Regular ArticleDose escalation of low molecular weight heparin in patients with recurrent cancer-associated thrombosis
Introduction
Cancer patients are at increased risk of developing a venous thrombosis compared to the general population [1], [2]. Although low molecular weight heparins (LMWH) have improved patient outcomes, patients with cancer-associated thrombosis remain at an increase risk of developing recurrent thrombosis despite anticoagulant therapy [3], [4], [5]. Approximately 10 to 17% of patients with cancer-associated thrombosis managed with a vitamin K antagonist (VKA) and 6 to 10% of patients treated with therapeutic doses of LMWH will have recurrent VTE during the initial 3 to 6 month of therapy [6], [7], [8]. Previous retrospective cohort studies have suggested that switching cancer patients with recurrent cancer-associated thrombosis while on VKA to therapeutic doses of LMWH seemed safe and effective [9], [10]. Similarly, an observation cohort study has also shown that escalating the dose of LMWH (by approximately 25% or increased to therapeutic doses if receiving lower doses) might be a potential treatment option to manage patients with recurrent cancer-associated thrombosis despite LMWH [9]. Although only one retrospective cohort study (n = 47) has shown potential benefit of dose escalation of LMWH, it has been proposed as a management strategy to treat patients with recurrent cancer-associated thrombosis despite anticoagulation [11], [12], [13]. We sought to confirm the benefits and risks associated with this empiric approach.
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Material & Methods
A retrospective cohort study of consecutive cancer outpatients seen for management of a symptomatic recurrent cancer-associated thrombosis while on anticoagulation was undertaken from July 2008 to December 2012. Patients were included if they had: 1) documented active malignancy (receiving therapy (chemotherapy or radiotherapy) or with metastatic disease); 2) objectively proven first episode of symptomatic cancer-related thrombosis (Proximal lower/upper extremity deep vein thrombosis (DVT) or
Results
Fifty-five cancer patients with a recurrent cancer-associated thrombosis despite ongoing anticoagulation were included. Baseline characteristic are depicted in Table 1. The median age was 63 years old (range 22-83). Twenty-eight (50.9%) were female and thirty (54.5%) had metastatic disease at the time of the initial cancer-associated thrombosis. Twenty eight (50.9%) were undergoing chemotherapy at the time of the recurrent event and three (5.5%) underwent a surgical procedure within the previous
Discussion
Our cohort study confirms that recurrent cancer-associated thrombosis can be effectively and safely managed by switching from VKA to LMWH or escalating the dose of LMWH.
Dose escalation of LMWH has been suggested as a treatment option to manage patients with recurrent cancer-associated thrombosis despite anticoagulation following confirmation of drug compliance and exclusion of heparin-induced thrombocytopenia (HIT) [11], [12], [13]. However, this approach was only described and reported in a
Conflict of Interest Statement
All authors have fulfilled the conditions required for authorship and the authors report no potential conflicts of interest.
Acknowlegements
MC is a recipient of a New Investigator Award from the Heart and Stroke Foundation of Canada and of a Tier 2 Research Chair in Thrombosis and Cancer
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