Department of Pharmacy Practice, University of Connecticut School of Pharmacy, Storrs, CT.
Evidence-Based Practice Center, Hartford Hospital, Hartford, CT.
Blood Adv. 2020 Sep 8;4(17):4045-4051. doi: 10.1182/bloodadvances.2020002242.
Guidelines provide differing recommendations regarding direct-acting oral anticoagulants vs low-molecular-weight heparin (LMWH) for treatment of cancer-associated thrombosis (CAT). This study was undertaken to evaluate the effectiveness and safety of rivaroxaban vs LMWH for treatment of CAT. Using US Surveillance, Epidemiology and End Results-Medicare-linked data from 2013 through 2016, we evaluated adults with active breast, lung, ovarian, or pancreatic cancer, who were admitted to the hospital or treated in the emergency department for CAT and were prescribed rivaroxaban or LMWH for outpatient anticoagulation. Patients with luminal gastrointestinal or genitourinary cancers were excluded. Rivaroxaban and LMWH users were 1:1 propensity score matched. Outcomes included the composite of recurrent thrombosis or major bleeding, each outcome separately, and mortality at 6 months, using an intent-to-treat approach. On-treatment analysis after 12 months was also performed. Proportional hazards models for the subdistribution of competing risk were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs). We included 529 rivaroxaban- and 529 LMWH-treated patients with CAT. Rivaroxaban was not associated with differences in risk of the composite outcome (HR, 0.71; 95% CI, 0.41-1.22), major bleeding (HR, 1.01; 95% CI, 0.50-2.01), or mortality (HR, 0.87; 95% CI, 0.70-1.07) vs LMWH, but it reduced recurrent thrombosis (HR, 0.37; 95% CI, 0.15-0.95). On-treatment analysis at 12 months showed similar results. Rivaroxaban may be a reasonable alternative to LMWH for patients with CAT without gastrointestinal or genitourinary cancer.
指南对癌症相关血栓形成（CAT）的直接作用口服抗凝剂与低分子量肝素（LMWH）的治疗提供了不同的建议。本研究旨在评估利伐沙班与 LMWH 治疗 CAT 的有效性和安全性。使用 2013 年至 2016 年美国监测、流行病学和最终结果-医疗保险相关数据，我们评估了患有活动性乳腺癌、肺癌、卵巢癌或胰腺癌的成年人，他们因 CAT 住院或在急诊科接受治疗，并开处利伐沙班或 LMWH 进行门诊抗凝治疗。排除 luminal 胃肠道或泌尿生殖系统癌症患者。将利伐沙班组和 LMWH 组患者按照 1:1 倾向评分匹配。采用意向治疗方法，主要结局为复发性血栓形成或大出血复合结局，分别评估每个结局，以及 6 个月时的死亡率。还进行了治疗后 12 个月的分析。采用竞争风险亚分布比例风险模型估计风险比（HR）及其 95%置信区间（CI）。我们纳入了 529 例利伐沙班和 529 例 LMWH 治疗的 CAT 患者。与 LMWH 相比，利伐沙班与复合结局（HR，0.71；95%CI，0.41-1.22）、大出血（HR，1.01；95%CI，0.50-2.01）或死亡率（HR，0.87；95%CI，0.70-1.07）风险无差异，但降低了复发性血栓形成风险（HR，0.37；95%CI，0.15-0.95）。治疗后 12 个月的分析结果相似。对于没有胃肠道或泌尿生殖系统癌症的 CAT 患者，利伐沙班可能是 LMWH 的合理替代选择。
