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Think about how you would treat the following patient.
Previously, there was often clinical uncertainty on the use of oral anticoagulants to treat cancer-associated thrombosis (CAT). However, in 2019, several guidelines were brought up to date with clinical evidence and now provide clear advice on protecting patients with cancer from venous thromboembolism (VTE).
The 2019 European Society of Cardiology (ESC) Guidelines for the Management of PE, the 2019 American Society of Clinical Oncology (ASCO) Guidelines Update for VTE Treatment in Patients with Cancer and the 2019 International Initiative on Thrombosis and Cancer (ITAC) Guidelines for the Treatment of VTE in Patients with Cancer all provide guidance on the situations where patients can be switched to oral anticoagulation.1-3
These new recommendations are based on the results of multiple clinical trials that show that, with regard to efficacy and safety, rivaroxaban or edoxaban are suitable alternatives to LMWH.4-6
So, would Joyce be considered suitable for anticoagulation with an oral anticoagulant?
Assuming that her renal function was not severely impaired (i.e. ≥30 ml/min) and that she did not have a high-risk of gastrointestinal or genitourinary bleeding, all three 2019 clinical guidelines would recommend rivaroxaban, edoxaban or LMWH equally for up to 6 months.-13
Beyond 6 months, extended anticoagulation would depend on an assessment of Joyce’s individual risk of recurrent VTE. If her risk of recurrence justified extended anticoagulation, continuation on rivaroxaban or edoxaban would be appropriate.1-3
Joyce is unlikely to be alone in wanting to stop parenteral anticoagulation.
The COSIMO study found that, assuming equal efficacy and safety, route of administration was the single most important factor that affected the treatment preferences of patients with CAT – more so than interactions with food or alcohol, or distance to visit the doctor. Unsurprisingly, oral administration was preferred to parenteral.7
Patients in COSIMO ranked route of administration as the most important element of anticoagulation treatment7
COSIMO also evaluated the change in patient-reported outcomes in patients with CAT who switched to rivaroxaban from standard of care (in 96.6% of cases this was LMWH therapy).8
Following the switch, patient-reported treatment satisfaction was significantly increased after 4 weeks, and this difference was maintained at 6 months.8Based on these data, switching Joyce to rivaroxaban would allow her to see a rapid improvement in her quality of life.
Until recently, there was uncertainty around whether non-vitamin K antagonist oral anticoagulants were suitable alternatives to LMWH. However, in light of recent data showing the efficacy and safety of rivaroxaban and edoxaban, updated guidelines now provide reassurance that patients with CAT can often be treated with these anticoagulants.1-3
Today, the major question around anticoagulation in patients with CAT is how treatment choices affect outcomes beyond efficacy and safety. Rivaroxaban is currently the only non-vitamin K antagonist oral anticoagulant with published data showing how it can improve the patient experience of anticoagulation.7,8
When treating patients like Joyce, always consider how anticoagulation decisions can both prevent a devastating VTE recurrence and allow patients to focus on living their lives.