BACKGROUND AND OBJECTIVES: Venous thromboembolism (VTE) is commonly encountered in the daily clinical practice. Cancer is an important VTE risk factor. Proper thromboprophylaxis is key to prevent VTE in patients with cancer, and proper treatment is essential to reduce VTE complications and adverse events associated with the therapy.
DESIGN AND SETTINGS: As a result of an initiative of the Ministry of Health of Saudi Arabia, an expert panel led by the Saudi Association for Venous Thrombo-Embolism (a subsidiary of the Saudi Thoracic Society) and the Saudi Scientific Hematology Society with the methodological support of the McMaster University working group produced this clinical practice guideline to assist health care providers in evidence-based clinical decision-making for VTE prophylaxis and treatment in patients with cancer.
METHODS: Six questions related to thromboprophylaxis and antithrombotic therapy were identified and the corresponding recommendations were made following the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.
RESULTS: Question 1. Should heparin versus no heparin be used in outpatients with cancer who have no other therapeutic or prophylactic indication for anticoagulation?
RECOMMENDATION: For outpatients with cancer, the Saudi Expert Panel suggests against routine thromboprophylaxis with heparin (weak recommendation; moderate quality evidence).Question 2. Should oral anticoagulation versus no oral anticoagulation be used in outpatients with cancer who have no other therapeutic or prophylactic indication for anticoagulation?
RECOMMENDATION: For outpatients with cancer, the Saudi Expert Panel recommends against thromboprophylaxis with oral anticoagulation (strong recommendation; moderate quality evidence).Question 3. Should parenteral anticoagulation versus no anticoagulation be used in patients with cancer and central venous catheters?
RECOMMENDATION: For outpatients with cancer and central venous catheters, the Saudi Expert Panel suggests thromboprophylaxis with parenteral anticoagulation (weak recommendation; moderate quality evidence).Question 4. Should oral anticoagulation versus no anticoagulation be used in patients with cancer and central venous catheters?
RECOMMENDATION: For outpatients with cancer and central venous catheters, the Saudi Expert Panel suggests against thromboprophylaxis with oral anticoagulation (weak recommendation; low quality evidence).Question 5. Should low-molecular-weight heparin versus unfractionated heparin be used in patients with cancer being initiated on treatment for venous thromboembolism?
RECOMMENDATION: In patients with cancer being initiated on treatment for venous thromboembolism, the Saudi Expert Panel suggests low-molecular-weight heparin over intravenous unfractionated heparin (weak; very low quality evidence).Question 6. Should heparin versus oral anticoagulation be used in patients with cancer requiring long-term treatment of VTE?
RECOMMENDATION: In patients with metastatic cancer requiring long-term treatment of VTE, the Saudi Expert Panel recommends low-molecular-weight heparin (LMWH) over vitamin K antagonists (VKAs) (strong recommendation; moderate quality evidence). In patients with non-metastatic cancer requiring long-term treatment of venous thromboembolism, the Saudi Expert Panel suggests LMWH over VKA (weak recommendation; moderate quality evidence).
INTRODUCTION: avantages et les inconvénients relatifs des anticoagulants sont nécessaires pour les décisions concernant l'anticoagulation appropriée chez les patients atteints de cancer.
OBJECTIFS: Examiner les avantages et les inconvénients des anticoagulants pour des indications d'amélioration prophylactiques, thérapeutiques et de survie chez les patients atteints de cancer.
Patients et méthodes: Vue d'ensemble de 6 recensions systématiques de l'anticoagulation dans le cancer de la suite de la Cochrane Collaboration et classement des recommandations d'évaluation, de développement et d'évaluation méthodologie.
RÉSULTATS: Central veineuse cathéters thromboprophylaxie avec de l'héparine ou la warfarine ne réduit pas significativement l'incidence de la thrombose veineuse profonde symptomatique (TVP) (risque relatif [RR] 0,43, IC 95% 0,18 à 1,06 et RR = 0,62, IC 95% de 0,30 à 1,27 respectivement) . Pour la thromboprophylaxie périopératoire, à faible poids moléculaire héparine (HBPM) et l'héparine non fractionnée (HNF) ont des effets similaires sur la mortalité (RR 0,89, IC 95% 0,61 à 1,28) et la morbidité. Pour le traitement initial de la maladie thromboembolique veineuse (MTEV), les HBPM par rapport à l'héparine non fractionnée réduit la mortalité à 3 mois (RR 0,71, IC 95% de 0,52 à 0,98). Pour le traitement à long terme de la TEV, les HBPM par rapport à des antagonistes de la vitamine K réduit la récurrence de TEV (hazard ratio [HR] 0,47, IC 95% de 0,32 à 0,71), mais pas la mortalité (HR 0,96, IC 95% 0,81 à 1,14). Comme les interventions visant à améliorer la survie, la warfarine suggère un bénéfice de survie à 6 mois dans le sous-groupe de cancer du poumon à petites cellules (SCLC) (RR = 0,69, IC 95% de 0,50 à 0,96), tandis que l'héparine suggèrent un bénéfice de survie chez les patients atteints de cancer en général (RH 0,77, IC 95% 0,65 à 0,91) et chez ceux ayant limité CPPC en particulier (HR 0,56, IC 95% 0,38 au 0,83).
CONCLUSIONS: Chez les patients atteints de cancer, les données actuelles ne supporte pas l'utilisation systématique de la thromboprophylaxie pour les cathéters veineux centraux ou un anticoagulant spécifique pour la thromboprophylaxie postopératoire. Anticoagulants peut améliorer la survie, mais davantage de données seront utiles dans le choix des sous-groupes qui bénéficient le plus.
Venous thromboembolism (VTE) is commonly encountered in the daily clinical practice. Cancer is an important VTE risk factor. Proper thromboprophylaxis is key to prevent VTE in patients with cancer, and proper treatment is essential to reduce VTE complications and adverse events associated with the therapy.
DESIGN AND SETTINGS:
As a result of an initiative of the Ministry of Health of Saudi Arabia, an expert panel led by the Saudi Association for Venous Thrombo-Embolism (a subsidiary of the Saudi Thoracic Society) and the Saudi Scientific Hematology Society with the methodological support of the McMaster University working group produced this clinical practice guideline to assist health care providers in evidence-based clinical decision-making for VTE prophylaxis and treatment in patients with cancer.
METHODS:
Six questions related to thromboprophylaxis and antithrombotic therapy were identified and the corresponding recommendations were made following the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.
RESULTS:
Question 1. Should heparin versus no heparin be used in outpatients with cancer who have no other therapeutic or prophylactic indication for anticoagulation?
RECOMMENDATION:
For outpatients with cancer, the Saudi Expert Panel suggests against routine thromboprophylaxis with heparin (weak recommendation; moderate quality evidence).Question 2. Should oral anticoagulation versus no oral anticoagulation be used in outpatients with cancer who have no other therapeutic or prophylactic indication for anticoagulation?
RECOMMENDATION:
For outpatients with cancer, the Saudi Expert Panel recommends against thromboprophylaxis with oral anticoagulation (strong recommendation; moderate quality evidence).Question 3. Should parenteral anticoagulation versus no anticoagulation be used in patients with cancer and central venous catheters?
RECOMMENDATION:
For outpatients with cancer and central venous catheters, the Saudi Expert Panel suggests thromboprophylaxis with parenteral anticoagulation (weak recommendation; moderate quality evidence).Question 4. Should oral anticoagulation versus no anticoagulation be used in patients with cancer and central venous catheters?
RECOMMENDATION:
For outpatients with cancer and central venous catheters, the Saudi Expert Panel suggests against thromboprophylaxis with oral anticoagulation (weak recommendation; low quality evidence).Question 5. Should low-molecular-weight heparin versus unfractionated heparin be used in patients with cancer being initiated on treatment for venous thromboembolism?
RECOMMENDATION:
In patients with cancer being initiated on treatment for venous thromboembolism, the Saudi Expert Panel suggests low-molecular-weight heparin over intravenous unfractionated heparin (weak; very low quality evidence).Question 6. Should heparin versus oral anticoagulation be used in patients with cancer requiring long-term treatment of VTE?
RECOMMENDATION:
In patients with metastatic cancer requiring long-term treatment of VTE, the Saudi Expert Panel recommends low-molecular-weight heparin (LMWH) over vitamin K antagonists (VKAs) (strong recommendation; moderate quality evidence). In patients with non-metastatic cancer requiring long-term treatment of venous thromboembolism, the Saudi Expert Panel suggests LMWH over VKA (weak recommendation; moderate quality evidence).
