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Venous Thromboembolism Prophylaxis and Treatment in Patients with Cancer

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3 ➤ 2.3. Patients with multiple myeloma receiving thalidomide- or lenalidomide-based regimens with chemotherapy and/or dexamethasone should be offered pharmacologic thromboprophylaxis with either aspirin or LMWH for lower-risk patients and LMWH for higher-risk patients. (Strong Recommendation; EB-I) ➤ 3.1. All patients with malignant disease undergoing major surgical intervention should be offered pharmacologic thromboprophylaxis with either unfractionated heparin (UFH) or LMWH unless contraindicated because of active bleeding, or high bleeding risk, or other contraindications. (Strong Recommendation; EB-H) ➤ 3.2. Prophylaxis should be commenced preoperatively. (Moderate Recommendation; EB-I) ➤ 3.3. Mechanical methods may be added to pharmacologic thromboprophylaxis but should not be used as monotherapy for VTE prevention unless pharmacologic methods are contraindicated because of active bleeding or high bleeding risk. (Strong Recommendation; EB-I) ➤ 3.4. A combined regimen of pharmacologic and mechanical prophylaxis may improve efficacy, especially in the highest-risk patients. (Moderate Recommendation; EB-I) ➤ 3.5. Pharmacologic thromboprophylaxis for patients undergoing major surgery for cancer should be continued for at least 7–10 days. Extended prophylaxis with LMWH for up to 4 weeks postoperatively is recommended for patients undergoing major open or laparoscopic abdominal or pelvic surgery for cancer who have high-risk features such as restricted mobility, obesity, history of VTE, or with additional risk factors. In lower-risk surgical settings, the decision on appropriate duration of thromboprophylaxis should be made on a case-by-case basis. (Strong Recommendation; EB-H) ➤ 4.1. Initial anticoagulation may involve LMWH, UFH, fondaparinux, or rivaroxaban. For patients initiating treatment with parenteral anticoagulation, LMWH is preferred over UFH for the initial 5–10 days of anticoagulation for the patient with cancer with newly diagnosed VTE who does not have severe renal impairment (defined as creatinine clearance <30 mL/min). (Strong Recommendation; EB-H) Treatment

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