Consensus guidelines on treatment of deep vein thrombosis or pulmonary embolism in patients with cancer
| . | ACCP 201221 . | NCCN 201113 . | ASCO 201314 . |
|---|---|---|---|
| Initial/acute treatment | Not addressed in cancer patients. | LMWH | LMWH is preferred for initial 5-10 d of treatment in patients with a CrCl >30 mL/min. |
| Dalteparin 200 U/kg OD | |||
| Enoxaparin 1 mg/kg BID | |||
| Tinzaparin 175 U/kg OD | |||
| Fondaparinux 5 mg (<50 kg), 7.5 mg (50-100 kg), or 10 mg (>100 kg) OD | |||
| APTT-adjusted UFH infusion | |||
| Long-term treatment | LMWH preferred to VKA [2B].* | LMWH is preferred for first 6 mo as monotherapy without warfarin in patients with proximal DVT or PE and metastatic or advanced cancer. | LMWH is preferred for long-term therapy. |
| In patients not treated with LMWH, VKA therapy is preferred to dabigatran or rivaroxaban [2C].* Patients receiving extended therapy should continue with the same agent used for the first 3 mo of treatment [2C].* | Warfarin 2.5-5 mg every day initially with subsequent dosing based on INR value targeted at 2-3. | VKAs (target INR, 2-3) are acceptable for long-term therapy if LMWH is not available. | |
| Duration of treatment | Extended anticoagulant therapy is preferred to 3 mo of treatment [2B].* | Minimum 3 mo. | At least 6 mo duration. |
| Indefinite anticoagulant if active cancer or persistent risk factors. | Extended anticoagulation with LMWH or VKA may be considered beyond 6 mo for patients with metastatic disease or patients who are receiving chemotherapy. |
| . | ACCP 201221 . | NCCN 201113 . | ASCO 201314 . |
|---|---|---|---|
| Initial/acute treatment | Not addressed in cancer patients. | LMWH | LMWH is preferred for initial 5-10 d of treatment in patients with a CrCl >30 mL/min. |
| Dalteparin 200 U/kg OD | |||
| Enoxaparin 1 mg/kg BID | |||
| Tinzaparin 175 U/kg OD | |||
| Fondaparinux 5 mg (<50 kg), 7.5 mg (50-100 kg), or 10 mg (>100 kg) OD | |||
| APTT-adjusted UFH infusion | |||
| Long-term treatment | LMWH preferred to VKA [2B].* | LMWH is preferred for first 6 mo as monotherapy without warfarin in patients with proximal DVT or PE and metastatic or advanced cancer. | LMWH is preferred for long-term therapy. |
| In patients not treated with LMWH, VKA therapy is preferred to dabigatran or rivaroxaban [2C].* Patients receiving extended therapy should continue with the same agent used for the first 3 mo of treatment [2C].* | Warfarin 2.5-5 mg every day initially with subsequent dosing based on INR value targeted at 2-3. | VKAs (target INR, 2-3) are acceptable for long-term therapy if LMWH is not available. | |
| Duration of treatment | Extended anticoagulant therapy is preferred to 3 mo of treatment [2B].* | Minimum 3 mo. | At least 6 mo duration. |
| Indefinite anticoagulant if active cancer or persistent risk factors. | Extended anticoagulation with LMWH or VKA may be considered beyond 6 mo for patients with metastatic disease or patients who are receiving chemotherapy. |
ACCP, American College of Chest Physicians; BID, twice-daily dosing; NCCN, National Comprehensive Cancer Network; OD, once-daily dosing.
ACCP adaptation of the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) Working Group evidence-based recommendations: 2B, weak recommendation, moderate-quality evidence; 2C, weak recommendation, low- or very-low-quality evidence.16