Should I consider a direct oral anticoagulant (DOAC) for my patient with pancreatic cancer and pulmonary embolism?

Classically, anticoagulant (AC) of choice in active malignancy with venous thromboembolism (VTE) has been low-molecular weight heparin (LMWH) (eg, enoxaparin) because of trials showing its superiority over warfarin. But now the pendulum is swinging toward DOACs as an alternative mode of treatment.

A 2018 trial found that oral edoxaban (an Xa inhibitor) was noninferior to subcutaneous dalteparin (a LMWH) with the composite outcome of recurrent VTE or major bleeding.1 Overall, recurrent VTE was significantly lower in edoxaban (7.9% vs 11.3%) but had higher major bleeding (6.9% vs 4.05). Of note, edoxaban was initiated after 5 days of treatment with LMWH.

More recently, the 2020 Caravaggio trial, showed non-inferiority of apixaban (at a dose of 10 mg twice daily for the first 7 days, followed by 5 mg twice daily) to dalteparin with recurrent VTE of 5.6% in the apixaban group vs 7.9% in the dalteparin.2 There was no significant difference in rates of major bleeding (3.8% vs 4%). A prior small study, the ADAM-VTE trial, compared apixaban to dalteparin in patients with malignancy and VTE.3 Apixaban had significantly lower VTE recurrence rates (0.7% to 6.3%) and non-significant lower major bleeding (0% vs 1.4%, p=0.138) consistent with the newer and larger trial. Of note, this trial excluded patients with brain tumor and had few patients with upper GI or hematologic malignancy.  

In addition, a pilot study, the SELECT-D trial, compared rivaroxaban to dalteparin.4 Rivaroxaban had significantly lower VTE recurrence (4% vs 11%), without a significant increase in major bleeding (6% vs 4%), but had an increased number of clinically relevant non-major bleeds (13% vs 4%), particularly in cancers of the upper GI tract.

Although decision regarding use of DOACs in patients with malignancy should be made on case-by-case basis, they are increasingly considered for treatment of VTE in this patient population with the strongest evidence supporting apixaban or the initial use of LMWH for 5 days followed by edoxaban.  

Contributed by Sean Mendez MD, Mass General Hospital, Boston, MA.

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References:  

  1. Raskob GE, van Es N, Verhamme P, Carrier M, Di Nisio M, Garcia D, Grosso MA, Kakkar AK, Kovacs MJ, Mercuri MF, Meyer G, Segers A, Shi M, Wang TF, Yeo E, Zhang G, Zwicker JI, Weitz JI, Büller HR. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med. 2018 Feb 15;378(7):615-624. doi: 10.1056/NEJMoa1711948. Epub 2017 Dec 12. PubMed PMID: 29231094.
  2. McBane Ii R, Loprinzi CL, Ashrani A, Perez-Botero J, Leon Ferre RA, Henkin S, Lenz CJ, Le-Rademacher JG, Wysokinski WE. Apixaban and dalteparin in active malignancy associated venous thromboembolism. The ADAM VTE Trial. Thromb Haemost. 2017 Oct 5;117(10):1952-1961. doi: 10.1160/TH17-03-0193. Epub 2017 Aug 24. PubMed PMID: 28837207.
  3. Agnelli G, Becattini C, Meyer G, Muñoz A, Huisman MV, Connors JM, Cohen A, Bauersachs R, Brenner B, Torbicki A, Sueiro MR, Lambert C, Gussoni G, Campanini M, Fontanella A, Vescovo G, Verso M. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med. 2020 Mar 29;. doi: 10.1056/NEJMoa1915103. [Epub ahead of print] PubMed PMID: 32223112.
  4. Young AM, Marshall A, Thirlwall J, Chapman O, Lokare A, Hill C, Hale D, Dunn JA, Lyman GH, Hutchinson C, MacCallum P, Kakkar A, Hobbs FDR, Petrou S, Dale J, Poole CJ, Maraveyas A, Levine M. Comparison of an Oral Factor Xa Inhibitor With Low Molecular Weight Heparin in Patients With Cancer With Venous Thromboembolism: Results of a Randomized Trial (SELECT-D). J Clin Oncol. 2018 Jul 10;36(20):2017-2023. doi: 10.1200/JCO.2018.78.8034. Epub 2018 May 10. PubMed PMID: 29746227.

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Massachusetts General Hospital, Harvard Catalyst, Harvard University, its affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

Should I consider a direct oral anticoagulant (DOAC) for my patient with pancreatic cancer and pulmonary embolism?