Department of Haematology, University Hospital Galway, Galway, Republic of Ireland.
Department of Haematology, Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom.
Br J Haematol. 2018 Nov;183(4):538-556. doi: 10.1111/bjh.15684. Epub 2018 Nov 18.
Multiple myeloma is associated with a significant risk of venous thromboembolism (VTE), causing substantial levels of morbidity and mortality. The thrombogenicity of myeloma is multifactorial, with disease- and treatment-related factors playing important roles. Immunomodulatory drugs (IMiDs) and high-dose dexamethasone, in particular, are known to enhance the thrombotic potential of myeloma. For this reason, assessment of the VTE risk has long been advocated prior to treatment initiation in patients with myeloma requiring IMiD-based regimens. However, despite routine use of thromboprophylaxis, these patients can still develop VTE and its sequelae. The optimum choice and dose of thromboprophylactic drug is not entirely clear, and with this, there is growing interest regarding use of the direct oral anticoagulants in this setting. In this review we discuss the pathogenesis of thrombosis in multiple myeloma, its relation to some of the commonly used chemotherapeutic regimens, current risk stratification and the evidence supporting the different anticoagulants used as thromboprophylaxis. We propose an amended risk stratification, and consider management of challenging patients, including those with renal impairment and recurrent thrombosis.
多发性骨髓瘤与静脉血栓栓塞症（VTE）的风险显著相关，导致大量的发病率和死亡率。骨髓瘤的血栓形成是多因素的，疾病和治疗相关因素起着重要作用。免疫调节药物（IMiDs）和高剂量地塞米松，特别是，已知会增强骨髓瘤的血栓形成潜力。出于这个原因，在需要基于 IMiD 方案的治疗之前，长期以来一直提倡对多发性骨髓瘤患者进行 VTE 风险评估。然而，尽管常规使用血栓预防措施，这些患者仍然可能发生 VTE 及其后遗症。最佳选择和剂量的血栓预防药物并不完全清楚，因此，对于在这种情况下使用直接口服抗凝剂的兴趣越来越大。在这篇综述中，我们讨论了多发性骨髓瘤血栓形成的发病机制，它与一些常用的化疗方案的关系，目前的风险分层以及支持用作血栓预防的不同抗凝剂的证据。我们提出了一种改良的风险分层，并考虑了具有挑战性的患者的管理，包括肾功能不全和复发性血栓形成的患者。
