Treatment Approach for DVT in Cancer Patients: Basics for Trainees

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Treatment Approach for DVT in Cancer Patients – Thread by

@sujeethemat
 

 

Q1. You have a patient with dx of cancer & DVT and u need to start anticoagulation. Your approach?

A1. Treatment approach Immediate anticoagulation (1-3 weeks) followed by continued anticoagulation (3-6 m).

Q2. Which drugs you will choose for Immediate anticoagulation?

A2. Either low molecular weight (LMW) heparin or a direct oral anticoagulant (DOAC) can be used.

Q3. Why not UFH?

A3. LMWH is possibly superior to UFH in the initial treatment of VTE in people with cancer. The evidence comes from a meta-analysis of 15 randomized controlled trials in cancer patients receiving anticoagulation for VTE (PMID: 29363105.

Q4. Is there any data to support use of DOAC for immediate treatment in cancer patients with DVT, as traditionally UFH or LMWH were considered only options?

A4. Yes!! Data is there. 

DATA

[1] Apixaban Vs LMWH (dalteparin) in a RCT CARAVAGGIO trial showed similar efficacy and bleeding rates.

[2] Rivaroxaban vs LMWH (dalteparin) in pilot sudy (n = 406) SELECT-D showed similar efficacy but increased non major bleeding in patients with GI cancer with rivaroxaban

Treatment approach Immediate anticoagulation (1-3 weeks) followed by continued anticoagulation (3-6 m)

In above points we talked about Immediate anticoagulation.

Now for continued Anticoagulation >> Continued use of the DOAC (apixaban or rivaroxaban) or LMW heparin can be done!!

5. Why not the cheaper warfarin?

A5.

[1] Drug interactions, malnutrition and liver dysfunction can lead to wide fluctuations in INR.

[2] RCTs (CLOT trial) and meta-analyses have shown superior efficacy of LMWH in patients with VTE in patients with active cancer (vs warfarin).

NOTE >> For patients with renal insufficiency (eg, crcl <30 mL/min), in whom LMWH (and fondaparinux) is contraindicated and DOACs have not been investigated, IV UFH is preferred, although some experts administer renally dosed enoxaparin with monitoring of antifactor Xa levels.

Q6. What about Platelet cutoffs for these drugs?

A6.

1. Platelet >50,000/microL is not a contraindication

2. Platelet <20,000/microL is a contraindication.

3. Platelet 20,000 – 50,000/microL, the decision to anticoagulant should be individualized and based upon the risk assessment

Q7. How will you administer enoxaparin?

A7. 1.5 mg/kg SC once daily or 1 mg/kg SC twice daily (up to 3-6 months). If you want to start oral ie DOAC after 1-3 weeks, then start apixaban or rivaroxaban at continued anticoagulation doses only after a minimum of 7 days of enoxaparin.

NOTE: Renally dosed enoxaparin (to be given when crcl <30 ml/min) – 1 mg/kg SC OD [ideally with monitoring of antifactor Xa Levels]

Q8. How will you administer dalteparin (LMWH) ?

A8. 200 international units IU/kg daily during month 1, then 150 IU/kg daily for months 2 to 6

Q9. What is dose for Rivaroxaban when it is started form 1st day?

A9. Rivaroxaban dose > Immediate anticoagulation by 15 mg twice daily for three weeks, then for continued anticoagulation with 20 mg once daily for (3-6 months).

Q10. What is dose for Apixaban when it is started form 1st day ?
 
A10. Apixaban dose > Immidiate Anticoagulation by 10 mg BD X 7 days followed by continued anticoagulation by 5 mg BD X (3-6 months).
 
NOTE: Apixaban renal dosing: 5 mg BD dose can be reduced to 2.5 mg orally BD if at least one criterion is met: serum creatinine 1.5 mg per dL or more, age 80 years or older, or weight 60 kg or less.
 
Note: Apixaban renal dosing mentioned above is based on trials for risk reduction of stroke and systemic embolism in patients with nonvalvular atrial fibrillation and not on patients with DVT and cancer.
 
Q11. What if there is recurrent VTE with ongoing Anticoagulation?
 
A11. ISTH guidelines (Practice Point – Not based on RCT/Trail Evidence) If on LMWH > Dose increase by 25% of current dose. If on DOAC then switch to LMWH.
 
This article is simplified and basic. For more details, readers are requested to refer to quoted articles.

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