Our considerations for selecting an anticoagulant in cancer patients
| Anticoagulant . | Considerations . |
|---|---|
| DOAC | |
| Relative indications | Patient without GI malignancy |
| Low risk for major bleeding* | |
| Ease of treatment of patient is a priority | |
| No strong drug-drug interactions | |
| Relative contraindications | Active GI malignancy |
| History of GI bleeding | |
| Extremes of weight (<50 or >150 kg)† | |
| Renal insufficiency/fluctuating renal status | |
| LMWH | |
| Relative indications | Frequent emetogenic chemotherapy, nausea and vomiting, difficulty with oral intake |
| Concerns for GI absorption (feeding tubes, gastric or bowel resections) | |
| Drug-drug interactions with DOAC or VKA | |
| Motivated patient willing to use for extended durations | |
| Known increased bleeding risk | |
| Recurrent cancer-associated VTE while on anticoagulants‡ | |
| Relative contraindications | Strong aversion or inability to use injectable therapy |
| Renal insufficiency/fluctuating renal status (unless regular anti-Xa monitoring with dose adjustment is feasible) | |
| Extremes of weight (<50 or >150 kg)† | |
| VKA | |
| Relative indications | Any situation in which close anticoagulant monitoring is necessary (eg, multiple prior bleeds) or concern for absorption and metabolism |
| Advanced chronic kidney disease | |
| Extremes of weight (<50 or >150 kg)† | |
| Relative contraindications | Lack of access to dedicated anticoagulation monitoring service with experience caring for cancer patients |
| Anticoagulant . | Considerations . |
|---|---|
| DOAC | |
| Relative indications | Patient without GI malignancy |
| Low risk for major bleeding* | |
| Ease of treatment of patient is a priority | |
| No strong drug-drug interactions | |
| Relative contraindications | Active GI malignancy |
| History of GI bleeding | |
| Extremes of weight (<50 or >150 kg)† | |
| Renal insufficiency/fluctuating renal status | |
| LMWH | |
| Relative indications | Frequent emetogenic chemotherapy, nausea and vomiting, difficulty with oral intake |
| Concerns for GI absorption (feeding tubes, gastric or bowel resections) | |
| Drug-drug interactions with DOAC or VKA | |
| Motivated patient willing to use for extended durations | |
| Known increased bleeding risk | |
| Recurrent cancer-associated VTE while on anticoagulants‡ | |
| Relative contraindications | Strong aversion or inability to use injectable therapy |
| Renal insufficiency/fluctuating renal status (unless regular anti-Xa monitoring with dose adjustment is feasible) | |
| Extremes of weight (<50 or >150 kg)† | |
| VKA | |
| Relative indications | Any situation in which close anticoagulant monitoring is necessary (eg, multiple prior bleeds) or concern for absorption and metabolism |
| Advanced chronic kidney disease | |
| Extremes of weight (<50 or >150 kg)† | |
| Relative contraindications | Lack of access to dedicated anticoagulation monitoring service with experience caring for cancer patients |
VKA, vitamin K antagonist.
If DOAC reversal agent is not readily available, LMWH may be preferred for patients with increased risk of bleeding at baseline.
Prescribing information for factor Xa inhibitors and LMWH recommend against use in extremes of weight, although a recent study suggests that DOACs may be appropriate for obese patients.60
Ideally using twice-daily dosing of enoxaparin given at 120% to 125% of standard twice-daily dosing. No data for DOACs in this setting are available, and how to increase the DOAC dose with limited pill strengths is not known. Please note that this is not an exhaustive list. Anticoagulant choices may be appropriate in some patients not meeting “optimal” criteria. Adapted from Al-Samkari and Connors61 with permission.