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Hematology/Oncology > VTE in cancer patients (3) > Flashcards

VTE in cancer patients (3) Flashcards

1
Q

Virchow’s Triad of Thrombosis

A
  1. Hypercoagulability
    -cancer can cause this
    -can be due to release of inflammatory cytokines
  2. Stasis of blood flow
    -immobility (which is common in cancer patients)
    -compression of vessel by tumor (physical stasis)
  3. Endothelial Injury
    -caused by surgery (which can be cancer related)
    -or irritation to endothelium by chemo, catheter, or the tumor itself
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2
Q

Incidence of VTE in cancer patients

A

VTE is 4-7 times more likely in cancer patients
2-6 fold increased mortality

2nd most common cause of outpatient cancer death

Increased risk of bleeding which makes it more challenging to treat

Higher risk of recurrence

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3
Q

Which pre-chemo factors increase risk of VTE? (4)

A
  1. Pre-chemo platelets high (> 350 x 10^9/L)
  2. Pre-chemo leukocyte high (> 11 x 10^9/L)
  3. Pre-chemo hemoglobin low (< 10 g/dL)
  4. Obesity (BMI 35 or above)
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4
Q

Which cancer related factors increase risk of VTE? (5)

A
  1. Recent diagnosis (last 3-6 months)
  2. Cancer site/type
    -highest risk: pancreatic and stomach
    -high risk: gynecological, lung, brain, and hematologic
  3. Surgery
  4. Catheter placement
  5. Active chemotherapy
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5
Q

Which patient specific factors increase risk for VTE? (5)

A
  1. Genetics
  2. Older age (> 65 years)
  3. Immobility
  4. Hospitalization
  5. General performance status (lower performance status, they will be less mobile, higher risk)
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6
Q

When is VTE prophylaxis done for ambulatory cancer patients? (3)

A

-multiple myeloma (the therapy for this increases risk)
-On asparaginase therapy
-Khorana score > 2 (note - this scoring tool is not applicable for brain tumors or myeloma, and it is not for diagnosing, just to assess risk)

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7
Q

VTE prophylaxis for hospitalized cancer patients

A

Pretty much all hospitalized patients will get VTE prophylaxis

This is typically LMWH, UFH, or fondaparinux

Second line option is mechanically prophylaxis (compression devices) - this can be done if needed but is not the preferred method

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8
Q

What is the preferred LMWH drug and its dose for VTE prophylaxis

A

Enoxaparin - 40 mg SQ daily

(for obese patients it is often done q12 instead of daily)

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9
Q

What is the dose of UFH for VTE prophylaxis

A

5000 units SQ q8h

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10
Q

When is fondaparinux considered DOC for VTE prophylaxis?

A

In patients that have history of HIT

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11
Q

When is warfarin useful for VTE prophylaxis?

A

In patients with multiple myeloma

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12
Q

What is the dose of apixaban for VTE prophylaxis

A

2.5 mg PO BID

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13
Q

What is the dose of rivaroxaban for VTE prophylaxis

A

10 mg PO once daily

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14
Q

What should be considered when deciding on if to treat of not to treat a patient and considering treatment options? In which situation do we always treat?

A

Can consider no treatment if…
-high bleed risk
-limited life expectancy

Consider treatment if…
-higher clot risk
-complications post clot

Consider patient goals - more aggressive treatment, or are they just receiving palliative care at this point - case by case discussion and individual patient decision

When deciding on which treatment to pick if treating consider - bleed risk, renal function, thrombocytopenia

Note - if it is an emergent situation - then we always treat

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15
Q

Which instances require emergent thrombolytic treatment? (4)

A

If a patient is in an emergent situation - then we always treat.

This is if…
-symptomatic extremity DVT (at risk for limb gangrene)
-massive or submassive PE (at risk for hypooxygenation)
-spersistent bradycardia (<40 bmp)
-sustained hypotension

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16
Q

How do we treat emergent situations?

A

If a patient is in an emergent situation - then we always treat

We treat with parenteral anticoagulation - heparin IV continuous infusion

17
Q

How long do we treat for?

A

There is some controversy in this

Ideally at least 6 months
-if they are not tolerating it or are a high bleed risk - 3 months
-in some cases we may treat for longer than 6 months

18
Q

What is the drug of choice for treatment of VTE for patients that are a high bleed risk?

A

LMWH (enoxaparin)

19
Q

Which patients are considered high bleed risk?

A

Luminal GI cancers

Those with increased risk of bleeding from genitourinary tract, bladder, or nephrostomy tubes

Those with active GI mucosal abnormalities - duodenal ulcers, gastritis, esophagitis, colitis

20
Q

What is the dosing of enoxaparin for treatment of VTE

A

1 mg/kg BID SQ
(use actual body weight)

Or another option (but with less data) - 1.5 mg/kg once daily SQ

21
Q

What should we monitor for with enoxaparin treatment?

A

Renal function
Risk of bleeding
Thrombosis symptom (cessation/improvement)

Anti Xa monitoring is controversial (can be done to make sure effective/appropriate dosing)

22
Q

What are the 3 DOACs, how do they work?

A

Apixaban (Eliquis)
Rivaroxaban (Xarelto)
Edoxaban (Lixiana)

MOA - inhibit factor Xa

(can also be used in for VTE treatment, but consider bleeding risks with each)

23
Q

Apixaban VTE treatment dosing

A

10 mg PO BID x 7 days
then 5 mg PO BID

24
Q

Rivaroxaban VTE treatment dosing

A

15 mg PO BID for the first 3 weeks
then 20 mg PO once a day

25
Q

Edoxaban VTE treatment dosing. And this dose is only if…

A

Start by overlapping for 5 days with parenteral anticoagulation
60 mg PO daily

Note - this dose is only if CrCl > 95 ml/min

26
Q

Rivaroxaban and edoxaban should NOT be used if …

A

CrCl < 30 ml/min

27
Q

DOACs should not be used for VTE treatment for patients with which type of cancer?

A

Gastrointestinal cancer - because these patients have a high bleed risk, so DOC is enoxaparin

28
Q

DOAC bleed risk comparison

A

Apixaban has the lowest bleed risk of the DOACs
Rivaroxaban is in the middle
Edoxaban has the highest bleed risk of the DOACs

(keep this in mind when choosing a drug)

29
Q

What is the efficacy of the 3 DOACs compared to LMWH?

A

Rivaroxaban
-reduces recurrent VTE risk compared to LMWH
-but increased risk of nonmajor bleeding

Edoxaban
-as efficacious as LMWH
-but increased risk of major bleeding

Apixaban
-may reduce recurrent VTE risk compared to LMWH
-no change in major bleeding risk

30
Q

VTE treatment pathway summary

A

First - consider if the patient is in critical danger (is emergent treatment needed?) …
-If yes … parenteral anticoagulation (heparin), then thrombolytic treatment

If patient is NOT in critical danger - consider is the patient a high bleed risk? …
-If yes - LMWH (enoxaparin)

If not a high bleed risk consider if the patient has a CrCl > 30 …
-If yes (CrCl>30) - DOAC or LMWH
-If no (CrCl<30) - UFH or warfarin, or potentially apixaban (limited data)

31
Q

LMWH vs fondaparinux efficacy/use

A

Similar recurrence of PE or DVT, major bleeding, and mortality

But, fondaparinux is usually not the DOC mainly because of its high cost

32
Q

LMWH vs DOACs vs VKA

A

LMWH and DOACs may reduce VTE recurrence compared to VKA (so warfarin may not be as good)

And they have similar risk of bleeding

33
Q

Long term anticoagulation considerations

A

There is some controversy in whether anticoagulation should be continued after 6 months
-have to consider the risk of recurrent VTE vs the risk of bleeding

Generally, if patients are still symptomatic after 6 months, they still have active cancer, or are still receiving chemotherapy - we continue treatment beyond 6 months indefinitely

Consider DOACs vs LMWH for long term treatment - DOACs may be better because they are PO (less invasive)

If risk factors have been addressed (no symptoms, no active cancer or chemo) - then there is less benefit to continue treatment, but there is also a risk of VTE recurrence- harder decision to make

34
Q

Recurrent thrombosis considerations

A

Consider potential changes in patient condition which may be causing this
-progression of cancer (metastasis may be the cause)
-type of cancer (pancreatic, brain, ovarian, lung)
-immobility
-heparin induced thrombocytopenia

We could increase the dose of enoxaparin - and in this case we would monitor anti Xa levels - 4 hours after dosing, to make sure levels are where we want them to be

Or we could switch the agent
-patient specific decisions

35
Q

Renal dysfunction is common in cancer patients, and this puts patients at increased risk of ______________

A

Bleeding

36
Q

Agents for CrCl 15-30 ml/min (2)

A

Enoxaparin can be used but requires a dose adjustment –> 1 mg/kg SQ DAILY (instead of BID with normal renal function)
-and anti-Xa levels should be monitored

VKA (warfarin)
-good for renal patients, because we can monitor INR and is easily reversible - but it is less effective

37
Q

Which agent should be used if CrCl is < 15 ml/min or patient is on dialysis?

A

Mostly warfarin (since we can monitor and control it better)

DOACs should be avoided for the most part, but apixaban has some limited evidence in ESRD

38
Q

What if a patient has thrombocytopenia, how do we treat VTE?

A

Thrombocytopenia is common in cancer patients (low platelets, < 150,000) - increases bleeding risk - so LMWH is preferred for VTE treatment

If platelets are > 50,000 –> full dose enoxaparin (1 mg/kg SQ BID)

If platelets are 25,000 - 50,000 –> half dose enoxaparin (0.5 mg/kg SQ BID)

If platelet are < 25,000 –> temporarily stop VTE therapy, restart when platelets are higher (>50,000) (can increase platelets with platelet transfusion)

Hematology/Oncology (17 decks)

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