4
Treatment
➤ 4.2. For long-term anticoagulation, LMWH, edoxaban, or rivaroxaban
for at least 6 months are preferred because of improved efficacy over
vitamin K antagonists (VKA). VKA are inferior but may be utilized
if LMWH or direct oral anticoagulants (DOAC) are not accessible.
There is an increase in major bleeding risk with DOAC, particularly
observed in GI and potentially GU malignancies. Caution with DOAC is
also warranted in other settings with high risk for mucosal bleeding.
Drug-drug interaction should be checked prior to using a DOAC.
(Strong Recommendation; EB-H)
➤ 4.3. Anticoagulation with LMWH, DOAC, or VKA beyond the initial 6
months should be offered to select patients with active cancer, such
as those with metastatic disease or those receiving chemotherapy.
Anticoagulation beyond 6 months needs to be assessed on an
intermittent basis to ensure a continued favorable risk-benefit profile.
(Weak to Moderate Recommendation; IC-L)
➤ 4.4. Based on expert opinion in the absence of randomized trial data,
uncertain short-term benefit, and mounting evidence of long-term
harm from filters, the insertion of a vena cava filter should not be
offered to patients with established or chronic thrombosis (VTE
diagnosis more than 4 weeks ago) nor to patients with temporary
contraindications to anticoagulant therapy (e.g., surgery). There also
is no role for filter insertion for primary prevention or prophylaxis of
PE or DVT due to its long-term harm concerns. It may be offered to
patients with absolute contraindications to anticoagulant therapy in
the acute treatment setting (VTE diagnosis within the past 4 weeks)
if the thrombus burden was considered life-threatening. Further
research is needed. (Moderate Recommendation; IC-L/I)
➤ 4.5. The insertion of a vena cava filter may be offered as an adjunct to
anticoagulation in patients with progression of thrombosis (recurrent
VTE or extension of existing thrombus) despite optimal anticoagulant
therapy. (Weak Recommendation; IC-L/I)
• This is based on the panel's expert opinion, given the absence of a survival
improvement, a limited short-term benefit, but mounting evidence of the long-term
increased risk for VTE.
➤ 4.6. For patients with primary or metastatic central nervous system
malignancies and established VTE, anticoagulation as described for
other patients with cancer should be offered, although uncertainties
remain about choice of agents and selection of patients most likely to
benefit. (Moderate Recommendation; IC-L)
