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Adverse event reporting can be found at the bottom of the page
Prescribing information for Fragmin® (dalteparin sodium) can be found here. Adverse event reporting can be found at the bottom of the page.
Concomitant bleeding risk makes the management of VTE patients challenging. It is crucial to find and anticoagulant that optimally balances efficacy (preventing VTE recurrence) with safety (reducing bleeding risk).1
Choosing the correct anticoagulant to suit your patients individual requirements may be challenging.
Example
Anticoagulant selection and length of therapy may be based on criteria such as: risk of recurrent VTE, risk of bleeding and special patient population characteristics (thrombocytopenia, renal or hepatic insufficiency).2
Over the past 20 years, LMWHs have been recommended as a standard of care for acute and long-term treatment of cancer-associated VTE based on studies comparing low molecular weight heparins (LMWH) to a vitamin K antagonist.3
Direct oral anticoagulants (DOAC) are attractive therapeutic drugs for treating VTE in patients with cancer because of the convenience of oral administration, rapid onset of action, and predictable efficacy and safety.3
There are always situations that need to be considered before using anticoagulants in cancer patients.
According to guidelines from the International Society on Thrombosis and Haemostasis (ISTH), DOACs can be used for the treatment of VTE in cancer patients.4 At the same time, recent studies have shown that while DOACs have a similar risk for VTE recurrence compared to LMWH, the use of DOACs was associated with increased rates of clinically relevant bleeding.1
The ISTH recommends the use of DOACs for:
Cancer patients with an acute diagnosis of VTE, or a low risk of bleeding, and no drug-drug interactions with current systemic therapy.
The ISTH recommends the use of LMWH for:
Cancer patients with an acute diagnosis of VTE and a high risk of bleeding, including patients with luminal gastrointestinal cancers with an intact primary, patients with cancers at risk of bleeding from the genitourinary tract, bladder, or nephrostomy tubes, or patients with active gastrointestinal mucosal abnormalities such as duodenal ulcers, gastritis, esophagitis, or colitis.
Offer people with active cancer and confirmed proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) anticoagulation treatment for 3 to 6 months. Review at 3 to 6 months according to clinical need.
It is clear from these recommendations, that cancer patients have complex clinical history and treatment regimens, and as such, it is critical to balance the risks of thrombosis and haemostasis alongside other contraindications when treating VTE.4
Most guidelines continue to recommend LMWH for at least 3–6 months post-VTE diagnosis owing to the lack of cancer specific data in DOAC use.4
References
Yamani N, Unzek S, Almas T, Musheer A, Ejaz A, Paracha AA, Shahid I, Mookadam F. DOACs or VKAs or LMWH - What is the optimal regimen for cancer-associated venous thromboembolism? A systematic review and meta-analysis. Ann Med Surg (Lond). 2022 Jun 9;79:103925
Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, Stevens SM, Vintch JRE, Wells P, Woller SC, Moores L. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016 Feb;149(2):315–352
Yhim HY. Challenging issues in the management of cancer-associated venous thromboembolism. Blood Res. 2022 Apr 30;57(S1):44–48.
Khorana AA, Noble S, Lee AYY, Soff G, Meyer G, O'Connell C, Carrier M. Role of direct oral anticoagulants in the treatment of cancer-associated venous thromboembolism: guidance from the SSC of the ISTH. J Thromb Haemost. 2018 Sep;16(9):1891–1894.
Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. NG158, published 26 March 2020. Available at: https://www.nice.org.uk/guidance/ng158/chapter/Recommendations [Accessed June 2023]
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