Pulmonary embolism special scenario cancer

Editor(s)-In-Chief: C. Michael Gibson, M.S., M.D. [1], The APEX Trial Investigators; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]

Overview

Cancer patients who have an episode of pulmonary embolism should receive an extended anticoagulation therapy for at least 3 months. The first line long term anticoagulation therapy for venous thromboembolism (VTE) in cancer patients is vitamin K antagonist (VKA) over low molecular weight heparin (LMWH). Outpatient cancer patients with no additional risk factors for VTE should not receive any routine VTE prophylaxis.^[1]

Class I
“1. In patients with PE who are treated with VKA, we recommend a therapeutic INR range of 2.0 to 3.0 (target INR of 2.5) over a lower (INR < 2) or higher (INR 3.0-5.0) range for all treatment durations. (Level of Evidence: B)”
“2. In patients with PE and active cancer, if there is a low or moderate bleeding risk, we recommend extended anticoagulant therapy over 3 months of therapy. (Level of Evidence: B)”

Class II
“1. In patients with PE and active cancer, if there is a high bleeding risk, we suggest extended anticoagulant therapy. (Level of Evidence: B)”
“2. In patients with PE and no cancer, we suggest VKA therapy over LMWH for long-term therapy (Level of Evidence: C). For patients with PE and no cancer who are not treated with VKA therapy, we suggest LMWH over dabigatran or rivaroxaban for long-term therapy. (Level of Evidence: C)”
“3. In patients with PE and cancer, we suggest LMWH over VKA therapy (Level of Evidence: B). In patients with PE and cancer who are not treated with LMWH, we suggest VKA over dabigatran or rivaroxaban for long-term therapy (Level of Evidence: C). ”

Class I
“1. For high-VTE-risk patients undergoing abdominal or pelvic surgery for cancer who are not otherwise at high risk for major bleeding complications, we recommend extended-duration pharmacologic prophylaxis (4 weeks) with LMWH over limited-duration prophylaxis. (Level of Evidence: B)”

Class I
“1. In outpatients with cancer who have no additional risk factors for VTE, we recommend against the prophylactic use of VKAs. (Level of Evidence: B)”

Class II
“1. In outpatients with cancer who have no additional risk factors for VTE, we suggest against routine prophylaxis with LMWH or LDUH. (Level of Evidence: B)”
“2. In outpatients with solid tumors who have additional risk factors for VTE and who are at low risk of bleeding, we suggest prophylactic-dose LMWH or LDUH over no prophylaxis. (Level of Evidence: B)”
“3. In outpatients with cancer and indwelling central venous catheters, we suggest against routine prophylaxis with LMWH or LDUH (Level of Evidence: B) and suggest against the prophylactic use of VKAs (Level of Evidence: C). ”