ASCO GUIDELINES Bundle

10 Treatment Table 3. Dosing Regimens for Prophylaxis/Treatment of VTE in Patients with Cancer – Footnotes a All doses are given as subcutaneous injections except as indicated; renal and liver function as well as weight and potential drug-drug interactions must be taken into account when selecting agents and doses. Inducers or inhibitors of p-glycoprotein can interact with edoxaban, rivaroxaban, and apixaban. Inducers or inhibitors of cytochrome P450 3A4 can interact with rivaroxaban and apixaban. Please see the FDA package inserts for further dosing information, including renal or liver function dose adjustment needs. b Duration for medical patients is for the length of hospital stay or until fully ambulatory; for surgical patients, prophylaxis should be continued for ≥7–10 days. Extended prophylaxis for ≤4 weeks should be considered for high-risk patients. Duration for outpatient prophylaxis is somewhat uncertain, since most studies did not assess beyond 6 months. c Unfractionated heparin 5,000 U every 12 hours has also been used in moderate-risk cancer but appears to be less effective, particularly in oncologic surgery. d is drug is not approved by the U.S. Food and Drug Administration for this indication. e UFH: e first prophylactic UFH dose should be administered no sooner than 1h aer needle/catheter placement. In patients receiving preoperative prophylactic low dose UFH, neuraxial puncture/catheter manipulation or removal should not occur within the first 4–6h aer UFH administration. Subsequent UFH administration may occur no earlier than 1h aer catheter removal. In patients receiving preoperative therapeutic UFH (>15,000 U/24h), neuraxial block/catheter removal or manipulation should not occur within 12 h aer UFH administration. LMWH: e first prophylactic LMWH dose should be administered no sooner than 4h aer needle/catheter placement. In patients receiving preoperative prophylactic LMWH doses, neuraxial puncture/catheter manipulation or removal should not occur within the first 12 h aer LMWH administration. Subsequent LMWH administration may occur no earlier than 4h aer catheter removal. In patients receiving preoperative therapeutic LMWH doses, neuraxial block/catheter removal or manipulation should not occur within 24 h aer heparin administration. Clinicians should refer to their institutional guidelines and/or the American Society of Regional Anesthesia Guidelines for more detailed information about LMWH and other agents. f Clinicians should follow the regimens for the initiation and dosing of preoperative LMWH approved by regulatory agencies, as shown in the package insert. g Higher prophylactic doses were used for pancreatic cancer patients: dalteparin 200 IU/ kg once daily for 4 weeks followed by a stepdown to 150 IU/kg for a further 8 weeks in FRAGEM and enoxaparin 1 mg/kg once daily in CONKO-004. h Fondaparinux has not been studied in the outpatient prophylaxis setting. It should be considered only if the patient has contraindications for other LMWH and DOAC use is considered an inferior option. i Contraindications to therapeutic anticoagulation are listed in Table 1. j Parenteral anticoagulants should overlap with warfarin for 5–7 days minimum and should be continued until the INR is in the therapeutic range for 2 consecutive days.

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