Summary of guidelines for anticoagulant choice in cancer patients with acute VTE
| . | Preferred options . | Alternative options . | |
|---|---|---|---|
| NCCN8 | Category 1* | Category 2A† | Category 2B‡ |
| Dalteparin | Enoxaparin | UFH IV, then UFH SC | |
| LMWH × 5 d, then edoxaban | Rivaroxaban | UFH SC load, then UFH SC | |
| Fondaparinux | |||
| Apixaban | |||
| UFH × 5 d, then edoxaban | |||
| LMWH, UFH, or fondaparinux × 5 d, then warfarin | |||
| ISTH9 | DOAC (edoxaban or rivaroxaban highest evidence) if low bleeding risk and no drug-DOAC interactions | LMWH in patients with low bleeding risk | |
| LMWH if high bleeding risk§ or potential drug-DOAC interactions | Edoxaban or rivaroxaban in patients with high bleeding risk§ | ||
| ASCO10 | Initial treatment (first 5-10 d): LMWH, UFH, fondaparinux, or rivaroxaban | After initial treatment (up to 6 mo): VKA if unable to obtain LMWH, edoxaban, or rivaroxaban | |
| After initial treatment (up to 6 mo): LMWH, edoxaban, or rivaroxaban | |||
| Long term (beyond 6 mo): LMWH, DOAC, or VKA | |||
| Check for risk of bleeding§ and drug interactions if using edoxaban or rivaroxaban | |||
| ITAC11 | LMWH (if CrCl ≥ 30) | UFH | |
| DOAC (rivaroxaban or edoxaban if CrCl ≥ 30 and no increased risk of GI or genitourinary bleeding) | Fondaparinux | ||
| . | Preferred options . | Alternative options . | |
|---|---|---|---|
| NCCN8 | Category 1* | Category 2A† | Category 2B‡ |
| Dalteparin | Enoxaparin | UFH IV, then UFH SC | |
| LMWH × 5 d, then edoxaban | Rivaroxaban | UFH SC load, then UFH SC | |
| Fondaparinux | |||
| Apixaban | |||
| UFH × 5 d, then edoxaban | |||
| LMWH, UFH, or fondaparinux × 5 d, then warfarin | |||
| ISTH9 | DOAC (edoxaban or rivaroxaban highest evidence) if low bleeding risk and no drug-DOAC interactions | LMWH in patients with low bleeding risk | |
| LMWH if high bleeding risk§ or potential drug-DOAC interactions | Edoxaban or rivaroxaban in patients with high bleeding risk§ | ||
| ASCO10 | Initial treatment (first 5-10 d): LMWH, UFH, fondaparinux, or rivaroxaban | After initial treatment (up to 6 mo): VKA if unable to obtain LMWH, edoxaban, or rivaroxaban | |
| After initial treatment (up to 6 mo): LMWH, edoxaban, or rivaroxaban | |||
| Long term (beyond 6 mo): LMWH, DOAC, or VKA | |||
| Check for risk of bleeding§ and drug interactions if using edoxaban or rivaroxaban | |||
| ITAC11 | LMWH (if CrCl ≥ 30) | UFH | |
| DOAC (rivaroxaban or edoxaban if CrCl ≥ 30 and no increased risk of GI or genitourinary bleeding) | Fondaparinux | ||
CrCl, creatinine clearance; IV, intravenous; SC, subcutaneous; VKA, vitamin K antagonist.
Category 1. Based on high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A. Based on lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B. Based on lower-level evidence, there is NCCN consensus that the intervention is appropriate.
As defined by patients with any of the following: luminal GI cancers with an intact primary or intralumen metastases; active GI mucosal abnormalities, such as duodenal ulcers, gastritis, esophagitis, or colitis; genitourinary tract cancers at risk of bleeding; or nephrostomy tubes.