Drug Topics - February 11, 2008 - (Page HSE7) www.drugtopics.com FEBRUARY 11, 2008 DRUG TOPICS HSE 7 Clinical Practice ASCO issues VTE guide specific to cancer patients Heidi Belden, Pharm.D. enous thromboembolism (VTE) is data, the need for laboratory monitoring, a major complication of cancer that and a relatively low VTE incidence in occurs in 4% to 20% of patients, a this population. “However, patients refact that may not be known by many ceiving treatment with thalidomide healthcare professionals. For this reason, (Thalomid, Celgene) or lenalidomide the American Society of Clinical Oncol(Revlimid, Celgene) plus chemotherapy ogy (ASCO) recently developed new or dexamethasone are at high risk for guidelines for the use of anticoagulation thrombosis and warrant prophylaxis,” exfor the prevention and treatment of VTE plained Shapiro, who also helps run a Nancy Shapiro in patients with cancer. pharmacist-managed antithrombosis “Patients with cancer have a 4.1-fold notes that cancer clinic at her institution. Either LMWH patients are more increased rate of VTE than non-cancer or adjusted-dose warfarin (INR~1.5) is prone to deep patients, and those receiving chemother- vein thrombosis recommended for this group. “There is apy have a 6.5-fold increased risk of than non-cancer still the need for randomized controlled patients VTE,” said Nancy L. Shapiro, Pharm.D., trials to determine the optimal form of BCPS, clinical assistant professor at the University prophylaxis in these myeloma patients,” she said. of Illinois College of Pharmacy. Cancer patients account for 20% of all patients with VTE and How guidelines were developed those on chemotherapy make up 13% of the total ASCO described its guidelines as different from burden, she explained. other organizations in that it focuses exclusively on cancer patients and are based on a comprehensive Which drugs to use review of the literature. Recommendations were The bottom-line message for all cancer patients developed from results of randomized clinical triwho are hospitalized is that VTE prophylaxis als that evaluated the safety and efficacy of anticoshould be initiated. Low-dose unfractionated he- agulants in cancer patients, focusing on prevention parin (UFH), low molecular weight heparin of VTE, adverse events, and overall survival. (LMWH), or fondaparinux (Arixtra, GlaxoThe agent of choice for both initial and longSmithKline) may be used, as long as no contraindi- term treatment (at least six months) of cancer pacation or active bleeding exists. According to tients with an established VTE (to prevent recurASCO, VTE incidence in hospitalized patients rence) is LMWH. Vitamin K antagonists may be with cancer ranges from 0.6% to 18%. used if LMWH is unavailable. Vena cava filter inIn addition, hospitalized patients undergoing ma- sertion is recommended when a patient has conjor surgery for malignant disease should be considered traindications to anticoagulation or when VTE refor thromboprophylaxis. Anticoagulation should be- curs while patients are on long-term LMWH gin pre-operatively or as soon as possible post opera- therapy. Patients who develop a VTE should be antion and should continue for at least seven to 10 days ticoagulated for at least six months and perhaps post-op following laparotomy, laparoscopy, or thora- longer if they continue treatment for active cancer, cotomy. Prophylaxis for up to four weeks could be according to ASCO. more effective following major abdominal or pelvic “Reducing VTE in cancer patients can have a sigsurgery with high-risk factors, such as residual cancer, nificant impact on morbidity, mortality, outcomes, obesity, and previous VTE. and use of healthcare resources,” Shapiro concluded. The new guidelines, Recommendations for Venous Role of prophylaxis Thromboembolism Prophylaxis and Treatment in PaAccording to the guideline panel, routine prophy- tients with Cancer, was published in the December 1, laxis is not recommended for ambulatory patients 2007, issue of the Journal of Clinical Oncology and is during systemic chemotherapy, due to conflicting available online at www.asco.org/guidelines. DT V http://www.drugtopics.com http://www.asco.org/guidelines
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