Direct oral anticoagulants for cancer associated venous thromboembolisms: a systematic review and network meta-analysis
View/ Open
File version
Accepted Manuscript (AM)
Author(s)
Samaranayake, Chinthaka B
Anderson, James
McCabe, Colm
Zahir, Syeda Farah
Upham, John
Keir, Gregory
Griffith University Author(s)
Year published
2020
Metadata
Show full item recordAbstract
BACKGROUND: Several recent randomized controlled trials (RCTs) have investigated the use of direct oral anticoagulants (DOACs) in the treatment of malignancy associated venous thromboembolisms (VTE). AIMS: This meta-analysis combines all RCT data to determine the risks of recurrent VTE and bleeding with DOACs in patients with malignancy associated VTE compared to low molecular weight heparin (LMWH). METHODS: The study followed PRISMA guidelines. MEDLINE, EMBASE, CENTRAL were systematically searched from inception to 1st of April 2020. References of reviews and relevant conference proceedings were hand-searched. Two authors ...
View more >BACKGROUND: Several recent randomized controlled trials (RCTs) have investigated the use of direct oral anticoagulants (DOACs) in the treatment of malignancy associated venous thromboembolisms (VTE). AIMS: This meta-analysis combines all RCT data to determine the risks of recurrent VTE and bleeding with DOACs in patients with malignancy associated VTE compared to low molecular weight heparin (LMWH). METHODS: The study followed PRISMA guidelines. MEDLINE, EMBASE, CENTRAL were systematically searched from inception to 1st of April 2020. References of reviews and relevant conference proceedings were hand-searched. Two authors independently evaluated study eligibility, extracted data, and assessed risk-of-bias. Direct and indirect meta-analyses were performed. RESULTS: In four RCTs with low risk-of-bias (2907 patients), high certainty evidence suggested that DOACs had a 37% reduction in risk of recurrent VTE compared to LMWH (direct pooled risk ratio (RR) 0.63, 95%CI 0.44-0.91; I2 = 28%). No significant difference was observed in the risk of major bleeding with DOACs compared to LMWH (RR 1.31, 95%CI 0.83-2.07; I2 = 22%; moderate certainty evidence), including in patients in gastrointestinal and genitourinary malignancy. An increased risk of combined major or CRNMB was seen with DOACs (RR 1.52, 95%CI 1.09-2.12; I2 = 51%; low certainty evidence). Apixaban had the highest probability of being ranked most effective and least bleeding risk amongst the DOACs. CONCLUSION: DOACs are effective in treating malignancy associated VTE, however caution is required in patients with high risk of bleeding. Apixaban had lower risk of bleeding compared to other DOACs in this population.
View less >
View more >BACKGROUND: Several recent randomized controlled trials (RCTs) have investigated the use of direct oral anticoagulants (DOACs) in the treatment of malignancy associated venous thromboembolisms (VTE). AIMS: This meta-analysis combines all RCT data to determine the risks of recurrent VTE and bleeding with DOACs in patients with malignancy associated VTE compared to low molecular weight heparin (LMWH). METHODS: The study followed PRISMA guidelines. MEDLINE, EMBASE, CENTRAL were systematically searched from inception to 1st of April 2020. References of reviews and relevant conference proceedings were hand-searched. Two authors independently evaluated study eligibility, extracted data, and assessed risk-of-bias. Direct and indirect meta-analyses were performed. RESULTS: In four RCTs with low risk-of-bias (2907 patients), high certainty evidence suggested that DOACs had a 37% reduction in risk of recurrent VTE compared to LMWH (direct pooled risk ratio (RR) 0.63, 95%CI 0.44-0.91; I2 = 28%). No significant difference was observed in the risk of major bleeding with DOACs compared to LMWH (RR 1.31, 95%CI 0.83-2.07; I2 = 22%; moderate certainty evidence), including in patients in gastrointestinal and genitourinary malignancy. An increased risk of combined major or CRNMB was seen with DOACs (RR 1.52, 95%CI 1.09-2.12; I2 = 51%; low certainty evidence). Apixaban had the highest probability of being ranked most effective and least bleeding risk amongst the DOACs. CONCLUSION: DOACs are effective in treating malignancy associated VTE, however caution is required in patients with high risk of bleeding. Apixaban had lower risk of bleeding compared to other DOACs in this population.
View less >
Journal Title
Internal Medicine Journal
Copyright Statement
© 2020 Royal Australasian College of Physicians. This is the peer reviewed version of the following article: Direct oral anticoagulants for cancer associated venous thromboembolisms: a systematic review and network meta-analysis, Internal Medicine Journal, 2020, which has been published in final form at https://doi.org/10.1111/imj.15049. This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Self-Archiving (http://olabout.wiley.com/WileyCDA/Section/id-828039.html)
Note
This publication has been entered in Griffith Research Online as an advanced online version.
Subject
Cardiovascular medicine and haematology
Clinical sciences
Health services and systems
Public health
Heparin, Low-Molecular-Weight
Venous thromboemolisms
factor Xa Inhibitors, direct oral anticoagulants
neoplasm
pulmonary embolism