2019 ITAC guidelines for treatment and prophylaxis of VTE in patients with cancer

Takeaway

• The 2019 updated guidelines from the International Initiative on Thrombosis and Cancer (ITAC) provide practical and accessible recommendations for the treatment and prophylaxis of cancer-associated venous thromboembolism (VTE).

Key highlights

Treatment of established VTE

Initial treatment

• Low-molecular-weight heparin (LMWH) is recommended when creatinine clearance (CrCL) is ≥30 mL/min.
• Alternatively, use rivaroxaban or edoxaban if gastrointestinal (GI) or genitourinary bleeding risk is not high.
• If LMWH or direct-acting oral anticoagulants (DOACs) are contraindicated or unavailable, consider unfractionated heparin (UFH) or fondaparinux.
• Consider inferior vena cava (IVC) filters if anticoagulants are contraindicated or there is recurrence under optimal anticoagulation.

Early maintenance and long-term therapy

• LMWHs are preferred over vitamin K antagonists (VKAs) when CrCL is ≥30 mL/min.
• DOACs are recommended when CrCL is ≥30 mL/min and in the absence of strong drug-drug interaction or impaired GI absorption. Caution is recommended for GI malignancies.
• Use LMWH or DOACs for at least 6 months.
• After 6 months, the decision regarding therapy should be made based on benefit-risk ratio, tolerability, drug availability, patient preference and cancer activity.

VTE recurrence under anticoagulation

1. Increase LMWH by 20-25% or switch to DOACs.
2. For DOACs, switch to LMWH.
3. For VKAs, switch to LMWH or DOACs.

Catheter-related thrombosis

• Anticoagulation is recommended for at least 3 months and as long as the central venous catheter is in place.

Prophylaxis of VTE

Post cancer surgery

• LMWH or low-dose UFH is recommended; to be started 2-12 hours preoperatively and continued for at least 7-10 days.
• Use LMWH at its highest prophylactic dose.
• Use of fondaparinux as an alternative to LMWH has insufficient evidence.
• Extended prophylaxis (4 weeks) with LMWH is recommended after major laparotomy or laparoscopic surgery in patients with high VTE risk and low bleeding risk.
• Mechanical methods alone are not routinely recommended except when pharmacological methods are contraindicated.
• IVC filters are not routinely recommended.

Patients with medical cancer

• Prophylaxis with LMWH or fondaparinux is recommended when CrCL is ≥30 mL/min, or with UFH in hospitalised patients with reduced mobility.
• Primary prophylaxis is not routinely recommended in ambulatory patients receiving systemic anticancer treatments; however:
  • For locally advanced or metastatic pancreatic cancer and low bleeding risk: LMWH is recommended.
  • For locally advanced or metastatic lung cancer and low bleeding risk: routine prophylaxis is not recommended outside trial settings.
  • For those with an intermediate-to-high risk of VTE, but no active bleeding or high bleeding risk: rivaroxaban or apixaban is recommended.
• Primary prophylaxis is recommended for patients treated with immunotherapy in combination with steroids or other systemic therapies.

Catheter-related thrombosis

• Anticoagulation is not routinely recommended for prophylaxis.

Special situations

Brain tumours

• LMWH or DOACs are recommended for treating established VTE.
• For those undergoing neurosurgery: Start LMWH or UFH postoperatively for prophylaxis.
• For those not undergoing neurosurgery: routine prophylaxis is not recommended.

Severe renal failure (CrCl <30 mL/min)

• UFH followed by early VKAs or LMWH adjusted to anti-Xa level is recommended for the treatment of VTE.
• Application of an external compression device and pharmacological prophylaxis could be considered on a case-by-case basis.
• Use UFH for prophylaxis on a case-by-case basis.

Thrombocytopenia

• Platelet count (PC) >50 G/L and no evidence of bleeding: Use full anticoagulant doses for VTE treatment.
• PC <50 G/L: Decide treatment and dosage on a case-by-case basis with utmost caution.
• PC >80 G/L: Use prophylaxis.
• PC <80 G/L: Consider prophylaxis on a case-by-case basis and with monitoring.

Pregnancy

• LMWH is recommended for treatment and prophylaxis of VTE. Avoid VKAs and DOACs.

Obesity

• Consider a higher dose of LMWH for cancer surgery.