Antikoagulation bei onkologischen Patienten

Tumorpatienten zeigen im Vergleich zur Normalbevölkerung ein erhöhtes Risiko für venöse Thromboembolien, welche erhebliche Auswirkungen auf Morbidität und Mortalität haben. Daher sind adäquate prophylaktische Maßnahmen sowie eine frühzeitige Diagnose und Therapie essenziell. Allerdings ist eine Antikoagulation bei Tumorpatienten mit einem gehäuften Auftreten von Blutungen und auch von Rezidiven verbunden. Angesichts dieser besonderen Herausforderungen haben mehrere Fachgesellschaften und Arbeitsgruppen spezifische Leitlinien und Empfehlungen zur Thromboseprophylaxe und -therapie bei Tumorpatienten veröffentlicht. Über diese soll im Folgenden ein Überblick gegeben werden.

Compared to the general population, cancer patients are at increased risk for venous thromboembolism with significant impact on morbidity and mortality. Appropriate prophylaxis as well as early diagnosis and treatment are therefore mandatory. However, anticoagulation of cancer patients is associated with an increased risk of bleeding and recurrence. To meet these challenges, national and international guidelines for the prevention and treatment of venous thromboembolism in patients with cancer have been published. We provide a summary of these specific recommendations.

Key words

Venous thrombosis - pulmonary embolism - cancer - heparin - vitamin K antagonist - direct oral anticoagulant

• Literatur

• 1 Prandoni P, Lensing AW, 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
• 2 Farge D, Bounameaux H, Brenner B et al International clinical practice guidelines including guidance for direct oral anticoagulants in the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol 2016; 17: e452-e466
• 3 Lyman GH, Bohlke K, Falanga A. Venous thromboembolism prophylaxis and treatment in patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Oncol Pract 2015; 11: e442-e444
• 4 Mandalà M, Falanga A, Roila F. Management of venous thromboembolism (VTE) in cancer patients: ESMO clinical practice guidelines. Ann Oncol 2011; 22 (Suppl. 06) vi85-vi92
• 5 Pabinger I, Alt-Epping B, Demarmels BiasuttiF et al Venöse Thrombembolien bei Tumorpatienten. Onkopedia-Leitlinie in Kooperation mit der Gesellschaft für Thrombose- und Hämostaseforschung e.V. und der Deutschen Gesellschaft für Palliativmedizin. Hämostaseologie 2011; 31: 281-290
• 6 Maraveyas A, Waters J, Roy R et al Gemcitabine versus gemcitabine plus dalteparin thromboprophylaxis in pancreatic cancer. Eur J Cancer 2012; 48: 1283-1292
• 7 Pelzer U, Opitz B, Deutschinoff G et al Efficacy of prophylactic low-molecular weight heparin for ambulatory patients with advanced pancreatic cancer: outcomes from the CONKO-004 trial. J Clin Oncol 2015; 33: 2028-2034
• 8 Lee AY, Levine MN, Baker RI et al Low-molecular-weight heparin versus a coumarin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003; 349: 146-153
• 9 Carrier M, Le Gal G, Cho R et al Dose escalation of low molecular weight heparin to manage recurrent venous thromboembolic events despite systemic anticoagulation in cancer patients. J Thromb Haemost 2009; 7: 760-765
• 10 Debourdeau P, Farge D, Beckers M et al International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer. J Thromb Haemost 2013; 11: 71-80
• 11 Short NJ, Connors JM. New oral anticoagulants and the cancer patient. Oncologist 2014; 19: 82-93
• 12 Levine MN, Gu C, Liebman HA et al A randomized phase II trial of apixaban for the prevention of thromboembolism in patients with metastatic cancer. J Thromb Haemost 2010; 10: 807-814
• 13 Agnelli G, Buller HR, Cohen A et al Oral apixaban for the treatment of venous thromboembolism in cancer patients: results from the AMPLIFY trial. J Thromb Haemost 2015; 13: 2187-2191
• 14 Prins MH, Lensing AW, Bauersachs R et al Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J 2013; 11: 21
• 15 Raskob GE, van Es N, Segers A et al Edoxaban for venous thromboembolism in patients with cancer: results from a non-inferiority subgroup analysis of the Hokusai-VTE randomised, double-blind, double-dummy trial. Lancet Haematol 2016; 3: e379-e387
• 16 Schulman S, Goldhaber SZ, Kearon C et al Treatment with dabigatran or warfarin in patients with venous thromboembolism and cancer. Thromb Haemost 2015; 114: 150-157
• 17 Ay C, Dunkler D, Marosi C et al Prediction of venous thromboembolism in cancer patients. Blood 2010; 116: 5377-5382
• 18 Khorana AA, Kuderer NM, Culakova E et al Development and validation of a predictive model for chemotherapy-associated thrombosis. Blood 2008; 111: 4902-4907