Direct oral anticoagulants for cancer associated venous thromboembolisms: a systematic review and network meta-analysis

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Samaranayake, Chinthaka B
Anderson, James
McCabe, Colm
Zahir, Syeda Farah
Upham, John
Keir, Gregory
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2020
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Abstract

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.

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Internal Medicine Journal

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© 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)

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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

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Samaranayake, CB; Anderson, J; McCabe, C; Zahir, SF; Upham, J; Keir, G, Direct oral anticoagulants for cancer associated venous thromboembolisms: a systematic review and network meta-analysis, Internal Medicine Journal, 2020

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