11
Table 3. Dosing Regimens for Prophylaxis/Treatment of VTE
in Patients with Cancer – Footnotes
k
Unfractionated heparin infusion rate should be adjusted to maintain the aPTT within
the therapeutic range in accordance with local protocols to correspond with a heparin
level of 0.3–0.7 U/mL using a chromogenic anti-factor Xa assay.
l
Dependent on significant renal clearance, avoid in patients with creatinine clearance
≤30 mL/min or adjust dose based on anti-factor Xa levels.
m
Optimal dose unclear in patients >120 kg.
n
Twice daily dosing may be more efficacious than once daily dosing for enoxaparin
based on post-hoc data.
o
is drug is not available in the U.S.
p
Fondaparinux had a higher rate of recurrent thrombosis and no difference in bleeding
compared with enoxaparin in cancer patients in a post-hoc, subgroup analysis. It is
not a standard option, but may be used for long-term anticoagulation if standard
LMWH or DOAC are not feasible options for the patient. Dosing for long term
treatment with fondaparinux is the same as for initial treatment. (Fondaparinux
Prescribing Information: https://www.accessdata.fda.gov/drugsatfda_docs/
label/2017/021345s035lbl.pdf ).
q
Total duration of therapy depends on clinical circumstances. See full text guideline for
more detailed discussion.
r
Apixaban and dabigatran do not have fully published results from cancer-specific
clinical trials. Prospective randomized trial data in cancer patients with active disease
on cancer therapy are needed prior to their use. erefore, they are currently not
recommended for routine use in cancer patients with active disease.
s
is is the only LMWH with FDA approval for extended therapy to prevent recurrent
thrombosis in cancer patients.
t
Edoxaban has the highest level of evidence for cancer patients among all the DOAC,
followed by rivaroxaban. Limited data from small, unpublished patient series suggest
that the efficacy of DOAC in patients with a weight above 120 kg might be reasonable
based on anti-Xa levels. e data are very limited however, and LMWH are likely still
preferred in this setting. Please refer to the package inserts for detailed information
regarding potential dosing adjustment needs, especially regarding renal impairment,
liver failure, weight extremes, or drug-drug interaction.
(cont'd)
