Based on the current guideline, treatment options for cancer-associated thrombosis include low molecular weight heparin (LMWH), unfractionated heparin (UFH), warfarin, and fondaparinux. However, in patients who do not have cancer, direct oral anticoagulants are preferred for the treatment of VTE. In some cases, the use of LMWH is limited due to administration by the subcutaneous route. In this study, we compared the efficacy and safety of oral anticoagulants including vitamin K antagonists (VKA) and direct-acting oral anticoagulants (DOAC) for the treatment of cancer-associated VTE.
We conducted a systematic literature review to identify all eligible randomized controlled trials (RCT) by searching PubMed, Web of Science, ASH, ASCO, EHA, and ESMO databases. The relative risks (RR) of recurrent VTE (efficacy) and major bleeding (safety) were analyzed using Bayesian network meta-analysis with a fixed-effect model.
Four DOACs (apixaban, dabigatran, edoxaban, rivaroxaban) were identified in five RCTs. When comparing the efficacy between VKA and DOACs, the recurrence rate of VTE was lower in the treatment with DOACs than with VKA, but not statistically significant. (apixaban: odds ratio [OR] 0.55, 95% credible intervals [CrI] 0.10-2.4; dabigatran: OR 0.76, 95% CrI 0.32-1.8; edoxaban: OR 0.49, 95% CrI 0.12-1.7; rivaroxaban OR 0.57, 95% CrI 0.19-1.7). In safety, the risk of major bleeding was relatively low in the use of DOACs compared to VKA, except for edoxaban (apixaban: OR 0.42, 95% CrI 0.058-2.2; dabigatran: OR 0.82, 95% CrI 0.25-2.7; edoxaban: OR 1.6, 95% CrI 0.38-8.4; rivaroxaban OR 0.47, 95% CrI 0.14-1.5).
For the treatment of VTE in cancer patients, DOAC has a favorable tendency for the efficacy and safety compared to VKA. DOACs could be one of the standard treatment options for management of VTE in cancer patients. Among DOACs, epixaban has a relatively good outcome.
Clinical trial identification
Legal entity responsible for the study
Has not received any funding.
All authors have declared no conflicts of interest.