ASCO GUIDELINES Bundle

7 Table 1. Contraindications to Therapeutic Anticoagulant in Patients with Cancer a – Footnotes a ese criteria are specific for therapeutic doses of anticoagulation and should not be applied to prophylactic doses of anticoagulation. Please refer to the DOAC section in the full text guidelines for additional safety considerations. e following settings also do not have adequate safety data for DOAC use — most high risk bleeding settings including but not necessarily limited to active mucosal bleeding, active mucosal tumors (given the observed increased bleeding risk in such settings, especially mucosal areas that absorb or renally clear the drug such as gastrointestinal and genitourinary malignancies prior to definitive cancer surgery), hemorrhagic malignant and non- malignant lesions, intracranial or CNS bleeding within past 4 weeks, serious nausea or vomiting precluding adequate oral DOAC intake, or conditions limiting drug absorption in general. b Absolute contraindications are situations in which anticoagulation should not be given because the risk of harm associated with bleeding is very likely to exceed the potential benefit from anticoagulation. c Relative contraindications are situations in which anticoagulation may be given if the risk of recurrent or progressive thrombosis is estimated to exceed the risk of bleeding. Due to DOACs' increased risk for major bleeding events compared to LMWHs in the VTE treatment setting, LMWHs are generally the preferred agents in settings with an increased bleeding risk, especially in settings of relative contraindications. Patient preferences also need to be taken into consideration when making anticoagulation choices. d ere is limited evidence regarding the safety of DOAC use in this setting. e e panel was not unanimous in the decision to list these as relative contraindications for DOAC, since we do not have adequate safety data in these clinical settings. Given the known increased risk in major and clinically-relevant non-major bleeding for DOAC compared to LMWH in the VTE treatment setting, these relative contraindications for non-DOAC anticoagulants may be considered absolute contraindications for DOAC use in some patients. Additional potential contraindications exist for DOAC including : non-healed surgical site in the perioperative period, trauma conferring a high bleeding risk, minor hemorrhagic malignant or non-malignant lesions, treated brain metastases, other central nervous system malignancies, the use of cyberknife, presence of lesser drug-drug interactions potentially impacting drug efficacy or safety, anticipated nausea or vomiting impacting oral DOAC intake, obesity (body mass index [BMI] >40 or a weight of >120 kg ). Table 2. Predictive Model for Chemotherapy-associated VTE in the Ambulatory Setting Patient Characteristic Points Site of cancer Very high risk (stomach, pancreas) 2 High risk (lung, lymphoma, g ynecologic, bladder, testicular, renal) 1 Pre-chemotherapy platelet count ≥350,000/µL 1 Hemoglobin level <10g/dL or use of red cell growth factors 1 Pre-chemotherapy leukocyte count >11,000/µL 1 Body mass index ≥35 kg/m 2 1 Calculate Total Score, adding points for each criterion in the model Interpretation High-risk score ≥3 points Intermediate risk score = 1–2 points Low-risk score = 0 points Adapted from: Khorana AA, Kuderer NM, Culakova E, et al: Development and validation of a predictive model for chemotherapy-associated thrombosis. Blood 2008;111:4902-7.

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