CATCH: Stay the Course With Low-Molecular-Weight Heparin for VTE in Cancer Patients

Samuel Z. Goldhaber, MD


March 03, 2016

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Samuel Z. Goldhaber, MD:Hello. This is Dr Sam Goldhaber for the Clot Blog at on Medscape, speaking to you from the American Heart Association (AHA) Scientific Sessions in Orlando, Florida.

Today I'm going to speak about cancer patients who are stricken with acute [deep venous thromboembolism] DVT or pulmonary embolism and how we should best anticoagulate them.

There was an important recent trial[1] published by Dr Agnes Lee, a randomized control trial of about 900 cancer patients with acute venous thromboembolism. They were randomized to receive either the low-molecular-weight heparin tinzaparin as monotherapy, or low-molecular-weight heparin as a bridge to warfarin.

The primary end points were prevention of recurrent venous thromboembolism and prevention of major bleeding.

What was found is that with tinzaparin there was a strong tendency—that was not quite statistically significant—toward a reduction in recurrent venous thromboembolism, compared with warfarin. In terms of major bleeding events, again there was a tendency toward fewer overall bleeding events with tinzaparin compared with warfarin.

Now, I will say that all three of the major guidelines from cancer societies show that they all endorse low-molecular-weight heparin as monotherapy. And this is based on the Agnes Lee study published in the New England Journal of Medicine[2] 12 years ago, called the CLOT trial. In that trial, Dr Lee showed that with a low-molecular-weight heparin, dalteparin, there was about a 50% reduction in recurrent venous thromboembolism, compared with dalteparin bridged to warfarin.

What happened over the ensuing 12 years is that the event rates actually became lower in all cancer patients with acute venous thromboembolism. And, furthermore, even though there were 900 patients in the current trial compared with about 600 patients in the prior trial, the event rates were not quite sufficient to power the trial the way one would have wanted to.

So we ended up with a slightly underpowered trial, but it really gives us the same message: that low-molecular-weight heparin as monotherapy continues to be the most effective approach to patients with cancer and venous thromboembolism.

I will say, from my personal experience taking care of cancer patients with VTE, that after about 6 to 12 months, they really want to switch away from daily injections of low-molecular-weight heparin. And so far we don't have any tested alternatives to offer them, other than warfarin. There are now trials that are under way with edoxaban (Lixiana, Daiichi Sankyo) and rivaroxaban (Xarelto, Bayer Pharma/Janssen Pharmaceuticals) going head to head against low-molecular-weight heparin as monotherapy. So we'll have to stay tuned for the results of those trials.

In the meantime, I think we should try to stick with low-molecular-weight heparin as monotherapy as our first-line therapy for cancer patients with either acute DVT or acute pulmonary embolism. And if the patients do insist on stopping injections, we could either give them warfarin or one of the novel oral anticoagulants.

This is Dr Sam Goldhaber signing off for the Clot Blog.


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