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Patient Evidence Summary
Doctor, I have cancer and a DVT or PE. Are the newer blood thinner pills as safe for me as the older injectable, heparin-based ones?
Newer anticoagulant pills known as DOACs (Eliquis®, Xarelto®, Lixiana®, and Pradaxa®) are as effective and safe for treating DVT and PE as low-molecular-weight heparin injections (LMWH) in most people with cancer. (Please note that LMWH is still preferred for some patients for reasons that are beyond the scope of this summary and are best discussed with your doctor.)
Study highlights
For patients with cancer and a DVT or PE diagnosed within the past 30 days, treatment with DOACs, the newer anticoagulants, did not differ from LMWH injections for risk of developing a new DVT or PE. There was also no increased risk of bleeding, while on treatment between the two groups.
Understanding the problem
Patients with cancer have a higher chance of developing a first DVT or PE and also recurrent DVT or PE on treatment than patients without a cancer diagnosis. They are also more likely to experience bleeding while taking an anticoagulant.
Injectable anticoagulants, LMWHs, have been shown to be effective and safe for treating DVT or PE in patients with cancer. However, they need to be injected under the skin, 1-2 times per day, which can be inconvenient and uncomfortable. The newer anticoagulants, DOACs, are known to be effective and safe for treating DVT and PE in people who do not have cancer. They require taking 1-2 pills per day. However, there has been concern that the DOACs may not be as effective as LMWH at protecting cancer patients from developing new DVT or PE and that the pills may also cause a higher risk of bleeding.
To learn more about the effects of DOACs in patients with cancer and a newly diagnosed DVT or PE, researchers in this study compared the risk of recurrent VTE and bleeding between patients with cancer taking either LMWH or DOACs, over 6 months.
Who? The study included 638 adult patients with cancer and a newly diagnosed DVT or PE. Patients were required to have a safe platelet count and good kidney function.
Patients with acute leukemia, transplant of stem cells, significant bleeding, pregnancy or breastfeeding, or taking medications that interfered with DOACs or LMWHs, were excluded from this study.
What? The study compared DOACs with LMWHs for the treatment of cancer-associated DVT or PE.
Direct Oral Anticoagulant (DOAC) | vs | Low-Molecular-Weight Heparin (LMWH) |
|---|---|---|
Eliquis® 10 mg pills twice a day for 7 days, then 5 mg pills twice a day Lixiana® 60 mg pill once a day after first injecting under the skin with LMWH for 5 to 10 days. Pradaxa® 150 mg pills twice a day after first injecting under the skin with LMWH for 5 to 10 days. Xarelto® 15 mg pills twice a day for 21 days, then 20 mg pill once a day. Treated for 6 months. | Fragmin®: 200 IU/kg injections under the skin once a day for 1 month, then 150 IU/kg injections under the skin once a day for 5 months. Lovenox®: 1 mg/kg injections under the skin two times a day; patients could also do 1.5 mg/kg injections under the skin once a day. Arixtra®: Based on patient's weight. Weight < 50 kg: 5 mg injections under the skin once a day; Weight 50-100kg: 7.5 mg injections under the skin once a day; Weight > 100 kg: 10 mg injections under the skin once a day. Warfarin: Pill taken once a day. Requires blood tests on a regular basis (about once a week to once a month). It also requires 5-10 days of LMWH injections when treatment is first started. Treated for 6 months. |
Direct Oral Anticoagulant (DOAC) vs. Low-Molecular-Weight Heparin (LMWH)
| Outcomes at 6 Months | Rate of Events with DOACs | Rate of Events with LMWHs | Results |
|---|---|---|---|
| Recurrent DVT or PE (Non-Fatal) | 61 out of 1000 people | 88 out of 1000 people | No effect* |
| Death from Any Cause | 215 out of 1000 people | 184 out of 1000 people | No effect* |
| Major Bleeding | 52 out of 1000 people | 56 out of 1000 people | No effect* |
*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:
Schrag D, Uno H, Rosovsky R, et al. Direct Oral Anticoagulants vs Low-Molecular-Weight Heparin and Recurrent VTE in Patients With Cancer: A Randomized Clinical Trial. JAMA. 2023 Jun 13;329(22):1924-1933. doi: 10.1001/jama.2023.7843. PubMed
Amin Zahrai is a MSc Clinical Epidemiology student and CanVECTOR trainee at the University of Ottawa. His research focuses on the prediction and treatment of VTEs using anticoagulants in adult patients with cancer and gastrointestinal diseases. He hopes to incorporate such clinical interests to provide curative treatments in his future trainings.
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: Friday, August 25, 2023
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