Anticoagulant therapy for acute venous thrombo-embolism in cancer patients: A systematic review and network meta-analysis.
Acute Disease
Administration, Oral
Anticoagulants
/ administration & dosage
Factor Xa Inhibitors
/ administration & dosage
Female
Hemorrhage
/ etiology
Heparin, Low-Molecular-Weight
/ administration & dosage
Humans
Male
Neoplasms
/ complications
Network Meta-Analysis
Recurrence
Risk Factors
Safety
Secondary Prevention
Venous Thromboembolism
/ drug therapy
Vitamin K
/ antagonists & inhibitors
Journal
PloS one
ISSN: 1932-6203
Titre abrégé: PLoS One
Pays: United States
ID NLM: 101285081
Informations de publication
Date de publication:
2019
2019
Historique:
received:
16
01
2019
accepted:
05
03
2019
entrez:
22
3
2019
pubmed:
22
3
2019
medline:
18
12
2019
Statut:
epublish
Résumé
Low-molecular-weight heparin (LMWH) is usually recommended for the treatment of cancer-associated thrombosis (CAT) but this treatment requires burdensome daily injections. We did a systematic review to compare the efficacy and safety of direct oral anticoagulants (DOAC), vitamin K antagonists (VKA) and LMWH in patients with CAT. We searched Pubmed, Embase and CENTRAL for randomised controlled trials comparing DOAC, VKA and LMWH in patients with CAT. Pairwise and network meta-analyses were computed for venous thromboembolism (VTE) recurrence and bleeding complications. We identified 14 studies, including 4,661 patients. In pairwise comparison, DOAC were superior to LMWH to prevent VTE recurrence (HR 0.63; 95% CI 0.42-0.96) and LMWH was superior to VKA (HR 0.53; 95% CI 0.40-0.70). The rate of major bleeding was higher with DOAC compared to LMWH (HR 1.78; 95% CI 1.11-2.87). In the network meta-analysis, DOAC had a lower, but non-significant, rate of VTE recurrence compared to LMWH (HR 0.74; 95% CI 0.54-1.01). Both DOAC (HR 0.42; 95% CI 0.29-0.61) and LMWH (HR 0.57; 95% CI 0.44-0.75) were associated with lower rates of recurrence compared to VKA. No significant difference in major bleeding rate was observed in the network meta-analysis. Inconsistency was observed between pairwise and network meta-analysis comparisons for major bleeding. DOAC are effective to prevent VTE recurrence in patients with CAT but are associated with an increased risk of bleeding compared to LMWH. The choice of anticoagulant should be personalised, taking into account the patient's bleeding risk, including cancer site, and patient's values and preferences.
Sections du résumé
BACKGROUND
Low-molecular-weight heparin (LMWH) is usually recommended for the treatment of cancer-associated thrombosis (CAT) but this treatment requires burdensome daily injections. We did a systematic review to compare the efficacy and safety of direct oral anticoagulants (DOAC), vitamin K antagonists (VKA) and LMWH in patients with CAT.
METHODS
We searched Pubmed, Embase and CENTRAL for randomised controlled trials comparing DOAC, VKA and LMWH in patients with CAT. Pairwise and network meta-analyses were computed for venous thromboembolism (VTE) recurrence and bleeding complications.
RESULTS
We identified 14 studies, including 4,661 patients. In pairwise comparison, DOAC were superior to LMWH to prevent VTE recurrence (HR 0.63; 95% CI 0.42-0.96) and LMWH was superior to VKA (HR 0.53; 95% CI 0.40-0.70). The rate of major bleeding was higher with DOAC compared to LMWH (HR 1.78; 95% CI 1.11-2.87). In the network meta-analysis, DOAC had a lower, but non-significant, rate of VTE recurrence compared to LMWH (HR 0.74; 95% CI 0.54-1.01). Both DOAC (HR 0.42; 95% CI 0.29-0.61) and LMWH (HR 0.57; 95% CI 0.44-0.75) were associated with lower rates of recurrence compared to VKA. No significant difference in major bleeding rate was observed in the network meta-analysis. Inconsistency was observed between pairwise and network meta-analysis comparisons for major bleeding.
CONCLUSIONS
DOAC are effective to prevent VTE recurrence in patients with CAT but are associated with an increased risk of bleeding compared to LMWH. The choice of anticoagulant should be personalised, taking into account the patient's bleeding risk, including cancer site, and patient's values and preferences.
Identifiants
pubmed: 30897142
doi: 10.1371/journal.pone.0213940
pii: PONE-D-19-01502
pmc: PMC6428324
doi:
Substances chimiques
Anticoagulants
0
Factor Xa Inhibitors
0
Heparin, Low-Molecular-Weight
0
Vitamin K
12001-79-5
Types de publication
Journal Article
Meta-Analysis
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
e0213940Déclaration de conflit d'intérêts
We have read the journal's policy and the authors of this manuscript have the following competing interests: A. Addeo reports consulting honoraria from Bristol Myers Squibb, MSD, Roche, Pfizer, Boehringher, AstraZeneca. Travel grant form Roche, MSD. Research grant form Boehringher. C. Marti reports participation to an advisory board for Daichii Sankyo. H. Robert-Ebadi reports participation to patient inclusion in the Einstein and Einstein-choice studies (Bayer), and in the Hokusai VTE study (Daichi Sankyo) and speakers honoria to her institution (Daichii Sankyo). JL Reny received a travel grant by Bayer. Other auhors have declared that no competing interests exist. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
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