can be a fatal complication of cancer. Despite advances in prevention, thousands of patients require treatment of cancer-associated thrombosis (CAT) each year. Guidelines have advocated low-molecular-weight heparin (LMWH) as the preferred anticoagulant for CAT for years, based on clinical trial data showing LMWH to be associated with a lower risk of recurrent thrombosis when compared with vitamin K antagonists. However, the potentially painful, subcutaneously administered LMWH injections can be expensive, and clinical practice has not been consistent with guideline recommendations. Recently, studies have compared LMWH to the direct oral anticoagulants (DOACs) for the management of CAT. Based on promising trial results outlined in this review, DOACs are now preferred anticoagulants for CAT occurring in patients without gastric or gastroesophageal lesions. For patients with gastrointestinal cancers, who may be at higher risk of hemorrhage with the DOACs, LMWH remains the anticoagulant of choice. Applying the latest data from this rapidly evolving field to care for diverse patient groups can be challenging. This article provides an evidence-based review of outpatient anticoagulant selection for lower-extremity deep vein thrombosis or pulmonary embolism in the setting of cancer, and takes into account special populations with cancer.
Submitted May 18, 2021; final revision received August 6, 2021; accepted for publication August 9, 2021.
Disclosures: Dr. Streiff has disclosed consulting for Bayer, Bristol-Myers Squibb, DisperSol, Janssen, and Pfizer; and receiving research support from Novo Nordisk, Sanofi, and Tremeau. Dr. Lim has disclosed receiving honorarium from Sanofi, Argenx, Dova Pharmaceuticals, and Hema Biologics; and receiving honorarium and travel expenses for educational participation in the Hemostasis and Thrombosis Research Society Trainee Workshop which was supported by Novo Nordisk. The remaining authors have disclosed that they have no financial interests, arrangements, or affiliations with the manufacturers of any products discussed in this article or their competitors.
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