Hirsh Jack
Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
Chest. 2007 Jan;131(1):275-7. doi: 10.1378/chest.06-2360.
Lenalidomide, an analog of thalidomide, is an effective new treatment for multiple myeloma. Both compounds are associated with an increased risk of venous thromboembolism, particularly when used in combination with high-dose dexamethasone. As new trials with lenalidomide are being planned and performed, investigators are placing high importance on reducing the risk of thrombosis by incorporating an antithrombotic agent into the therapeutic regimen. Low-molecular-weight heparin, warfarin, and aspirin have all been suggested as candidate drugs for thromboprophylaxis, but none of these agents have been evaluated in randomized clinical trials. A body of opinion has evolved that aspirin is very effective in preventing venous thrombosis in myeloma patients treated with lenalidomide. If correct, this view has important implications, because aspirin is inexpensive and is safer and more convenient than anticoagulants. On the other hand, aspirin is less effective than anticoagulants for preventing venous thrombosis in other high-risk groups, and therefore might not be the most appropriate choice for preventing of venous thrombosis in myeloma patients. This commentary examines the strength of the evidence supporting the effectiveness of aspirin in preventing venous thrombosis in multiple myeloma patients treated with lenalidomide. It is concluded that the evidence that aspirin is efficacious in preventing venous thrombosis in myeloma patients is based on "before/after" and retrospective studies, with potential for bias and confounders. There is, therefore, a critical need to incorporate a randomized comparison of aspirin with an anticoagulant in future trials evaluating lenalidomide in multiple myeloma.
来那度胺是沙利度胺的类似物，是一种治疗多发性骨髓瘤的有效新药。这两种化合物都与静脉血栓栓塞风险增加有关，尤其是在与大剂量地塞米松联合使用时。随着来那度胺新试验的规划和开展，研究人员高度重视通过在治疗方案中加入抗血栓药物来降低血栓形成风险。低分子量肝素、华法林和阿司匹林都被建议作为血栓预防的候选药物，但这些药物均未在随机临床试验中进行评估。有一种观点逐渐形成，即阿司匹林在预防接受来那度胺治疗的骨髓瘤患者静脉血栓形成方面非常有效。如果这一观点正确，将具有重要意义，因为阿司匹林价格低廉，且比抗凝剂更安全、更方便。另一方面，阿司匹林在预防其他高危人群静脉血栓形成方面不如抗凝剂有效，因此可能不是预防骨髓瘤患者静脉血栓形成的最合适选择。本评论探讨了支持阿司匹林在预防接受来那度胺治疗的多发性骨髓瘤患者静脉血栓形成有效性的证据力度。得出的结论是，阿司匹林在预防骨髓瘤患者静脉血栓形成方面有效的证据基于“前后”研究和回顾性研究，存在偏差和混杂因素的可能性。因此，在未来评估来那度胺治疗多发性骨髓瘤的试验中，迫切需要纳入阿司匹林与抗凝剂的随机对照研究。
