Treatment and secondary prevention of venous thrombo -embolism in cancer patients

Summary

Cancer is a major and independent risk factor of venous thromboembolism (VTE). In clinical practice, a high number of VTE events occurs in patients with cancer, and treatment of cancer-associated VTE differs in several aspects from treatment of VTE in the general population. However, treatment in cancer patients remains a major challenge, as the risk of recurrence of VTE as well as the risk of major bleeding during anticoagulation is substantially higher in patients with cancer than in those without cancer. In several clinical trials, different anticoagulants and regimens have been investigated for treatment of acute VTE and secondary prophylaxis in cancer patients to prevent recurrence. Based on the results of these trials, anticoagulant therapy with low-molecular-weight heparins (LMWH) has become the treatment of choice in cancer patients with acute VTE in the initial period and for extended and long-term anticoagulation for 3–6 months. New oral anti-coagulants directly inhibiting thrombin or factor Xa, have been developed in the past decade and studied in large phase III clinical trials. Results from currently completed trials are promising and indicate their potential use for treatment of VTE also in cancer patients. However, the role of the new oral thrombin and factor Xa inhibitors for VTE treatment in cancer patients still has to be clarified in further studies specifically focusing on cancer-associated VTE. This brief review will summarize the current strategies of initial and long-term VTE treatment in patients with cancer and discuss the potential use of the new oral anticoagulants.

Zusammenfassung

Krebserkrankungen zählen zu den bedeutendsten Risikofaktoren einer venösen Thromboembolie (VTE). Daher treten bei Krebspatienten im klinischen Alltag eine Vielzahl von VTEs auf. Die Therapie der Krebs-assoziierten VTE unter-scheidet sich jedoch in der Allgemeinbevölkerung und stellt darüber hinaus eine große He-rausforderung dar, weil Krebspatienten sowohl ein erhöhtes Risiko haben, an einem VTE-Rezidiv zu erkranken, als auch ein erhöhtes Blutungsrisiko unter Antikoagulation auf-weisen. Bisher wurden in klinischen Studien verschiedene Antikoagulanzien und Therapie-schemata für die Behandlung der akuten VTE und deren Sekundärprophylaxe zur Prävention eines Rezidivs untersucht. Basierend auf Ergebnisse dieser Studien stellen heute niedermolekulare Heparine bei Krebspatienten die Therapie der Wahl zur Behandlung einer akuten VTE in der initialen Periode als auch in der verlängerten Dauer der Antikoagulation für mindestens 3–6 Monate dar. Neue orale Antikoagulanzien, die ihre Wirkung über eine direkte Hemmung des Thrombins oder des aktivierten Blutgerinnungsfaktors X (FXa) entfalten, wurden in den vergangenen Jahren entwickelt und in großen klinischen Phase III Studien zur Prophylaxe und Therapie einer VTE untersucht. Die bisherigen Resultate sind sehr vielversprechend für einen Einsatz dieser neuen antithrombotischen Medikamente in der Prophylaxe und Therapie einer VTE. Bei Krebspatienten ist jedoch deren Nutzen noch nicht geklärt, da bisher spezifische Studien für die Prophylaxe und Therapie einer Krebs-asso-ziierten VTE fehlen.

In diesem Übersichtartikel werden die aktuellen Strategien für die Behandlung der akuten VTE und deren Sekundärprophylaxe bei Patienten mit Krebserkrankung zusammenge-fasst. Zudem wird der potenzielle Einsatz der neuen oralen Antikoagulanzien diskutiert.

Keywords

Venous thromboembolism - cancer - anti -coagulation - treatment - secondary prevention - secondary prophylaxis

Schlüsselwörter

Venöse Thromboembolie - Krebs - Antikoagulation - Therapie - Sekundärprophylaxe

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