A consensus viewpoint on the role of direct factor Xa inhibitors in the management of cancer-associated venous thromboembolism in the UK.

OBJECTIVE: Cancer patients are at high risk of venous thromboembolism (VTE), a significant cause of cancer-related death. Historically, low molecular weight heparins (LMWH) were the gold standard therapy for cancer-associated VTE, but recent evidence supports the use of direct factor Xa inhibitors in cancer-associated VTE and this is now reflected in many guidelines. However, uptake of direct factor Xa inhibitors varies and guidance on the use of direct factor Xa inhibitors in specific cancer sub-populations and clinical situations is lacking. This review presents consensus expert opinion alongside evaluation of evidence to support healthcare professionals in the use of direct factor Xa inhibitors in cancer-associated VTE. METHODS: Recent guidelines, meta-analyses, reviews and clinical studies on anticoagulation therapy for cancer-associated VTE were used to direct clinically relevant topics and evidence to be systematically discussed using nominal group technique. The consensus manuscript and recommendations were developed based on these discussions. RESULTS: Considerations when prescribing anticoagulant therapy for cancer-associated VTE include cancer site and stage, systemic anti-cancer therapy (including vascular access), drug-drug interactions, length of anticoagulation, quality of life and needs during palliative care. Treatment of patients with kidney or liver impairment, gastrointestinal disorders, extremes of bodyweight, elevated bleeding or recurrence risk, VTE recurrence and COVID-19 is discussed. CONCLUSION: Anticoagulant therapy for cancer-associated VTE patients should be carefully selected with consideration given to the relative benefits of specific drugs when individualizing care. Direct factor Xa inhibitors are typically the treatment of choice for preventing VTE recurrence in non-cancer patients and should also be considered as such for cancer-associated VTE in most situations.

Implementation of a standardised annual anticoagulation specialist review in primary care.

An increasing number of patients are being prescribed direct oral anticoagulants (DOACs), while the patients who remain on warfarin are becoming more complex. There is currently a lack of a standardised anticoagulation review for patients in primary care, resulting in potentially preventable harm events. Our aim was to implement a new service, where a standardised review is carried out by a specialist multidisciplinary secondary care anticoagulation team. Overall, the implementation of a standardised review resulted in better optimisation of anticoagulation management for patients taking either a DOAC or a warfarin. Of the 172 eligible patients prescribed warfarin, 47 (27%) chose to switch a DOAC. The average time in therapeutic range for patients on warfarin before and after the pilot increased from 73.5% to 75%. Of 482 patients taking a DOAC, 35 (7%) were found to be on incorrect dose. In 32 (91%) of 35 patients, the dose was amended after notifying the patient's general practitioner. We also found a significant number of patients inappropriately prescribed concomitant medication such as antiplatelet or non-steroidal anti-inflammatory drugs, potentially putting the patients at an elevated risk of bleeding. While further research is needed; we believe the results of this pilot can be used to help build a case to influence the commissioning of anticoagulation services. Secondary care anticoagulation teams, like our own, may be well-placed to provide or support such services, by working across the primary care and secondary care interface to support our primary care colleagues.