Bazarbashi Shouki, El Zawahry Heba Mohamed, Owaidah Tarek, AlBader Mohammad A, Warsi Ashraf, Marashi Mahmoud, Dawoud Emad, Jaafar Hassan, Sholkamy Sherif M, Haddad Fady, Cohen Alexander T
Section of Medical Oncology, Oncology Center, King Faisal Specialist Hospital and Research Center, Alfaisal University, Riyadh, Saudi Arabia.
Department of Medical Oncology, The National Cancer Institute, Cairo University, Cairo, Egypt.
J Blood Med. 2024 Apr 25;15:171-189. doi: 10.2147/JBM.S411520. eCollection 2024.
Venous thromboembolism is a leading cause of morbidity and mortality in patients with active cancer who require anticoagulation treatment. Choice of anticoagulant is based on careful balancing of the risks and benefits of available classes of treatment: vitamin K antagonists, low-molecular-weight heparin (LMWH), and direct oral anticoagulants (DOACs). Results from randomized controlled trials have shown the consistent efficacy of DOACs versus LMWH in the treatment of cancer-associated venous thromboembolism (VTE). However, increased major gastrointestinal bleeding was observed for edoxaban and rivaroxaban, but not apixaban, compared with LMWH dalteparin. Most guidelines recommend DOACs for the treatment of cancer-associated VTE in patients without gastrointestinal or genitourinary cancer, and with considerations for renal impairment and drug-drug interactions. These updates represent a major paradigm shift for clinicians in the Middle East and North Africa. The decision to prescribe a DOAC for a patient with cancer is not always straightforward, particularly in challenging subgroups of patients with an increased risk of bleeding. In patients with gastrointestinal malignancies who are at high risk of major gastrointestinal bleeds, apixaban may be the preferred DOAC; however, caution should be exercised if patients have upper or unresected lower gastrointestinal tumors. In patients with gastrointestinal malignancies and upper or unresected lower gastrointestinal tumors, LMWH may be preferred. Vitamin K antagonists should be used only when DOACs and LMWH are unavailable or unsuitable. In this review, we discuss the overall evidence for DOACs in the treatment of cancer-associated VTE and provide treatment suggestions for challenging subgroups of patients with cancer associated VTE.
静脉血栓栓塞是需要抗凝治疗的活动性癌症患者发病和死亡的主要原因。抗凝剂的选择基于对现有治疗类别（维生素K拮抗剂、低分子肝素（LMWH）和直接口服抗凝剂（DOACs））风险和益处的仔细权衡。随机对照试验结果表明，DOACs与LMWH在治疗癌症相关静脉血栓栓塞（VTE）方面疗效一致。然而，与LMWH达肝素相比，依度沙班和利伐沙班的主要胃肠道出血有所增加，但阿哌沙班没有。大多数指南推荐DOACs用于治疗无胃肠道或泌尿生殖系统癌症、且需考虑肾功能损害和药物相互作用的癌症相关VTE患者。这些更新对中东和北非的临床医生来说是一个重大的范式转变。为癌症患者开具DOAC的决定并不总是简单直接的，特别是在出血风险增加的具有挑战性的亚组患者中。在有重大胃肠道出血高风险的胃肠道恶性肿瘤患者中，阿哌沙班可能是首选的DOAC；然而，如果患者有上消化道或未切除的下消化道肿瘤，则应谨慎使用。在患有胃肠道恶性肿瘤以及上消化道或未切除的下消化道肿瘤的患者中，LMWH可能是首选。只有在无法获得或不适合使用DOACs和LMWH时，才应使用维生素K拮抗剂。在本综述中，我们讨论了DOACs治疗癌症相关VTE的总体证据，并为具有挑战性的癌症相关VTE患者亚组提供治疗建议。
