Evidence-based guidance on venous thromboembolism in patients with solid tumours

Abstract

Venous thromboembolism (vte) is a serious, life-threatening complication of cancer. Anticoagulation therapy such as low molecular weight heparin (lmwh) has been shown to treat and prevent vte. Cancer therapy is often complex and ongoing, making the management of vte less straightforward in patients with cancer. There are no published Canadian guidelines available to suggest appropriate strategies for the management of vte in patients with solid tumours. We therefore aimed to develop a clear, evidence-based guideline on this topic. A systematic review of clinical trials and meta-analyses published between 2002 and 2013 in PubMed was conducted. Reference lists were hand-searched for additional publications. The National Guidelines Clearinghouse was searched for relevant guidelines. Recommendations were developed based on the best available evidence. In patients with solid tumours, lmwh is recommended for those with established vte and for those without established vte but with a high risk for developing vte. Options for lmwh include dalteparin, enoxaparin, and tinzaparin. No one agent can be recommended over another, but in the setting of renal insufficiency, tinzaparin is preferred. Unfractionated heparin can be used under select circumstances only (that is, when rapid clearance of the anticoagulant is desired). The most common adverse event is bleeding, but major events are rare, and with appropriate follow-up care, bleeding can be monitored and appropriately managed.

Keywords: Anticoagulation; clinical practice guidelines; deep-vein thrombosis; low molecular weight heparin; pulmonary embolism; solid tumours; systematic reviews; venous thromboembolism.

FIGURE 1

Algorithm for prophylaxis and treatment of venous thromboembolism in patients with solid tumours. dvt = deep-vein thrombosis; pe = pulmonary embolism; sc = subcutaneously; bid = twice daily; inr = international normalized ratio; IV = intravenously; lmwh = low molecular weight heparin; rbc = red blood cells.