The risk of major bleeding did not differ for people who took Eliquis® compared with those who took Lovenox® for 28 days after gynecological cancer surgery. There were no differences in the number of VTE, but this study was not large enough to be certain of this result.
Understanding the problem
Gynecological cancers include cancer in the uterus (endometrial), ovaries, cervix, and vulva. Surgeries to remove these cancers increase the risk of forming DVT and PE because: (1) surgery usually takes hours so patients are lying still are under anesthesia for long periods of time, (2) there may be trauma to blood vessels during surgery, and (3) cancer, with or without surgery, triggers activation of the clotting system. To protect themselves from DVT and PE, cancer surgery patients are often asked to inject themselves with anticoagulants by needle for 28 days.
However, the blood clotting system is needed to stop bleeding at the surgery site. This means patients taking anticoagulants may bleed longer from their surgery site than patients who are not taking anticoagulants.
Other studies have shown that low doses of anticoagulants given by needle reduce the risk of DVT or PE without making bleeding worse for most people. However, people often dislike or are afraid of needles.
The researchers in this study wanted to know if a pill form of anticoagulant (Eliquis®) is as safe as an anticoagulant given by needle (Lovenox®) for preventing DVT and PE in people having gynecological surgery for treatment of cancer.
Who? The study included 400 people (ages ranged from 18 to 89 years; average length of surgery was 3.5 hours; 79% required a large surgical incision; 40% had Stage 3 or Stage 4 cancer) who were known to have or were suspected to have cancer in their uterus, ovaries, cervix, or vulva. People with a personal or family history of a clotting disorder or bleeding disorder or who needed to continue to take non-steroidal anti-inflammatory medication (NSAIDs including aspirin) were excluded.
What? The study compared low-dose Eliquis® with low-dose Lovenox® after surgery. All study participants were given heparin by needle on the day of surgery and on the first day after surgery before starting the study drug. Pneumatic compression devices that gently squeeze the calves to keep blood flowing were also used to reduce risk of blood clots while participants were in hospital.
Eliquis® (pill): 2.5 mg twice a day for 28 days
starting postoperative day 1 to 7*
(*when the surgeon said it was safe)
Note: Eliquis cannot be given until an epidural left in for pain control is removed
Lovenox® (needle): once a day for 28 days
Eliquis® vs Lovenox® in people who have surgery for suspected or confirmed gynecologic cancer
Rate of events with Eliquis®
Rate of events with Lovenox®
(up to 30 days after treatment finished)
1 out of 100 people
1 out of 100 people
No difference in the number of major bleeds between the two study groups
DVT or PE
(up to 60 days after treatment finished)
2 out of 100 people
3 out of 100 people
No difference in the number of VTE between the two study groups*
*Although the rates for the 2 groups look 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:
Guntupalli SR, Brennecke A, Behbakht K, et al. Safety and Efficacy of Apixaban vs Enoxaparin for Preventing Postoperative Venous Thromboembolism in Women Undergoing Surgery for Gynecologic Malignant Neoplasm: A Randomized Clinical Trial. JAMA Netw Open. 2020 Jun 1;3(6):e207410. doi: 10.1001/jamanetworkopen.2020.7410. PubMed
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. She is Co-Editor of the ACP Journal Club and Co-lead on the CanVECTOR Knowledge Translation Platform.
Published: Wednesday, August 18, 2021
Last Updated: Monday, August 23, 2021