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Patient Evidence Summary
Doctor, should I take anticoagulants to prevent blood clots while I am receiving chemotherapy?
In cancer patients receiving chemotherapy who also have additional risk factors for VTE, taking low-dose Eliquis® two times per day reduces the risk of having a PE or DVT but increases the risk of bleeding.
Study highlights
In cancer patients who were receiving chemotherapy and had other risk factors for VTE, Eliquis® reduced the risk developing DVT or PE.
The risk of bleeding was higher in patients taking Eliquis®.
Note: not all cancer patients can safely take Eliquis® and cost of the drug may be a barrier for some patients
Understanding the problem
Patients with cancer are at high risk of developing a DVT or PE, especially when they are receiving chemotherapy. It is important to prevent blood clots because they can lead to serious complications, including death. Physicians use the Khorana score to estimate a cancer patient's risk of experiencing a blood clot when starting chemotherapy. The Khorana score looks at certain characteristics of the patient's blood test results (platelet count, hemoglobin, white blood cell count), body mass index (BMI) and the type of cancer to help the physician decide whether the patient has a low, intermediate or high risk for developing a blood clot. We know that about 1 in 10 cancer patients with an intermediate to high Khorana score will develop a blood clot during the first 6 months of chemotherapy treatment.
Eliquis® (apixaban) is an anticoagulant, which is taken by mouth two times per day. Low doses of anticoagulant can be used to reduce the risk of forming blood clots. The most important complication of taking an anticoagulant is bleeding. Just as there are risk factors for developing VTE, there are risk factors for developing bleeding while taking anticoagulants. For example, people who have a previous history of bleeding, certain types of cancer or kidney disease will have a higher risk of bleeding when taking anticoagulants than people who do not have these risk factors.
In this study, the researchers asked the question: "Can we reduce the risk of DVT or PE in cancer patients who are receiving chemotherapy and have additional risk factors for VTE by giving them low-dose Eliquis®?"
Who? The study included 574 patients (mean age 60 years; 42% men) with a new diagnosis of cancer or progression of cancer, who needed to start chemotherapy and were at intermediate to high risk of developing a blood clot (using the Khorana score). Most patients in the study had a diagnosis of gynecological cancer, lymphoma (a type of blood cancer) or cancer of the pancreas.
What? The study compared Eliquis® to a placebo (a pill made to be identical to Eliquis® but without any active drug).
Low-dose Eliquis® | vs | Placebo |
|---|---|---|
Eliquis® 2.5 mg by mouth, two times per day for 6 months. | Placebo: A pill containing an inactive substance that has no effect on the outcome but looks to be the same as Eliquis®. Sometimes, it is referred to as a “sugar pill.” |
Low-dose Eliquis® vs Placebo in patients who have cancer plus an intermediate to high risk of developing VTE and are starting chemotherapy.
Outcomes at 6 months | Rate of events with Eliquis® | Rate of events with Placebo | Results |
|---|---|---|---|
Venous Thromboembolism | 4 out of 100 people | 10 out of 100 people | About 6 fewer people out of 100 had a VTE while taking Eliquis® |
Major Bleeding | 4 out of 100 people | 2 out of 100 people | About 2 more people out of 100 had a major bleeding event while taking Eliquis® |
| Death from any cause | 12 out of 100 people | 10 out of 100 people | No difference* |
*Although the rates for the 2 groups look slightly different, the differences were not statistically significant—this means that the difference could simply be due to chance rather than due to the different treatments.
This Evidence Summary is based on the following article:
Carrier M, Abou-Nassar K, Mallick R, et al. Apixaban to Prevent Venous Thromboembolism in Patients with Cancer. N Engl J Med. 2018 Dec 4. doi: 10.1056/NEJMoa1814468. PubMed
Miriam Kimpton, MD
Dr. Kimpton has completed her Internal Medicine residency at the University of Ottawa, and her Hematology residency at the University of Toronto. She is currently enrolled in the Adult Thrombosis Medicine fellowship at the University of Ottawa, funded by the CanVECTOR Research Training Award and the University of Ottawa’s Department of Medicine Scholarship Program. During this fellowship, she will also be completing a Master of Science in Epidemiology as part of the Clinician Investigator Program. Dr. Kimpton’s research interests include prophylaxis and treatment of cancer-associated thrombosis, especially as they pertain to hematological malignancies.
Lori-Ann Linkins, MD, MSc (Clin Epi), FRCPC
Dr. Linkins is an Associate Professor of Medicine (thrombosis) at McMaster University in Hamilton, Canada. She holds a Masters Degree in Health Research Methodology and is a Deputy Editor with the Health Information Research Unit, McMaster. Her research interests include heparin-induced thrombocytopenia and cancer-associated thrombosis. She was editor of the ACCP Guidelines, 9th Edition HIT chapter and is currently a member of the ASH VTE Guidelines HIT Panel.
Published: Thursday, February 14, 2019
Last Updated: Thursday, July 30, 2020
Please note that the information contained herein is not to be interpreted as an alternative to medical advice from a professional healthcare provider. If you have any questions about any medical matter, you should consult your professional healthcare providers, and should never delay seeking medical advice, disregard medical advice or discontinue medication based on information provided here.
, McMaster University