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DVT/PE treatment and cancer

Case history:

A 68 year old woman presented to my office for LVEF evaluation prior to cancer chemotherapy. Notably, the ejection fraction was normal, but the patient told me about pulmonary embolism she experienced during radiotheraphy following surgical excision of her lung cancer. The patient was on enoxaparin 4000 IU daily since 2013 and to date her clinical history was uneventful as to vascular events. Unfortunately, cancer was discovered in the contralateral lung.

I’d like to point out some issues:

The ACCP guidelines [1]state that LMWH (with full-dosage regimen) is preferred to other agents for extended ( > 3 mo to indefinte) treatment; nonetheless the authors underscore the lack of data when the guidelines were being prepared (Figure 1). ESC guidelines seem to be just a bit more restrictive with respect to rivaroxaban and cancer patients[2]
Prins et al [3]performed a pooled analysis of the EINSTEIN trials, demonstarting that rivaroxaban is effective as LMWH in the treatment of DVT in patients with cancer, as well as cutting down the risk of bleeding.
Please consider also the oral once-daily administration of rivaroxaban as an adjunctive positive feature of the drug itself in such patients.

LMWH cancer

  1. Kearon Clive, Akl ElieA, Comerota AnthonyJ, Prandoni Paolo, Bounameaux Henri, Goldhaber SamuelZ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e419S–94S.
  2. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Gali`e N, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov;35(43):3033–69, 3069a–3069k.
  3. Prins MartinH, Lensing AnthonieWA, Brighton TimA, Lyons RogerM, Rehm Jeffrey, Trajanovic Mila, et al. Oral rivaroxaban versus enoxaparin with vitamin K antagonist for the treatment of symptomatic venous thromboembolism in patients with cancer (EINSTEIN- DVT and EINSTEIN-PE): a pooled subgroup analysis of two randomised controlled trials. The Lancet Haematology 2014;1(1):e37–e46.

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