National Comprehensive Cancer Network 2020
for patients without GI malignancies
Apixaban (category 1),
edoxaban after at least 5 days of parenteral anticoagulation (category 1),
rivaroxaban (category 2A) preferred over LMWH
in patients with GI malignancies
LMWH (dalteparin category 1)preferred over DOACs.
Dabigatran after at least 5 days of parenteral anticoagulation (alternative to apixaban, edoxaban, rivaroxaban, or LMWH if not appropriate or unavailable) (category 2A).
for patients with CrCl <30 mL/min.
UFH is an alternative to LMWH for initial therapy (category 2B)
Special recommendation
1_Fondaparinux is contraindicated in patients with CrCl <30 mL/min and should be used with caution with CrCl 30–50 mL/min.
2_Dabigatran, edoxaban, and rivaroxaban are contraindicated with CrCl <30 mL/min. Apixaban is contraindicated if CrCl <25 mL/min.
3_Apixaban and edoxaban are contraindicated in patients with clinically significant liver disease (total bilirubin >1.5 × ULN or transaminases >2 × ULN).
4_Dabigatran and rivaroxaban are contraindicated if transaminases >3 × ULN.
5_Apixaban and rivaroxaban should not be used in conjunction with strong inducers/inhibitors of CYP3A4 and P-glycoprotein.
6_Dabigatran and edoxaban should not be used in conjunction with strong inducers/inhibitors of P-glycoprotein.
7_Choice of anticoagulation regimen should be based on individual risk of thrombosis and bleeding, renal and hepatic function, inpatient/outpatient status, FDA approval status, ease of administration, cost, burden of laboratory monitoring, agent reversibility, and patient preferences.
8_Consider catheter-directed pharmacomechanical thrombolysis for DVT in patients at low risk for bleeding but at risk for limb loss or severe persistent symptoms despite anticoagulation (category 2A).
9_Consider systemic or catheter-directed thrombolysis (category 2A) or embolectomy (category 2B) for patients with hemodynamically unstable PE at low risk for bleeding.
10_Consider IVC filter (retrievable preferred) if anticoagulation is contraindicated for acute VTE (within 1 month of diagnosis). Recommend filter retrieval once patient is tolerating anticoagulation (category 2A).
11_Incidental PE should be treated similarly to symptomatic PE (category 2A).
12_Recommended duration of anticoagulation therapy is for as long as the patient's cancer is active or under treatment. Providers should continue to discuss the risks and benefits (category 2A).
13_For recurrent VTE on UFH, recommend considering HIT, antiphospholipid syndrome (check UFH anti-Xa level), increase dose of UFH, or switch to LMWH or DOAC (category 2B).
14_For recurrent VTE on LMWH, recommend considering HIT, switch to twice-daily injections or increase dose or switch to fondaparinux or DOAC (category 2B).
15_or recurrent VTE on fondaparinux, recommend considering HIT or switching to UFH, LMWH, or DOAC (category 2B).
16_For recurrent VTE on warfarin, recommend switching to LMWH, UFH, fondaparinux, or DOAC (category 2B).
17_For recurrent VTE on DOAC, recommend switching to LMWH or fondaparinux (category2B).
https://theoncologist.onlinelibrary.wiley.com/doi/full/10.1002/onco.13596
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