Direct oral anticoagulants lower VTE recurrence risk in cancer-associated thrombosis
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Key takeaways:
- Low molecular-weight heparin and warfarin appeared associated with a higher risk for VTE recurrence in comparison.
- Researchers observed an increased risk for major bleeds and all-cause mortality with LMWH.
Direct oral anticoagulants for cancer-associated thrombosis appeared associated with lower risk for venous thromboembolism recurrence and major bleeds, as well as a reduction in mortality rates, among patients with cancer.
The findings, published in JAMA Network Open, additionally showed that warfarin may still be considered for patients with contraindications to direct oral anticoagulants and patients with poor persistence on low-molecular-weight heparin (LMWH).
Rationale and methodology
“Patterns of clinical utilization and comparative effectiveness of anticoagulants for cancer-associated thrombosis remain largely unexplored,” Irbaz Bin Riaz, MD, PhD, researcher in the department of hematology/oncology at Mayo Clinic, and colleagues wrote.
The retrospective cohort study included 5,100 patients (mean age, 66.3 years; 52.4% women; 69.8% white) with active cancer in a clinical setting included in OptumLabs electronic health record claims database between Jan. 1, 2012, and Sept. 30, 2019.
Riaz and colleagues sought to assess the patterns of and factors associated with anticoagulant use and to evaluate the comparative effectiveness of contemporary anticoagulants.
They grouped patients according to the anticoagulant prescribed, including direct oral anticoagulants, LMWH and warfarin. Researchers used ORs to show the association between factors of interest and use of anticoagulants.
Risk for VTE recurrence and all-cause mortality served as main efficacy outcomes, with risk for hospitalization due to major bleed as main safety outcomes.
Findings
Nearly half of filled prescriptions were for direct oral anticoagulants (49.3%), followed by LMWH (29.2%) and warfarin (28.6%). Median treatment duration was 3.2 months for direct oral anticoagulants, 3.1 months for warfarin and 1.8 months for LWMH.
Results showed an increase in prescription fills for LMWH vs. direct oral anticoagulants among patients with lung (OR = 2.07; 95% CI, 1.12-3.65), urologic (OR = 1.94; 95% CI,1.08-3.49), gynecologic (OR = 4.25; 95% CI, 2.31-7.82) and colorectal (OR = 2.26; 95% CI, 1.2-4.32) cancers.
LMWH (HR = 1.47; 95% CI, 1.14-1.9) and warfarin (HR = 1.46; 95% CI, 1.13-1.87) appeared associated with increased risk for VTE recurrence compared with direct oral anticoagulants. Moreover, LMWH appeared associated with an increased risk for major bleeding (HR = 2.27; 95% CI, 1.62-3.2) and higher all-cause mortality (HR = 1.61; 95% CI, 1.15-2.25) compared with direct oral anticoagulants.
Limitations of the study included information bias, the use of International Classification Disease billing codes to identify patients with VTE and a lack of radiologic evidence of VTE in the database.
Implications
The findings “reinforce the general efficacy and safety of direct oral anticoagulants in this patient population; they were associated with a nearly 50% reduction in VTE recurrence rates and a more than twofold reduction in hospitalization for major bleeding compared with LMWH therapy,” the researchers wrote.
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