Summary of key evidence supporting dose adjustment of anticoagulation in acute cancer-associated thrombosis and thrombocytopenia
| Author (year) . | Study design . | Participants . | Interventions . | Key findings . |
|---|---|---|---|---|
| Kopolovic et al (2015)12 | Single-center retrospective study | N = 74 hospitalized patients with CAT and thrombocytopenia at single center 2005-2011. | 23% (n = 17) got no therapy, 40.5% (n = 30) had full-dose anticoagulation, and 36.5% (n = 27%) received partial treatment (dose reduced, interrupted, or shortened). | 31.1% (n = 13) experienced recurrent VTE and 17.6% (n = 23) had bleeding events, of which 4.1% (n = 3) were major. |
| Mantha et al (2017)7 | Single-center, quality initiative, retrospective study | N = 99 patients with CAT on therapeutic-dose enoxaparin from 2011 through 2013 and experienced at least one 7-day period of thrombocytopenia (platelet count ≤50 000/µL). | Enoxaparin full dose for a platelet count >50 000/µL, half dose for a platelet count of 25 000 to 50 000/µL, and drug held for platelet count <25 000/µL. | Enoxaparin dose was modified in 95% of thrombocytopenic episodes. No recurrent VTE events or major bleeding episodes during dose reduction. 1 major bleeding episode occurred on full-dose enoxaparin. |
| Raskob et al (2018)13 | Randomized control trial. Edoxaban compared to dalteparin in patients with cancer-associated thrombosis | N = 524 (dalteparin arm), 10% (n = 53) of patients developed platelets <100 000/µL during study and 2% (n = 10) had a platelet count <50 000/µL. | Dalteparin was held for platelets <50 000/µL and dose reduced for platelets (50 000-100 000/µL). Dose reductions were prespecified in trial. | Anticoagulant dose reduction was not tested as a trial question but demonstrates feasibility of dose-adjusted LMWH for thrombocytopenia in CAT. |
| Agnelli et al (2020)14 | Randomized control trial. Apixaban compared to dalteparin in patients with cancer-associated thrombosis | N = 579 (dalteparin arm). Thrombocytopenia reported in 2.9% (n = 17) patients. | Dalteparin was held for platelets <50 000/µL and dose reduced for platelets (50 000-100 000/µL). Investigators referred to package insert of dalteparin for dose reductions. | Anticoagulant dose reduction was not tested as a trial question but demonstrates feasibility of dose-adjusted LMWH for thrombocytopenia in CAT. |
| Carney et al (2021)8 | Prospective multicenter cohort study | N = 121 patients with CAT and thrombocytopenia | 62% (n = 75) were initially treated with full-dose anticoagulation and 27% (n = 33) with modified-dose anticoagulation. 13 patients did not receive anticoagulation. Most common agent used was LMWH; 16 patients were initially started on a direct oral anticoagulant. | VTE recurrence was 5.6% (95% CI, 0.2%-11%) and major bleeding was 12.8% (95% CI, 4.9%-20.8%) with full-dose anticoagulation. Recurrent VTE rate was 0 and major bleeding was 6.6% (95% CI, 2.4%-15.7%) with modified dose anticoagulation. |
| Author (year) . | Study design . | Participants . | Interventions . | Key findings . |
|---|---|---|---|---|
| Kopolovic et al (2015)12 | Single-center retrospective study | N = 74 hospitalized patients with CAT and thrombocytopenia at single center 2005-2011. | 23% (n = 17) got no therapy, 40.5% (n = 30) had full-dose anticoagulation, and 36.5% (n = 27%) received partial treatment (dose reduced, interrupted, or shortened). | 31.1% (n = 13) experienced recurrent VTE and 17.6% (n = 23) had bleeding events, of which 4.1% (n = 3) were major. |
| Mantha et al (2017)7 | Single-center, quality initiative, retrospective study | N = 99 patients with CAT on therapeutic-dose enoxaparin from 2011 through 2013 and experienced at least one 7-day period of thrombocytopenia (platelet count ≤50 000/µL). | Enoxaparin full dose for a platelet count >50 000/µL, half dose for a platelet count of 25 000 to 50 000/µL, and drug held for platelet count <25 000/µL. | Enoxaparin dose was modified in 95% of thrombocytopenic episodes. No recurrent VTE events or major bleeding episodes during dose reduction. 1 major bleeding episode occurred on full-dose enoxaparin. |
| Raskob et al (2018)13 | Randomized control trial. Edoxaban compared to dalteparin in patients with cancer-associated thrombosis | N = 524 (dalteparin arm), 10% (n = 53) of patients developed platelets <100 000/µL during study and 2% (n = 10) had a platelet count <50 000/µL. | Dalteparin was held for platelets <50 000/µL and dose reduced for platelets (50 000-100 000/µL). Dose reductions were prespecified in trial. | Anticoagulant dose reduction was not tested as a trial question but demonstrates feasibility of dose-adjusted LMWH for thrombocytopenia in CAT. |
| Agnelli et al (2020)14 | Randomized control trial. Apixaban compared to dalteparin in patients with cancer-associated thrombosis | N = 579 (dalteparin arm). Thrombocytopenia reported in 2.9% (n = 17) patients. | Dalteparin was held for platelets <50 000/µL and dose reduced for platelets (50 000-100 000/µL). Investigators referred to package insert of dalteparin for dose reductions. | Anticoagulant dose reduction was not tested as a trial question but demonstrates feasibility of dose-adjusted LMWH for thrombocytopenia in CAT. |
| Carney et al (2021)8 | Prospective multicenter cohort study | N = 121 patients with CAT and thrombocytopenia | 62% (n = 75) were initially treated with full-dose anticoagulation and 27% (n = 33) with modified-dose anticoagulation. 13 patients did not receive anticoagulation. Most common agent used was LMWH; 16 patients were initially started on a direct oral anticoagulant. | VTE recurrence was 5.6% (95% CI, 0.2%-11%) and major bleeding was 12.8% (95% CI, 4.9%-20.8%) with full-dose anticoagulation. Recurrent VTE rate was 0 and major bleeding was 6.6% (95% CI, 2.4%-15.7%) with modified dose anticoagulation. |
CI, confidence interval.