Treatment of cancer-associated venous thromboembolism in the age of direct oral anticoagulants
Cette étude passe en revue les recommandations et les essais récents concernant la prise en charge de patients atteints d'une thromboembolie veineuse associée aux traitements anticancéreux
Anticoagulation for cancer-associated venous thromboembolism (VTE) can be challenging due to complications—including bleeding and potential drug-drug interactions with chemotherapy—associated with vitamin K antagonists and inconvenience of low-molecular-weight heparin (LMWH). Direct oral anticoagulants (DOACs) could partially overcome these issues, but until recently there were no large clinical trials assessing their efficacy and safety in cancer patients.This review summarizes clinical treatment guidelines, prior clinical and real-world evidence for anticoagulant choice, recent clinical trials assessing DOACs for cancer-associated VTE (ie, Hokusai-VTE Cancer, SELECT-D, CARAVAGGIO, and ADAM VTE), and special considerations for DOAC use.Based on established data, clinical guidelines recommend patients with cancer-associated VTE receive LMWH treatment for at least 3–6 months. Nevertheless, LMWH is underused and associated with poor compliance and persistence in these patients relative to oral anticoagulants. Clinical data supporting DOAC use in cancer patients are becoming available. In Hokusai-VTE Cancer, edoxaban was noninferior to dalteparin for the composite of recurrent VTE and major bleeding (12.8% vs 13.5%), with numerically lower recurrent VTE (7.9% vs 11.3%) and significantly higher major bleeding (6.9% vs 4.0%); only patients with gastrointestinal cancer had significantly higher risk of bleeding with edoxaban. In SELECT-D, rivaroxaban had numerically lower VTE recurrence (4% vs 11%), comparable major bleeding (6% vs 4%), and numerically higher clinically relevant nonmajor bleeding (13% vs 4%) vs dalteparin. Most bleeding events were gastrointestinal or urologic; patients with esophageal/gastroesophageal cancer had higher rates of major bleeding with rivaroxaban (36% vs 11%). For comparison of apixaban vs dalteparin, CARAVAGGIO is ongoing, and preliminary results from ADAM VTE are favorable.DOACs appear to be reasonable alternatives to LMWH for treatment of cancer-associated VTE. In patients with gastrointestinal cancer, DOAC use should be considered on a case-by-case basis with consideration of the relative risks and benefits.