-
Critical dz, requiring emergent tx (PE w/ hemodynamic instability or RV dysfxn; limb-threatening DVT)
Give thrombolytic tx in pts w/ hemodynamic instability & select others - If hemodynamically unstable w/ PE & not high risk for bleeding:1,2 Give initial thrombolytic tx, followed by anticoagulation; systemic thrombolytic preferred, little data for cath-directed thrombolysis (CDT)3,4
- Consider cath-assisted thrombus removal in unstable pts w/ any of: high bleed risk; failed systemic thrombolysis; or shock likely to cause death before onset of systemic thrombolytic2
- May consider thrombolysis for pts w/ limb-threatening DVT (phlegmasia cerulea dolens), per ASH; consider cath-directed tx (CDT) over systemic thrombolysis
- If hemodynamically stable w/ PE, but (+) signs of RV dysfxn (via echo, biomarkers): Consider anticoagulation alone w/o thrombolysis; monitor closely for decompensation,5 start thrombolytic if hypotension develops2,6
- If thrombolytics & anticoagulants contraindicated, may consider IVC filter;2 per ASH, use retrievable IVC filter, remove as soon as the pt is able to receive anticoagulation
- After initial thrombolysis, anticoagulate w/ IV UFH
Footnotes 1 ACCP 2016. Pts w/ higher bleeding risk w/ access to CDT expertise/resources may favor CDT; in pts w/ PE & hypotension, CDT preferred over no thrombolysis if high bleeding risk, failed systemic thrombolysis, or shock that’s likely to become fatal before onset of systemic thrombolysis.
Kearon C, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. CHEST. 2016. Feb;149:(2)315-352. Free full-text article online
2 ACCP 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021. Aug 2;S0012-3692(21)01506-3. PubMed® abstract
3 ACCP 2016. Cardiopulmonary deterioration (sx, VS, tissue perfusion, gas exchange, biomarkers) that has not progressed to hypotension may alter risk-benefit in favor of thrombolysis in pts initially treated w/ anticoagulation alone.
4 ASH 2020. Risk factors for bleeding w/, and contraindications to use of, thrombolytic tx:
• Major contraindications: Structural intracranial dz; previous intracranial hemorrhage; ischemic stroke <3mo prior; active bleeding, recent brain or spinal surgery; recent head trauma w/ fracture or brain injury; bleeding diathesis
• Relative contraindications: SBP >180; DBP >110; recent bleeding (non-intracranial); recent surgery or invasive procedure; ischemic stroke >3mo prior; anticoagulated (eg, VKA therapy); traumatic CPR; pericarditis or pericardial fluid; diabetic retinopathy; pregnancy; age >75 yo; low body wt (eg, wt <60 kg); female; Black race*
*epocrates note: Recent concern has been raised about possible introduction of bias & disparities of care when race is used as a risk adjustment factor.
Ortel TL, et al. et al. American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism. Blood Adv. 2020. Oct 13;4(19):4693-4738. Free full-text PDF @ PubMed® Central
5 ASH 2020. CDT may be an option, esp in pts w/ intermediate high risk of bleeding, as total dose & duration of thrombolytic is lower than systemic tx.
6 ASH 2020. Thrombolysis reasonable in younger pts w/ low bleeding risk, or in pts w/ high risk of decompensation.
Ongoing tx after stabilization Transition to anticoagulation, DOACs favored in most pts - Consider DOACs over vit K antagonists (VKA) in most pts;1,2 in general, no DOAC preferred over another3
If pt w/ CA-assoc PE or DVT, suggested tx: Other clinical considerations: - Initiate shorter course (ASH: 3-6mo; ACCP: 3mo, ASCO: 6mo for CA pts) of anticoagulation for primary tx, regardless of provocation
- Offer extended-phase anticoagulation to pts w/ VTE and no transient provocation; DOAC pref’d over VKA (consider reduced-dose apixaban or rivaroxaban7
- If pt w/ stable ASCVD (no recent ACS or PCI) previously on aspirin for risk reduction: Consider suspending aspirin while on anticoagulant tx
- Don’t insert IVC filter in pts on anticoagulation tx, per ACCP
Footnotes 1 ASH 2020. DOAC may not be preferred over VKA if: CrCl<30 mL/min, mod-severe liver dz, antiphospholipid syndrome.
Ortel TL, et al. et al. American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism. Blood Adv. 2020. Oct 13;4(19):4693-4738. Free full-text PDF @ PubMed® Central
2 ACCP 2021. In pts w/ confirmed APS, ACCP suggests VKA (target INR 2.5) over DOACs.
Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021. Aug 2;S0012-3692(21)01506-3. PubMed® abstract
3 ASH 2020. Factors to consider when selecting DOAC: need for lead-in parenteral anticoagulation, qd vs bid dosing, out-of-pocket cost, renal fxn, other med interactions, underlying CA.
4 ACCP 2021. Edoxaban and rivaroxaban assoc w/ ↑risk of major bleed in pts w/ luminal GI malignancy. Apixaban or LMWH may be preferred in these pts.
5 ASCO 2023. For pts initiating tx w/ parenteral anticoagulation, LMWH preferred over UFH for first 5-10 days of anticoagulation for pts w/ CA & newly diagnosed VTE who don’t have severe renal impairment (defined as CrCl <30 mL/min).
Direct factor Xa inhibitors assoc w/ ↑ in clinically relevant nonmajor bleeding risk, esp in GI & GU malignancies. Caution w/ direct factor Xa inhibitors also warranted in other settings w/ high risk for mucosal bleeding.
If primary or metastatic CNS malignancies & established VTE, anticoagulate as for other pts w/ CA, although uncertainties remain about choice of agents & selection of pts most likely to benefit.
Initial anticoagulation may involve LMWH, UFH, fondaparinux, rivaroxaban, or apixaban.
For long-term anticoagulation, LMWH, edoxaban, rivaroxaban, or apixaban for at least 6mo are preferred over vit K antagonists (VKAs).
Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2023. Jun 1;41(16):3063-3071. Free full-text article online
6 ASH 2021. Of DOACs, only rivaroxaban & apixaban are approved for use as initial tx.
Use DOACs cautiously in pts w/ GI malignancies d/t bleeding risk.
UFH might be preferred over LMWH in pts w/ CrCl <30 mL/min; fondaparinux might be preferred over LMWH in pts w/ hx of HIT.
Lyman GH, et al. American Society of Hematology 2021 Guidelines for Management of Venous Thromboembolism: Prevention and Treatment in Patients With Cancer. Blood Adv. 2021. Feb 23;5(4):927-974. Free full-text PDF @ PubMed® Central
7 ACCP 2021. Reduced-dose: apixaban 2.5 mg bid or rivaroxaban 10 mg qd.
Reduced-dose DOAC recommended over aspirin, rivaroxaban is only DOAC directly c/w aspirin. -
First VTE/PE, awaiting initial mgmt Start short course of anticoagulation w/ DOACs for primary tx of DVT/PE before deciding on continued tx for secondary prevention - Consider home tx or early d/c for pts w/ uncomplicated DVT or PE at low risk for complications1,2
- Consider DOACs over vit K antagonists (VKA) in most pts;3-5 in general, no DOAC preferred over another6
- If unable to use DOACs, VKA+ initial heparin tx preferred over LMWH alone7
If pt w/ CA-assoc PE or DVT, suggested tx: Other clinical considerations: - If extensive DVT: Consider initial thrombolytic tx, followed by anticoagulation in select pts; consider cath-directed tx (CDT) over systemic thrombolysis
- If isolated, distal, leg DVT w/o severe sx or risk of extension:11 Consider serial imaging x2wk; anticoagulate if high-risk of extension or w/ any degree of extension2
- In pts w/ subsegmental PE + no DVT in legs: Consider clinical surveillance in those w/ low risk of recurrent VTE (anticoagulate if high risk for recurrence12 or pt w/ CA13)2
- Favor shorter course (3-6mo, per ASH, 3mo, per ACCP, 6mo, per ASCO for CA pts) of anticoagulation for primary tx, regardless of provocation, in most pts; evaluate at end of primary tx for need to continue tx as secondary prevention14,15
- If pt w/ stable ASCVD (no recent ACS or PCI) previously on aspirin for risk reduction: Consider suspending aspirin while on anticoagulant tx
- Compression stockings may help ↓edema & pain assoc w/ acute DVT, but unlikely to ↓risk of PTS
- Don’t insert IVC filter in pts on anticoagulation tx, per ACCP; per ASCO, don’t offer IVC filter to pts w/ established or chronic VTE (Dx >4wk prior), nor to pts w/ temp contraindications to anticoagulant tx d/t long-term harms
Footnotes 1 ASH 2020. Does not apply to pts w/ other conditions that would require hospitalization, have limited support at home, cannot afford meds or have a hx of poor adherence. Pts w/ high bleeding risk & those requiring IV analgesics may benefit from initial treatment in the hospital.
Clinical prediction scores, such as Pulmonary Embolism Severity Index (PESI) or simplified PESI may help select pts at lower risk. PESI calculator accessible through epocrates search.
Ortel TL, et al. et al. American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism. Blood Adv. 2020. Oct 13;4(19):4693-4738. Free full-text PDF @ PubMed® Central
2 ACCP 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021. Aug 2;S0012-3692(21)01506-3. PubMed® abstract
3 ACCP 2016. In pts w/ upper extremity DVT (axillary vein or more proximal), consider anticoagulation over thrombolysis. Pts w/ access to cath-directed thrombolysis who attach a high value to prevention of PTS & a lower value to complexity, cost & bleeding risk may opt for thrombolysis.
Kearon C, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. CHEST. 2016. Feb;149:(2)315-352. Free full-text article online
4 ASH 2020. DOAC may not be preferred over VKA if: CrCl<30 mL/min, mod-severe liver dz, antiphospholipid syndrome.
5 ASH 2020. Thrombolysis may be considered in younger pts w/ symptomatic DVT & low bleeding risk; such pts who value rapid resolution of sx, are averse to possibility of post-thrombotic syndrome (PTS), accept the added risk of bleeding may opt for thrombolysis.
6 ASH 2020. Factors to consider when selecting DOAC: need for lead-in parenteral anticoagulation, qd vs bid dosing, out-of-pocket cost, renal fxn, other med interactions, underlying CA.
7 ACCP 2016. Initial parenteral anticoagulation is given w/ dabigatran & edoxaban, overlapped w/ VKA. Parenteral anticoagulation not required before rivaroxaban & apixaban.
8 ACCP 2021. Edoxaban and rivaroxaban assoc w/ ↑risk of major bleed in pts w/ luminal GI malignancy. Apixaban or LMWH may be preferred in these pts.
9 ASCO 2023. Tx usually identical, whether VTE is symptomatic or incidental. However, tx of isolated subsegmental PE, or splanchnic or visceral vein thrombi dx incidentally should be offered tx on a case-by-case basis, considering potential benefits & risks of anticoagulation.
For pts initiating tx w/ parenteral anticoagulation, LMWH preferred over UFH for first 5-10 days of anticoagulation for pts w/ CA & newly diagnosed VTE who don’t have severe renal impairment (defined as CrCl <30 mL/min).
Direct factor Xa inhibitors assoc w/ ↑ in clinically relevant nonmajor bleeding risk, esp in GI & GU malignancies. Caution w/ direct factor Xa inhibitors also warranted in other settings w/ high risk for mucosal bleeding.
For pts w/ primary or metastatic CNS malignancies & established VTE, anticoagulation as described for other pts w/ CA should be offered, although uncertainties remain about choice of agents and selection of pts most likely to benefit.
Initial anticoagulation may involve LMWH, UFH, fondaparinux, rivaroxaban, or apixaban.
For long-term anticoagulation, LMWH, edoxaban, rivaroxaban, or apixaban for at least 6mo are preferred over vit K antagonists (VKAs).
IVC filters should not be offered to pts w/ established or chronic VTE (dx >4wk prior), nor to pts w/ temporary contraindications to anticoagulant tx d/t long-term harms.
Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2023. Jun 1;41(16):3063-3071. Free full-text article online
10 ASH 2021. Of DOACs, only rivaroxaban and apixaban are approved for use as initial tx.
Use DOACs cautiously in pts w/ GI malignancies d/t bleeding risk.
UFH might be preferred over LMWH in pts w/ CrCl <30 mL/min; fondaparinux might be preferred over LMWH in pts w/ hx of HIT.
For pts w/ visceral or splanchnic vein thrombus, primary tx or observation is suggested.
Lyman GH, et al. American Society of Hematology 2021 Guidelines for Management of Venous Thromboembolism: Prevention and Treatment in Patients With Cancer. Blood Adv. 2021. Feb 23;5(4):927-974. Free full-text PDF @ PubMed® Central
11 ACCP 2016.
Risk factors for thrombus extension:
• (+) D-dimer (particularly when markedly so, w/o alternative reason)
• extensive thrombosis (eg, >5 cm in length, involves multiple veins, >7 mm in max diameter)
• thrombosis is close to the proximal veins
• no reversible provoking factor for DVT
• active CA
• previous hx of VTE
• inpt status
12 ACCP 2016.
Risk factors for recurrence:
• pt hospitalized or has ↓mobility for another reason
• active CA (particularly if metastatic or on chemo-tx)
• no reversible risk factor for VTE, such as recent surgery
13 ASH 2021. For pts w/ incidental or subsegmental PE, primary tx w/ anticoagulation is suggested.
14 ACCP 2016. In pts w/ unprovoked 1st DVT or PE & low-mod bleeding risk, extended anticoagulant tx (no stop date) favored over 3-mo duration. Short course (3mo) is preferred in those w/ high bleeding risk.
15 ASH 2020. Could consider longer course (6-12mo) if improvement in a chronic risk factor is expected over time (eg, improved mobility w/ rehab). Completed primary tx of first VTE/PE Upon conclusion of primary tx, decide upon continued long-term anticoagulation for secondary prevention of recurrent VTE - If DVT or PE provoked by transient risk factor (eg, surgery), may d/c anticoagulation after primary tx (3-6mo, per ASH; 3mo, per ACCP)
- Consider extended (no stop date) anticoagulation in pts w/ either unprovoked DVT/PE, or VTE provoked by chronic risk factor, unless high risk of bleeding;1 DOAC preferred over VKA2
- In pts requiring continued secondary prevention, consider anticoagulants over aspirin, per ASH; per ACCP, if pt w/ unprovoked PE or proximal DVT stops anticoagulant, consider aspirin over no tx at all2
- Continue anticoagulation indefinitely in pts w/ CA-assoc DVT/PE, per ACCP3 & ASH;4 per ASCO, offer continued tx w/ LMWH, direct factor Xa inhibitor, or VKA beyond the initial 6mo to select pts w/ active CA (eg, those w/ metastatic dz or those receiving chemo-tx)5
- Prognostic scores, D-dimer, and US to visualize residual DVT not routine for pts w/ unprovoked VTE, but may be useful in select pts
- If pt on extended VKA, use INR 2.0-3.0; if on DOAC, consider continued standard dosing over lower dosing, per ASH,6 but ACCP suggests reduced-dose apixaban or rivaroxaban over standard dosing7
Footnotes 1 ASH 2020. Could consider longer course w/ end point (6-12mo) if improvement in a chronic risk factor is expected over time (eg, improved mobility w/ rehabilitation).
Ortel TL, et al. et al. American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism. Blood Adv. 2020. Oct 13;4(19):4693-4738. Free full-text PDF @ PubMed® Central
2 ACCP 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021. Aug 2;S0012-3692(21)01506-3. PubMed® abstract
3 ACCP 2016. As in all pts on extended anticoagulant tx, reassess continued tx regularly (eg, annually).
4 ASH 2021. DOAC or LMWH suggested in pts needing long-term/indefinite secondary prevention.
Long-term anticoagulation may be d/c’ed when pt no longer at high risk of VTEs or if pt enters last wks of life.
Lyman GH, et al. American Society of Hematology 2021 Guidelines for Management of Venous Thromboembolism: Prevention and Treatment in Patients With Cancer. Blood Adv. 2021. Feb 23;5(4):927-974. Free full-text PDF @ PubMed® Central
5 ASCO 2023. Anticoagulation beyond 6mo needs to be assessed on an intermittent basis to ensure continued favorable risk:benefit profile.
Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2023. Jun 1;41(16):3063-3071. Free full-text article online
6 ASH 2020. Lower-dose DOAC regimens that may be considered after conclusion of primary tx incl rivaroxaban 10 mg qd & apixaban 2.5 mg bid.
7 ACCP 2021. Reduced-dose: apixaban 2.5 mg bid or rivaroxaban 10 mg qd.
Reduced-dose DOAC recommended over aspirin, rivaroxaban is only DOAC directly c/w aspirin.
Recurrence usually warrants indefinite antithrombotic tx. Breakthrough VTE/PE on vit K antagonist (VKA) or DOAC is unusual, warrants additional eval - Consider home tx or early d/c for pts w/ uncomplicated DVT or PE at low risk for complications1,2
- For pts w/ breakthrough DVT/PE during therapeutic VKA or DOAC tx: Consider switching to LMWH (for at least 1mo, per ACCP); if INR control poor on VKA, switch to DOAC may be reasonable3
- For pts w/ breakthrough DVT/PE on long-term LMWH: Consider ↑dose4 (by 1/4 to 1/3, per ACCP)
- Recurrent VTE while on therapeutic anticoagulant tx is unusual, should prompt: (1) re-eval of whether there truly was recurrent VTE; (2) eval of compliance w/ anticoagulant tx; (3) consideration of underlying CA
- Additional considerations for pts w/ known CA:5 per ASCO, IVC filter should be last resort (no survival benefit and ↑long-term risk for VTE development); ASH also suggests not using IVC filter in pts w/ CA & recurrent VTE on anticoagulation
Footnotes 1 ASH 2020. Does not apply to pts w/ other conditions that would require hospitalization, have limited support at home, cannot afford meds or have a hx of poor adherence. Pts w/ a high risk for bleeding & those requiring IV analgesics may benefit from initial treatment in the hospital.
Clinical prediction scores, such as Pulmonary Embolism Severity Index (PESI) or simplified PESI may help select pts at lower risk. > PESI calculator accessible through epocrates search.
Ortel TL, et al. et al. American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism. Blood Adv. 2020. Oct 13;4(19):4693-4738. Free full-text PDF @ PubMed® Central
2 ACCP 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021. Aug 2;S0012-3692(21)01506-3. PubMed® abstract
3 ASH 2020. Factors to consider when selecting DOAC: need for lead-in parenteral anticoagulation, qd vs bid dosing, out-of-pocket cost, renal fxn, other med interactions, underlying CA.
4 ASCO 2019. Mgmt options incl txt w/ alternative anticoagulant regimen or ↑dose of LMWH.
Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2020. Feb 10;38(5):496-520. Free full-text article online
5 ASCO 2019. Assess for tx compliance, heparin-induced thrombocytopenia, evidence of mechanical compression resulting from malignancy.
Pt w/ recurrence after previous tx Treat w/ same anticoagulation options as initial VTE/PE, but consider extending tx indefinitely after 2nd event - Consider home tx or early d/c for pts w/ uncomplicated DVT or PE at low risk for complications1,2
- Consider DOACs over vit K antagonists (VKA) in most pts;3 no DOAC preferred over another;4 if unable to use DOACs, VKA + initial heparin tx preferred over LMWH alone5
If pt w/ CA- assoc PE or DVT, suggested tx: Other clinical considerations: - If extensive DVT: Consider initial thrombolytic tx, followed by anticoagulation; consider cath-directed tx (CDT) over systemic thrombolysis
- If recurrent unprovoked DVT/PE: Recommend indefinite anticoagulation
- If recurrent DVT/PE provoked by transient risk factor in pt w/ either previous unprovoked or chronic risk factor provoked VTE: Consider indefinite anticoagulation
- May consider stopping anticoagulation after primary tx (3-6mo, per ASH, 3mo, per ACCP) only in those w/ recurrent DVT/PE, provoked by transient risk factors
Footnotes 1 ASH 2020. Does not apply to pts w/ other conditions that would require hospitalization, have limited support at home, cannot afford medications or have a hx of poor adherence. Pts w/ high bleeding risk & those requiring IV analgesics may benefit from initial treatment in the hospital.
Clinical prediction scores, such as Pulmonary Embolism Severity Index (PESI) or simplified PESI may help select pts at lower risk. PESI calculator accessible through epocrates search.
Ortel TL, et al. et al. American Society of Hematology 2020 Guidelines for Management of Venous Thromboembolism: Treatment of Deep Vein Thrombosis and Pulmonary Embolism. Blood Adv. 2020. Oct 13;4(19):4693-4738. Free full-text PDF @ PubMed® Central
2 ACCP 2021. Stevens SM, et al. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021. Aug 2;S0012-3692(21)01506-3. PubMed® abstract
3 ASH 2020. DOAC may not be preferred over VKA if: CrCl<30 mL/min, mod-severe liver dz, antiphospholipid syndrome.
4 ASH 2020. Factors to consider when selecting DOAC: need for lead-in parenteral anticoagulation, qd vs bid dosing, out-of-pocket cost, renal fxn, other med interactions, underlying CA.
5 ACCP 2016. Initial parenteral anticoagulation is given w/ dabigatran & edoxaban, overlapped w/ VKA. Parenteral anticoagulation not required before rivaroxaban & apixaban.
Kearon C, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. CHEST. 2016. Feb;149:(2)315-352. Free full-text article online
6 ACCP 2021. Edoxaban and rivaroxaban assoc w/ ↑risk of major bleed in pts w/ luminal GI malignancy. Apixaban or LMWH may be preferred in these pts.
7 ASCO 2023. Tx usually identical, whether VTE is symptomatic or incidental. However, tx of isolated subsegmental PE, or splanchnic or visceral vein thrombi dx incidentally should be offered tx on a case-by-case basis, considering potential benefits & risks of anticoagulation.
For pts initiating tx w/ parenteral anticoagulation, LMWH preferred over UFH for first 5-10 days of anticoagulation for pts w/ CA & newly diagnosed VTE who don’t have severe renal impairment (defined as CrCl <30 mL/min).
Direct factor Xa inhibitors assoc w/ ↑ in clinically relevant nonmajor bleeding risk, esp in GI & GU malignancies. Caution w/ direct factor Xa inhibitors also warranted in other settings w/ high risk for mucosal bleeding.
For pts w/ primary or metastatic CNS malignancies & established VTE, anticoagulation as described for other pts w/ CA should be offered, although uncertainties remain about choice of agents & selection of pts most likely to benefit.
Initial anticoagulation may involve LMWH, UFH, fondaparinux, rivaroxaban, or apixaban.
For long-term anticoagulation, LMWH, edoxaban, rivaroxaban, or apixaban for at least 6mo are preferred over vit K antagonists (VKAs).
Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update. J Clin Oncol. 2023. Jun 1;41(16):3063-3071. Free full-text article online
8 ASH 2021. Of DOACs, only rivaroxaban & apixaban are approved for use as initial tx.
Use DOACs cautiously in pts w/ GI malignancies d/t bleeding risk.
UFH might be preferred over LMWH in pts w/ CrCl <30 mL/min; fondaparinux might be preferred over LMWH in pts w/ hx of HIT.
For pts w/ incidental or subsegmental PE, primary tx w/ anticoagulation is suggested; for those w/ visceral or splanchnic vein thrombus, primary tx or observation is suggested.
Lyman GH, et al. American Society of Hematology 2021 Guidelines for Management of Venous Thromboembolism: Prevention and Treatment in Patients With Cancer. Blood Adv. 2021. Feb 23;5(4):927-974. Free full-text PDF @ PubMed® Central
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