The use of DOACs in cancer patients with VTE

Assessing the pros and cons of the treatment option

At the 63rd Annual Meeting of the Society for Thrombosis and Haemostasis Research, Florian Langer, Hamburg, and Martin Grünewald discussed the pros and cons of using DOACs in tumor-associated VTE.

The use of direct oral anticoagulants (DOACs) in tumor-associated venous thromboembolism (VTE) is currently the subject of heated debate. The guidelines still recommend a different approach for cancer patients with VTE compared to non-tumor patients. In the former, low molecular weight heparins (NMHs) are given as standard in the first three to six months, but there is increasing evidence that DOACs could also be an option for this patient group in the first treatment phase. 

The use of NMHs is limited. On the one hand, according to study results, complications frequently occur even with a guideline-compliant application; on the other hand, treatment with NMHs more frequently leads to therapy discontinuations. A European study showed an abortion rate of 21 percent in the first six months. The main reason for this is the subcutaneous method of application, which is stressful for patients and can be accompanied by pain, hematomas and allergic reactions. The acceptance of oral anticoagulants, on the other hand, is significantly higher and shows lower abort rates. This also applies to vitamin K antagonists (VKA). Therapy persistence is therefore likely to increase with the administration of DOACs, which may be particularly important with the longer therapy durations recommended according to the guidelines.

However, against the background of an increased risk of bleeding when DOACs are used, a precise assessment of risk and benefit should be made. Cancer-associated thrombosis (CAT) - Patients with a low risk of bleeding and stable tumor disease are more likely to be treated with Edoxaban or Rivaroxaban, whereas NOACs should only be used to a limited extent if the risk of bleeding is expected to be high. However, a tendency to decrease recurrent VTE was observed with Edoxaban or Rivaroxaban, while the statistically significantly increased risk of bleeding in most cases was limited to mucosal bleeding and remained manageable.

Further potential risk factors for the use of DOACs in tumor-associated VTE are:

Edoxaban and rivaroxaban can be regarded as evidence-based oral therapy alternatives in the therapy of tumor-associated VTE, which are comparable to NMH in efficacy and safety, but which contribute to greater therapy persistence through oral administration.

It cannot be assumed that the choice of the appropriate therapy will in future be an "either-or decision". Rather, an initial therapy with NMH, followed by DOACs, may become established in stable tumor diseases with a low risk of complications and a high significance of quality of life, while a change from DOACs to NMH may become necessary in the presence of bleeding complications or other of the risk factors mentioned above.

Source:
DOACs in cancer patients with venous thromboembolism: pros and cons, GTH19, 27.02.2019

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