Kirschner Martin, do Ó Hartmann Nicole, Parmentier Stefani, Hart Christina, Henze Larissa, Bisping Guido, Griesshammer Martin, Langer Florian, Pabinger-Fasching Ingrid, Matzdorff Axel, Riess Hanno, Koschmieder Steffen
Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074 Aachen, Germany.
Center for Integrated Oncology Aachen Bonn Cologne Düsseldorf (CIO ABCD), 52074 Aachen, Germany.
Cancers (Basel). 2021 Jun 10;13(12):2905. doi: 10.3390/cancers13122905.
Patients with cancer, both hematologic and solid malignancies, are at increased risk for thrombosis and thromboembolism. In addition to general risk factors such as immobility and major surgery, shared by non-cancer patients, cancer patients are exposed to specific thrombotic risk factors. These include, among other factors, cancer-induced hypercoagulation, and chemotherapy-mediated endothelial dysfunction as well as tumor-cell-derived microparticles. After an episode of thrombosis in a cancer patient, secondary thromboprophylaxis to prevent recurrent thromboembolism has long been established and is typically continued as long as the cancer is active or actively treated. On the other hand, primary prophylaxis, even though firmly established in hospitalized cancer patients, has only recently been studied in ambulatory patients. This recent change is mostly due to the emergence of direct oral anticoagulants (DOACs). DOACs have a shorter half-life than vitamin K antagonists (VKA), and they overcome the need for parenteral application, the latter of which is associated with low-molecular-weight heparins (LMWH) and can be difficult for the patient to endure in the long term. Here, first, we discuss the clinical trials of primary thromboprophylaxis in the population of cancer patients in general, including the use of VKA, LMWH, and DOACs, and the potential drug interactions with pre-existing medications that need to be taken into account. Second, we focus on special situations in cancer patients where primary prophylactic anticoagulation should be considered, including myeloma, major surgery, indwelling catheters, or immobilization, concomitant diseases such as renal insufficiency, liver disease, or thrombophilia, as well as situations with a high bleeding risk, particularly thrombocytopenia, and specific drugs that may require primary thromboprophylaxis. We provide a novel algorithm intended to aid specialists but also family practitioners and nurses who care for cancer patients in the decision process of primary thromboprophylaxis in the individual patient.
癌症患者，包括血液系统恶性肿瘤和实体恶性肿瘤患者，发生血栓形成和血栓栓塞的风险增加。除了非癌症患者共有的诸如活动减少和大手术等一般风险因素外，癌症患者还面临特定的血栓形成风险因素。这些因素包括癌症诱导的高凝状态、化疗介导的内皮功能障碍以及肿瘤细胞衍生的微粒等。在癌症患者发生血栓形成事件后，长期以来一直确立了二级血栓预防措施以防止复发性血栓栓塞，并且通常在癌症处于活动期或正在积极治疗期间持续进行。另一方面，一级预防虽然在住院癌症患者中已得到确证，但直到最近才在门诊患者中进行研究。这种最近的变化主要是由于直接口服抗凝剂（DOACs）的出现。DOACs的半衰期比维生素K拮抗剂（VKA）短，并且它们克服了肠外给药的需求，而肠外给药与低分子量肝素（LMWH）相关，患者长期难以耐受。在此，首先，我们讨论一般癌症患者人群中一级血栓预防的临床试验，包括VKA、LMWH和DOACs的使用，以及需要考虑的与现有药物的潜在药物相互作用。其次，我们关注癌症患者中应考虑一级预防性抗凝的特殊情况，包括骨髓瘤、大手术、留置导管或活动减少、诸如肾功能不全、肝病或血栓形成倾向等合并症，以及高出血风险情况，特别是血小板减少症，以及可能需要一级血栓预防的特定药物。我们提供了一种新颖的算法旨在帮助专科医生，也帮助照顾癌症患者的家庭医生和护士在个体患者的一级血栓预防决策过程中做出决策。
