Goldberg Idan, Spectre Galia, Raanani Pia, Cate Hugo Ten, Leader Avi
Institute of Hematology, Davidoff Cancer Centre, Rabin Medical Centre, Petah Tikva, Israel.
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Acta Haematol. 2025;148(4):477-493. doi: 10.1159/000542872. Epub 2024 Dec 11.
Managing cancer-associated thrombosis (CAT) is a significant clinical challenge due to several factors such as increased bleeding tendency, frailty, and drug-drug interactions. For many years, the drug of choice for treating CAT was low molecular weight heparin (LMWH). Recently, direct oral anticoagulants (DOACs) entered to the therapeutic milieu of CAT. However, due to the large diversity among patients with CAT in clinical and laboratory characteristics, not all patients will equally benefit from treatment with DOACs. Furthermore, several subgroups of patients with CAT have specific characteristics that influence the anticoagulant decision-making process.
In this review, we present four different theoretical clinical case scenarios, each representing a different challenge that is associated with thrombosis management; brain metastasis, malignancies of the gastrointestinal tract, drug-drug interactions (DDIs), and thrombocytopenia. By reviewing current literature, we suggest our clinical approach for managing these cases in the era of DOACs.
(1) The management of patients with brain tumors and CAT is challenging due to increased risk for both intracranial hemorrhage and recurrent venous thromboembolism. Both LMWH and DOACs are optional treatment in this setting. (2) There are conflicting data regarding the bleeding risk in patients with GI malignancies. Treatment with LMWH should be considered specifically in patients with advanced disease and unresectable tumors. (3) There is a paucity of data regarding DDI in patients with CAT. However, caution should be exercised when prescribing DOACs to patients receiving concurrent medications that either affect DOAC metabolism or influence bleeding risk. (4) The management of patients with CAT and thrombocytopenia depends on the severity of thrombocytopenia and the timing of the thrombotic event.
由于多种因素，如出血倾向增加、身体虚弱和药物相互作用，管理癌症相关血栓形成（CAT）是一项重大的临床挑战。多年来，治疗CAT的首选药物是低分子量肝素（LMWH）。最近，直接口服抗凝剂（DOACs）进入了CAT的治疗领域。然而，由于CAT患者在临床和实验室特征方面存在很大差异，并非所有患者都会从DOACs治疗中同样受益。此外，CAT患者的几个亚组具有影响抗凝决策过程的特定特征。
在本综述中，我们呈现了四种不同的理论临床病例场景，每种场景代表与血栓管理相关的不同挑战；脑转移、胃肠道恶性肿瘤、药物相互作用（DDIs）和血小板减少症。通过回顾当前文献，我们提出了在DOACs时代管理这些病例的临床方法。
（1）脑肿瘤和CAT患者的管理具有挑战性，因为颅内出血和复发性静脉血栓栓塞的风险增加。在这种情况下，LMWH和DOACs都是可选的治疗方法。（2）关于胃肠道恶性肿瘤患者出血风险的数据存在冲突。对于晚期疾病和不可切除肿瘤的患者，应特别考虑使用LMWH进行治疗。（3）关于CAT患者药物相互作用的数据很少。然而，在给正在接受影响DOAC代谢或影响出血风险的同时用药的患者开DOACs时应谨慎。（4）CAT和血小板减少症患者的管理取决于血小板减少症的严重程度和血栓形成事件的时间。
