Update: Antikoagulationstherapie bei tumorassoziierter venöser Thromboembolie

Bei Tumorpatienten sind symptomatische und sogenannte inzidentelle tiefe Venenthrombosen und Lungenembolien häufig. Es wird eine prolongierte, regelhaft über 3 Monate hinausgehende Antikoagulation empfohlen, wobei die therapiebedingte Zunahme eines bei Malignompatienten vorbestehend erhöhten Blutungsrisikos besonderer Berücksichtigung bedarf. Neben den parenteralen niedermolekularen Heparinen stehen orale Faktor-Xa-Inhibitoren mit hohem Evidenzniveau gleichwertig für die Initialtherapie und Sekundärprophylaxe von Tumorpatienten zur Verfügung. Eine präferenzielle Empfehlung über die Art, Dauer und Intensität einer prolongierten Antikoagulation ist evidenzbasiert nicht zu geben. Sie sollte neben den individuellen und tumorentitätsspezifischen Risiken für Blutungen und Rezidivthrombosen auch Präparate-spezifische Charakteristika, Therapiekosten und die Patientenpräferenz einbeziehen.

Abstract

Symptomatic as well as so-called incidental deep venous thromboses and pulmonary embolisms are frequent complications in cancer patients. A prolonged anticoagulation, regularly for more than three months, considering the treatment-associated enhancement of a preexisting increased cancer-associated bleeding risk, is recommended. In addition to parenteral low molecular weight heparins oral factor Xa inhibitors became an equally good, high-level evidence-based option for initial treatment and secondary prophylaxis of cancer patients. An evidence-based preferential recommendation of kind, duration and intensity of anticoagulation cannot be given. It needs to consider individual and the cancer type associated risks of bleeding and recurrent thromboembolism, as well as characteristics of anticoagulant drugs, treatment costs and patient’s preference.

Schlüsselwörter

Tumor - venöse Thromboembolie - Antikoagulation - niedermolekulare Heparine - Faktor-Xa-Inhibitoren

Keywords

cancer - venous thromboembolism - anticoagulation - low molecular weight heparins - factor Xa inhibitors

Publication History

Article published online:
02 April 2025

• Literatur

• 1 Mulder FI, Horváth-Puhó E, van Es N. et al. Venous thromboembolism in cancer patients: a population-based cohort study. Blood 2021; 137: 1959-1969
• 2 Meyer G, Planquette B. Incidental venous thromboembolism, detected by chance, but still venous thromboembolism. Eur Respir J 2020; 55
• 3 AWMF. S2 k-Leitlinie: Venenthrombose und Lungenembolie: Diagnostik und Therapie. AWMF-Register-Nr. 065–002 . Accessed February 15, 2025 at: https://www.awmf.org/leitlinien/detail/ll/065-002.html
• 4 Prandoni P, Lensing AWA, Piccioli A. et al. Recurrent venous thromboembolism and bleeding complications during anticoagulant treatment in patients with cancer and venous thrombosis. Blood 2002; 100: 3484-3488
• 5 Carrier M, Cameron C, Delluc A. et al. Efficacy and safety of anticoagulant therapy for the treatment of acute cancer-associated thrombosis: a systematic review and meta-analysis. Thromb Res 2014; 134: 1214-1219
• 6 Mulder FI, Bosch FTM, Young AM. et al. Direct oral anticoagulants for cancer-associated venous thromboembolism: a systematic review and metaanalysis. Blood 2020; 136: 1433-1441
• 7 Raskob GE, van Es N, Verhamme P. et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med 2018; 378: 615-624
• 8 Young AM, Marshall A, Thirlwall J. et al. Comparison of an Oral Factor Xa Inhibitor With Low Molecular Weight Heparin in Patients With Cancer With Venous Thromboembolism: Results of a Randomized Trial (SELECTD). J Clin Oncol 2018; 36: 2017-2023
• 9 McBane RD, Wysokinski WE, Le-Rademacher JG. et al. Apixaban and dalteparin in active malignancy-associated venous thromboembolism: The ADAM VTE trial. J Thromb Haemost 2020; 18: 411-421
• 10 Agnelli G, Becattini C, Meyer G. et al. Apixaban for the Treatment of Venous Thromboembolism Associated with Cancer. N Engl J Med 2020; 382: 1599-1607
• 11 Klamroth R, Sinn M, Pollich C. et al. Anticoagulation practice in patients with cancer-associated thrombosis: Insights from GeCAT, a German prospective registry study. Oncol Res Treat 2021;
• 12 Riess H, Kretzschmar A, Heinken A. et al. Anticoagulation Therapy in Cancer Patients with Thrombosis in the Outpatient Sector of Germany (The CERTIFICAT Initiative)-German Practice of Anticoagulation Therapy of Cancer Patients with Thrombosis. Hamostaseologie 2022; 42 (03) 166-173
• 13 Carrier M, Abou-Nassar K, Mallick R. et al. Apixaban to prevent venous thromboembolism in patients with cancer. N Engl J Med 2019; 380: 711-719
• 14 Khorana AA, Soff GA, Kakkar AK. et al. Rivaroxaban for thromboprophylaxis in high-risk ambulatory patients with cancer. N Engl J Med 2019; 380: 720-728
• 15 McBane 2nd RD, Loprinzi CL, Zemla T. et al. Extending venous thromboembolism secondary prevention with apixaban in cancer patients. The EVE trial. J Thromb Haemost 2024; 22 (06) 1704-1714
• 16 Mahé I, Agnelli G, Ay C. et al. Extended Anticoagulant Treatment with Full- or Reduced-Dose Apixaban in Patients with Cancer-Associated Venous Thromboembolism: Rationale and Design of the API-CAT Study. Thromb Haemost 2022; 122 (04) 646-656