ABSTRACT
The International Initiative on Thrombosis and Cancer is an independent academic working group of experts aimed at establishing global consensus for the treatment and prophylaxis of cancer-associated thrombosis. The 2013, 2016, and 2019 International Initiative on Thrombosis and Cancer clinical practice guidelines have been made available through a free, web-based mobile phone application. The 2022 clinical practice guidelines, which are based on a literature review up to Jan 1, 2022, include guidance for patients with cancer and with COVID-19. Key recommendations (grade 1A or 1B) include: (1) low-molecular-weight heparins (LMWHs) for the initial (first 10 days) treatment and maintenance treatment of cancer-associated thrombosis;(2) direct oral anticoagulants for the initial treatment and maintenance treatment of cancer-associated thrombosis in patients who are not at high risk of gastrointestinal or genitourinary bleeding, in the absence of strong drug-drug interactions or of gastrointestinal absorption impairment;(3) LMWHs or direct oral anticoagulants for a minimum of 6 months to treat cancer-associated thrombosis;(4) extended prophylaxis (4 weeks) with LMWHs to prevent postoperative venous thromboembolism after major abdominopelvic surgery in patients not at high risk of bleeding;and (5) primary prophylaxis of venous thromboembolism with LMWHs or direct oral anticoagulants (rivaroxaban or apixaban) in ambulatory patients with locally advanced or metastatic pancreatic cancer who are treated with anticancer therapy and have a low risk of bleeding.
ABSTRACT
Background : Prophylactic anticoagulation is now considered standard-of-care for hospitalized COVID-19 patients . Since evidence-based guidelines for thrombo-prophylaxis are lacking, clinical practice has been based evidence showing a high risk of venous thromboembolism (VTE) among these patients. Aims : To evaluate the change in anticoagulation practice patterns in hospitalized patients with COVID-19 among Hemostasis and Thrombosis (H&T) experts in Latin America. Methods : An invitation was sent by email and website to CLAHT members. The same questionnaire was issued twice: May-June and August-September 2020. with five multiple-choice questions regarding the use of standard or weight-adjusted dosing (SWAD), intermediate or full-dose (IFD) of low molecular weight heparin (LMWH), or no prophylaxis in the following scenarios: i.Hospitalized patients without comorbidities or ii. with comorbidities and D-dimer (DD) levels three-fold above reference values;iii. Patients on mechanical ventilation (MV), iv. Patients on MV with suspected VTE;iv.LMWH management based solely on DD. Differences between surveys were analyzed using chi-square test. Results : The first and second surveys were answered by 200 and 174 individuals respectively, representing themselves or institutional practices. Distribution of participants by country is shown in Table 1. Clinical practice was heterogeneous. When comparing surveys, we found that preference for IDF for non-ICU patients without comorbidities increased (6.4%-14%) while SWAD decrease from 88.6% to 72%. IFD preference also increased from (40.6%-49%) for patients with comorbidities and high DD. Half (49%) suggested using IFD for ICU patients without VTE, while 90% preferred IFD for established or suspected VTE. More aggressive prophylaxis was favored initially in patients based on DD levels 6-fold above baseline, decreasing by 20% (from 60.6% to 49.1%) in the second survey. Conclusions : Prophylactic anticoagulation for COVID-19 varied, with a trend towards a decrease in preference for IFD, likely reflecting reported bleeding incidents. Awaited final publication of results from prospective studies will likely homogenize clinical practice worldwide.