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

  • Farge D & al.
  • Lancet Oncol
  • 1 Oct 2019

  • curated by Pavankumar Kamat
  • UK Clinical Digest
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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

  • 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
  • PC >80 G/L: Use prophylaxis.
  • PC

Pregnancy

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

Obesity

  • Consider a higher dose of LMWH for cancer surgery.