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Editor's Choice - A Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients with Cancer.
Eur J Vasc Endovasc Surg. 2019 May; 57(5):685-701.EJ

Abstract

OBJECTIVE/BACKGROUND

The aim was to review the relative efficacy and safety of anticoagulation for managing venous thromboembolism (VTE) in patients with cancer.

METHODS

A systematic review and meta-analysis was carried out. On 17 May 2018 the MEDLINE and Scopus databases were searched for randomised controlled trials (RCTs). Eligible RCTs had to be performed in patients with cancer exclusively or to report results on a subset of patients with cancer. The main study outcomes (efficacy/recurrent VTE and safety/bleeding events) were expressed as risk ratios (RR) with a 95% confidence interval (CI). The quality of evidence was assessed following the GRADE method.

RESULTS

Twenty-three RCTs with 6980 patients were identified. Low molecular weight heparins (LMWHs) were more effective than vitamin K antagonists (VKAs) in preventing recurrent VTE (RR 0.58, 95% CI 0.45-0.75) and deep vein thrombosis (RR 0.44, 95% CI 0.29-0.69) but not pulmonary embolism (PE), bleeding, or overall mortality. Direct oral anticoagulants (DOACs) were more effective than VKAs in preventing recurrent VTE (RR 0.65, 95% CI 0.45-0.95) but not DVT, PE, overall mortality, or bleeding. However, anti-Xa DOACs were more effective (RR for VTE 0.64, 95% CI 0.42-0.97) and caused less bleeding than VKAs, although major bleeding was reduced only with DOACs not requiring initial parenteral anticoagulation (RR 0.45, 95% CI 0.21-0.97). In a direct comparison, DOACs were more effective than LMWHs in preventing VTE recurrence (RR 0.64, 95% CI 0.45-0.90) but caused more major bleeding (RR 1.75, 95% CI 1.10-2.77), with no difference in fatal bleeding and overall mortality. Quality of evidence, where sufficient, was mostly moderate or high.

CONCLUSION

Compared with VKAs, LMWHs and DOACs are more effective in treating VTE, but the former caused less bleeding. DOACs are more effective than LMWHs in preventing VTE recurrence but may carry a higher risk of major bleeding, pending additional information by ongoing trials.

Authors+Show Affiliations

Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.Department of Vascular Surgery, University Hospital of Patras, Patras, Greece. Electronic address: kakkos@upatras.gr.Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.

Pub Type(s)

Journal Article
Meta-Analysis
Systematic Review

Language

eng

PubMed ID

31097186

Citation

Kirkilesis, George I., et al. "Editor's Choice - a Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients With Cancer." European Journal of Vascular and Endovascular Surgery : the Official Journal of the European Society for Vascular Surgery, vol. 57, no. 5, 2019, pp. 685-701.
Kirkilesis GI, Kakkos SK, Tsolakis IA. Editor's Choice - A Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients with Cancer. Eur J Vasc Endovasc Surg. 2019;57(5):685-701.
Kirkilesis, G. I., Kakkos, S. K., & Tsolakis, I. A. (2019). Editor's Choice - A Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients with Cancer. European Journal of Vascular and Endovascular Surgery : the Official Journal of the European Society for Vascular Surgery, 57(5), 685-701. https://doi.org/10.1016/j.ejvs.2018.11.004
Kirkilesis GI, Kakkos SK, Tsolakis IA. Editor's Choice - a Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients With Cancer. Eur J Vasc Endovasc Surg. 2019;57(5):685-701. PubMed PMID: 31097186.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Editor's Choice - A Systematic Review and Meta-Analysis of the Efficacy and Safety of Anticoagulation in the Treatment of Venous Thromboembolism in Patients with Cancer. AU - Kirkilesis,George I, AU - Kakkos,Stavros K, AU - Tsolakis,Ioannis A, PY - 2018/09/17/received PY - 2018/11/08/accepted PY - 2019/5/18/entrez PY - 2019/5/18/pubmed PY - 2019/7/3/medline KW - Anticoagulation KW - Cancer KW - Venous thromboembolism SP - 685 EP - 701 JF - European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery JO - Eur J Vasc Endovasc Surg VL - 57 IS - 5 N2 - OBJECTIVE/BACKGROUND: The aim was to review the relative efficacy and safety of anticoagulation for managing venous thromboembolism (VTE) in patients with cancer. METHODS: A systematic review and meta-analysis was carried out. On 17 May 2018 the MEDLINE and Scopus databases were searched for randomised controlled trials (RCTs). Eligible RCTs had to be performed in patients with cancer exclusively or to report results on a subset of patients with cancer. The main study outcomes (efficacy/recurrent VTE and safety/bleeding events) were expressed as risk ratios (RR) with a 95% confidence interval (CI). The quality of evidence was assessed following the GRADE method. RESULTS: Twenty-three RCTs with 6980 patients were identified. Low molecular weight heparins (LMWHs) were more effective than vitamin K antagonists (VKAs) in preventing recurrent VTE (RR 0.58, 95% CI 0.45-0.75) and deep vein thrombosis (RR 0.44, 95% CI 0.29-0.69) but not pulmonary embolism (PE), bleeding, or overall mortality. Direct oral anticoagulants (DOACs) were more effective than VKAs in preventing recurrent VTE (RR 0.65, 95% CI 0.45-0.95) but not DVT, PE, overall mortality, or bleeding. However, anti-Xa DOACs were more effective (RR for VTE 0.64, 95% CI 0.42-0.97) and caused less bleeding than VKAs, although major bleeding was reduced only with DOACs not requiring initial parenteral anticoagulation (RR 0.45, 95% CI 0.21-0.97). In a direct comparison, DOACs were more effective than LMWHs in preventing VTE recurrence (RR 0.64, 95% CI 0.45-0.90) but caused more major bleeding (RR 1.75, 95% CI 1.10-2.77), with no difference in fatal bleeding and overall mortality. Quality of evidence, where sufficient, was mostly moderate or high. CONCLUSION: Compared with VKAs, LMWHs and DOACs are more effective in treating VTE, but the former caused less bleeding. DOACs are more effective than LMWHs in preventing VTE recurrence but may carry a higher risk of major bleeding, pending additional information by ongoing trials. SN - 1532-2165 UR - https://www.unboundmedicine.com/medline/citation/31097186/Editor's_Choice___A_Systematic_Review_and_Meta_Analysis_of_the_Efficacy_and_Safety_of_Anticoagulation_in_the_Treatment_of_Venous_Thromboembolism_in_Patients_with_Cancer_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S1078-5884(18)30850-5 DB - PRIME DP - Unbound Medicine ER -