Evaluation of direct oral anticoagulants versus low molecular weight heparins for venous thromboembolism treatment in patients with gastrointestinal malignancies

Tiffany Guan; Arianna Laguna; Alisha Soares; Carlo S Legasto; Shanna Block; Ila M Saunders; Kathryn Alvarez; Tiffany Pon; Nimish Patel; Anjlee Mahajan; Angela Lee

doi:10.1007/s11239-023-02858-y

Evaluation of direct oral anticoagulants versus low molecular weight heparins for venous thromboembolism treatment in patients with gastrointestinal malignancies

J Thromb Thrombolysis. 2023 Oct;56(3):439-446. doi: 10.1007/s11239-023-02858-y. Epub 2023 Jul 8.

Authors

Affiliations

¹ Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, CA, USA. Tiffany.Guan@ucsf.edu.
² Department of Pharmacy Services, University of California, Davis Medical Center, Sacramento, CA, USA.
³ Department of Pharmacy, University of California, San Diego Health, La Jolla, CA, USA.
⁴ Department of Pharmaceutical Services, University of California, San Francisco Medical Center, San Francisco, CA, USA.
⁵ Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, La Jolla, CA, USA.
⁶ Department of Hematology/Oncology, University of California, Davis Medical Center, Sacramento, CA, USA.

PMID: 37421494
DOI: 10.1007/s11239-023-02858-y

Abstract

Background: Direct oral anticoagulant (DOAC) use in cancer-associated venous thromboembolism (CA-VTE) has increased due to updates in recent guidelines and literature. However, select guidelines caution against DOAC use in patients with gastrointestinal (GI) malignancies due to reported increased bleeding events. The objective of this study was to compare the safety and effectiveness of DOACs versus low-molecular-weight heparins (LMWHs) for CA-VTE treatment in patients with GI malignancies.

Patients and methods: This multicenter, retrospective cohort study included patients with primary GI malignancies who received therapeutic anticoagulation with a DOAC or LMWH for CA-VTE between January 1, 2018, and December 31, 2019. The primary outcome was the incidence rate of bleeding events (major, clinically relevant non-major, or minor bleeding events) within a 12-month period following the initiation of therapeutic anticoagulation. The secondary endpoint was the incidence rate of recurrent VTE events within a 12-month period following the start of therapeutic anticoagulation.

Results: After screening, 141 patients met inclusion criteria. The incidence rate of all bleeding events significantly differed between DOAC (4.98 events/100 person-months) and LWMH (10.2 events/100 person-months) recipients. The corresponding incidence rate ratio (IRR) with the DOAC group serving as the reference was 2.05 (p = 0.01), with the majority of bleeds in both groups presenting as minor bleeds. No difference was found between the incidence rate of recurrent VTE within a 12-month period of starting therapeutic anticoagulation between groups (IRR 3.08, p = 0.06).

Conclusion: Our results suggest that DOACs do not pose an additional bleeding risk compared to LMWH in patients with certain GI malignancies. Careful selection of DOAC therapy with respect to bleeding risk is still warranted.

Keywords: DOAC; Direct oral anticoagulant; Gastrointestinal malignancies; LMWH; Low-molecular-weight heparin; VTE; Venous thromboembolism.

Publication types

Multicenter Study

MeSH terms

Administration, Oral
Anticoagulants / adverse effects
Gastrointestinal Neoplasms* / complications
Gastrointestinal Neoplasms* / drug therapy
Hemorrhage / drug therapy
Heparin, Low-Molecular-Weight / adverse effects
Humans
Neoplasms* / complications
Retrospective Studies
Venous Thromboembolism* / prevention & control

Substances

Heparin, Low-Molecular-Weight
Anticoagulants