And the Answer Is...
Answer: Low molecular weight heparin
Venous thromboembolism (VTE) is a serious health threat among cancer patients. Although low molecular weight heparin (LMWH) is recommended for the initial 5 to 10 days of treatment for cancer patients with established VTE, Dr. Alok Khorana, of the Cleveland Clinic’s Department of Hematology and Medical Oncology, said little is known about what treatments patients receive in the real-world setting. His recent review of nearly 3,000 cancer patients who were diagnosed with an initial VTE episode between January 2013 and December 2014 provided some insights. The findings, which he presented at the 2015 annual meeting of the American Society of Hematology, revealed that only about a quarter of the patients received LMWH, another quarter of the patients received the direct oral anticoagulant (DOAC) rivaroxaban, and approximately half of the patients received warfarin alone or in combination with LMWH.
Why isn’t LMWH, the guideline-approved first-line treatment option, used more often? Dr. Khorana said convenience and cost are factors; prescribers might hesitate to add a daily self-injection to an already burdensome cancer therapy regimen, and both the acquisition costs and direct-to-patient expenses of LMWH are substantially greater than warfarin. Dr. Khorana said his research highlighted a need for clinicians to do a better job of complying with national treatment guidelines and that it’s time to move away from treating cancer-associated VTE with warfarin, which carries risks of drug-drug interactions and bleeding events. He also suggested DOACs, which are at least as effective as warfarin in reducing clotting risks and clearly more convenient, are appropriate treatment options in carefully selected patients. Future research is needed to directly compare the efficacy of rivaroxaban and other DOACs with LMWH in order to develop anticoagulant strategies that are based on an individual’s VTE risk factors, according to Dr. Khorana.
—Dan Cook
