Potential causes of anticoagulant failure in cancer
| Factors . | Details . | Management implications . |
|---|---|---|
| Anticoagulation adherence | • Noncompliance • Drug interruptions | • Counseling or alternative anticoagulant • Bridging or IVC filter if additional interruptions needed |
| Drug-drug interactions | • CYP3A4 inducers (Table 2) | • Alternative anticoagulant or increased doses of DOAC with Xa monitoring |
| Extrinsic compression | • Tumor compression • May-Thurner syndrome • Thoracic outlet obstruction | • Consideration of intravascular stenting |
| LMWH ineffectiveness | • Heparin-induced thrombocytopenia • Antithrombin deficiency (eg, asparaginase therapy) • Appropriate weight-based dosing | • Diagnosis of HIT mandates alternative anticoagulants such as direct thrombin inhibitors, DOAC, or fondaparinux • In cases of asparaginase deficiency, strategies include confirmation of therapeutic factor Xa levels, antithrombin repletion, alternative anticoagulants |
| DOAC ineffectiveness | • Antiphospholipid antibody syndrome • Reduced gastrointestinal absorption | • Warfarin for antiphospholipid antibody syndrome • LMWH if reduced absorption, rivaroxaban largely absorbed in the stomach |
| Intravascular | • Central venous catheter • IVC filter | • Consider removal of central venous catheter in setting of thrombosis |
| Tumor thrombus | • Renal cell carcinoma • Hepatocellular carcinoma • Thyroid cancer • Metastatic disease | • Tumor-directed therapy • Benefit of anticoagulation uncertain |
| Myeloproliferative neoplasms | • Polycythemia vera • Essential thrombocythemia | • Consideration of cytoreductive therapy with hydroxyurea ± aspirin |
| Factors . | Details . | Management implications . |
|---|---|---|
| Anticoagulation adherence | • Noncompliance • Drug interruptions | • Counseling or alternative anticoagulant • Bridging or IVC filter if additional interruptions needed |
| Drug-drug interactions | • CYP3A4 inducers (Table 2) | • Alternative anticoagulant or increased doses of DOAC with Xa monitoring |
| Extrinsic compression | • Tumor compression • May-Thurner syndrome • Thoracic outlet obstruction | • Consideration of intravascular stenting |
| LMWH ineffectiveness | • Heparin-induced thrombocytopenia • Antithrombin deficiency (eg, asparaginase therapy) • Appropriate weight-based dosing | • Diagnosis of HIT mandates alternative anticoagulants such as direct thrombin inhibitors, DOAC, or fondaparinux • In cases of asparaginase deficiency, strategies include confirmation of therapeutic factor Xa levels, antithrombin repletion, alternative anticoagulants |
| DOAC ineffectiveness | • Antiphospholipid antibody syndrome • Reduced gastrointestinal absorption | • Warfarin for antiphospholipid antibody syndrome • LMWH if reduced absorption, rivaroxaban largely absorbed in the stomach |
| Intravascular | • Central venous catheter • IVC filter | • Consider removal of central venous catheter in setting of thrombosis |
| Tumor thrombus | • Renal cell carcinoma • Hepatocellular carcinoma • Thyroid cancer • Metastatic disease | • Tumor-directed therapy • Benefit of anticoagulation uncertain |
| Myeloproliferative neoplasms | • Polycythemia vera • Essential thrombocythemia | • Consideration of cytoreductive therapy with hydroxyurea ± aspirin |