Clot Chronicles: Treating VTE in Cancer

Hello, I’m Dr. Sam Goldhaber, President of NATF, and I’m talking with you today on Clot Chronicles about new strategies for treating acute pulmonary embolism (PE) or acute deep vein thrombosis (DVT) in patients with cancer. 

Traditionally, based on a study published in the New England Journalmore than 15 years ago, cancer patients who develop PE or DVT have been treated with injectable low-molecular-weight heparin (LMWH; either enoxaparin or dalteparin, trade names Lovenox or Fragmin), rather than with traditional warfarin or other oral anticoagulants. Over time, particularly since the novel oral anticoagulants have been introduced in 2010, there have been increasing questions about whether we can stop using LMWH injections and switch to oral anticoagulants, particularly these new anticoagulants. In that original study more than 15 years ago, warfarin was not shown to be that effective in actually preventing recurrent PE or DVT, even when the INR was in the desired target therapeutic range between 2.0 and 3.0. But now, this is all being reexamined in the era of direct oral anticoagulants (DOACs). 

I’m pleased to tell you that three randomized controlled trials have been done: one with edoxaban versus LMWH, a second with rivaroxaban versus LMWH, and the third with apixaban versus LMWH. These trials really came up with the same message: it’s now quite acceptable to stop using LMWH for many types of cancer patients with PE and DVT and to use the DOACs instead. The one exception is in patients with cancers of the GI tract; they should probably stick with LMWH. In the edoxaban and rivaroxaban studies, there was a significantly higher rate of GI bleeding with the DOAC compared with LMWH. However, in all three trials, the DOAC was considerably more effective in preventing recurrent PE or recurrent DVT than the LMWH.

So, the bottom line is that if you, a family member, or a friend has cancer and is then stricken with a PE or DVT, the doctor managing the PE or DVT should be asked whether it’s appropriate to prescribe a DOAC over LMWH since the DOACs have been shown in clinical trials to have more benefits than risks. Furthermore, the cancer guideline societies and the hematology guideline society are endorsing the transition from LMWH as monotherapy and are considering the use of DOACs. 

This is Dr. Sam Goldhaber signing off for Clot Chronicles.