Τίτλος:
International clinical practice guidelines for the treatment and
prophylaxis of venous thromboembolism in patients with cancer
Γλώσσες Τεκμηρίου:
Αγγλικά
Περίληψη:
. Background: Guidelines addressing the management of venous
thromboembolism (VTE) in cancer patients are heterogeneous and their
implementation has been suboptimal worldwide. Objectives: To establish a
common international consensus addressing practical, clinically relevant
questions in this setting. Methods: An international consensus working
group of experts was set up to develop guidelines according to an
evidence-based medicine approach, using the GRADE system. Results: For
the initial treatment of established VTE: low-molecular-weight heparin
(LMWH) is recommended [1B]; fondaparinux and unfractionated heparin
(UFH) can be also used [2D]; thrombolysis may only be considered on a
case-by-case basis [Best clinical practice (Guidance)]; vena cava
filters (VCF) may be considered if contraindication to anticoagulation
or pulmonary embolism recurrence under optimal anticoagulation; periodic
reassessment of contraindications to anticoagulation is recommended and
anticoagulation should be resumed when safe; VCF are not recommended for
primary VTE prophylaxis in cancer patients [Guidance]. For the early
maintenance (10 days to 3 months) and long-term (beyond 3 months)
treatment of established VTE, LMWH for a minimum of 3 months is
preferred over vitamin K antagonists (VKA) [1A]; idraparinux is not
recommended [2C]; after 36 months, LMWH or VKA continuation should be
based on individual evaluation of the benefit-risk ratio, tolerability,
patient preference and cancer activity [Guidance]. For the treatment
of VTE recurrence in cancer patients under anticoagulation, three
options can be considered: (i) switch from VKA to LMWH when treated with
VKA; (ii) increase in LMWH dose when treated with LMWH, and (iii) VCF
insertion [Guidance]. For the prophylaxis of postoperative VTE in
surgical cancer patients, use of LMWH o.d. or low dose of UFH t.i.d. is
recommended; pharmacological prophylaxis should be started 122 h
preoperatively and continued for at least 710 days; there are no data
allowing conclusion that one type of LMWH is superior to another [1A];
there is no evidence to support fondaparinux as an alternative to LMWH
[2C]; use of the highest prophylactic dose of LMWH is recommended
[1A]; extended prophylaxis (4 weeks) after major laparotomy may be
indicated in cancer patients with a high risk of VTE and low risk of
bleeding [2B]; the use of LMWH for VTE prevention in cancer patients
undergoing laparoscopic surgery may be recommended as for laparotomy
[Guidance]; mechanical methods are not recommended as monotherapy
except when pharmacological methods are contraindicated [2C]. For the
prophylaxis of VTE in hospitalized medical patients with cancer and
reduced mobility, we recommend prophylaxis with LMWH, UFH or
fondaparinux [1B]; for children and adults with acute lymphocytic
leukemia treated with l-asparaginase, depending on local policy and
patient characteristics, prophylaxis may be considered in some patients
[Guidance]; in patients receiving chemotherapy, prophylaxis is not
recommended routinely [1B]; primary pharmacological prophylaxis of VTE
may be indicated in patients with locally advanced or metastatic
pancreatic [1B] or lung [2B] cancer treated with chemotherapy and
having a low risk of bleeding; in patients treated with thalidomide or
lenalidomide combined with steroids and/or chemotherapy, VTE prophylaxis
is recommended; in this setting, VKA at low or therapeutic doses, LMWH
at prophylactic doses and low-dose aspirin have shown similar effects;
however, the efficacy of these regimens remains unclear [2C].
Special situations include brain tumors, severe renal failure (CrCl < 30
mL min-1), thrombocytopenia and pregnancy. Guidances are provided in
these contexts. Conclusions: Dissemination and implementation of good
clinical practice for the management of VTE, the second cause of death
in cancer patients, is a major public health priority.
Συγγραφείς:
Farge, D.
Debourdeau, P.
Beckers, M.
Baglin, C. and
Bauersachs, R. M.
Brenner, B.
Brilhante, D.
Falanga, A. and
Gerotzafias, G. T.
Haim, N.
Kakkar, A. K.
Khorana, A. A. and
Lecumberri, R.
Mandala, M.
Marty, M.
Monreal, M.
Mousa,
S. A.
Noble, S.
Pabinger, I.
Prandoni, P.
Prins, M. H.
and Qari, M. H.
Streiff, M. B.
Syrigos, K.
Bounameaux, H.
and Buller, H. R.
Περιοδικό:
Journal of Thrombosis and Haemostasis
Λέξεις-κλειδιά:
Anticoagulant; Bleeding; Cancer; Clinical practice guidelines; GRADE
system; Venous thromboembolism
