Which Anticoagulation Agent Is Best for Patients With Cancer-Related VTE?

Efficacy appeared to be similar among direct oral anticoagulants (DOACs) used for managing cancer-related venous thromboembolism (VTE); however, apixaban may hold a more favorable safety profile, according to a meta-analysis published in JACC CardioOncology.

“Apixaban may confer an antithrombotic benefit without an increased risk for bleeding, distinguishing it from other contemporary anticoagulation strategies in patients with active cancer and VTE,” specified the first author, Tomohiro Fujisaki, MD, of Kumamoto University in Japan.

The analysis reviewed 6,623 patients from 17 randomized controlled trials that evaluated vitamin K antagonists, parenteral anticoagulation, or DOACs. Outcomes of interest included recurrences of VTE, pulmonary embolism, and deep venous thrombosis, as well as major bleeding, clinically relevant nonmajor bleeding (CRNMB), and a composite of major bleeding or CRNMB.

Reportedly, there were no significant differences among DOACs for recurrent VTE events. For major bleeding, apixaban safety was comparable with dabigatran and rivaroxaban but showed lower risk compared with edoxaban (hazard ratio [HR], 0.38; 95% CI, 0.15-0.93). For CRNMB, edoxaban safety was comparable with apixaban but had a lower risk versus rivaroxaban (HR, 0.31; 95% CI, 0.10-0.91).

Compared with parenteral anticoagulation (low-molecular weight heparin), apixaban was associated with a lower risk of recurrent VTE events (HR, 0.60; 95% CI, 0.38-0.93) without an increase in major bleeding risk, while edoxaban was associated with increased major bleeding or CRNMB risk (HR, 1.35; 95% CI, 1.02-1.79) and rivaroxaban was associated increased CRNMB risk (HR, 3.76; 95% CI, 1.43-9.88).

In closing, Dr. Fujisaki and colleagues stated that “further large-scale randomized controlled studies are needed to directly compare various DOACs in patients with VTE and active cancer.”

Reference

Fujisaki T, Sueta D, Yamamoto E, et al. Comparing anticoagulation strategies for venous thromboembolism associated with active cancer: a systematic review and meta-analysis. JACC CardioOncol. 2024;6(1):99-113. 2024. doi:10.1016/j.jaccao.2023.10.009