Parenteral anticoagulation in ambulatory patients with cancer
Sübutlu məlumatların xülasələri
08.11.2017 • Sonuncu dəyişiklik 08.11.2017
Editors
Low molecular weight heparin (LMWH) reduces symptomatic venous thromboembolism and increases minor bleeding events in ambulatory cancer patients with no standard therapeutic or prophylactic indication for anticoagulation. LMWH appears to have a survival benefit in patients with small cell lung cancer at 12 months.
A Cochrane review included 19 studies with a total of 9 650 subjects. In all included RCTs, the intervention consisted of heparin (either unfractionated heparin or low molecular weight heparin). Overall, heparin appears to have no effect on mortality at 12 months (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.93 to 1.03; risk difference (RD) 10 fewer per 1000; 95% CI 35 fewer to 15 more; moderate certainty of evidence) and mortality at 24 months (RR 0.99; 95% CI 0.96 to 1.01; RD 8 fewer per 1000; 95% CI 31 fewer to 8 more; moderate certainty of evidence). Heparin therapy reduces the risk of symptomatic VTE (RR 0.56; 95% CI 0.47 to 0.68; RD 30 fewer per 1000; 95% CI 36 fewer to 22 fewer; high certainty of evidence), while it increases in the risks of major bleeding (RR 1.30; 95% 0.94 to 1.79; RD 4 more per 1000; 95% CI 1 fewer to 11 more; moderate certainty of evidence) and minor bleeding (RR 1.70; 95% 1.13 to 2.55; RD 17 more per 1000; 95% CI 3 more to 37 more; high certainty of evidence). Results failed to confirm or to exclude a beneficial or detrimental effect of heparin on thrombocytopenia (RR 0.69; 95% CI 0.37 to 1.27; RD 33 fewer per 1000; 95% CI 66 fewer to 28 more; moderate certainty of evidence); quality of life (moderate certainty of evidence).
Meta-analysis found that the use of heparin compared to no heparin had no effect on mortality rates at 12 months (table
) or 24 months (RR 0.95, 95% CI 0.90 to 1.00; 7 studies, n=1 621). Eleven studies (n=5 254) reported data allowing their inclusion in the time-to-event meta-analysis: heparin was associated with a statistically significant reduction in the risk of death compared to no heparin (HR 0.84, 95% CI 0.74 to 0.96; statistical heterogeneity I
2 = 58%). Heparin therapy was associated with a reduction in venous thromboembolism and an increase in the risk of minor bleeding but was not associated with a statistically significant effect on major bleeding (table
).
In a subgroup analysis (at 12 months) of patients with small cell lung cancer (SCLC), versus other types of cancer, the test for subgroup difference had a P value of 0.05 (mortality with heparin vs. placebo: RR 0.86, 95% CI 0.75 to 0.98 for SCLC and RR 0.98, 95% CI 0.93 to 1.03 for other types of cancer).
Heparin compared to placebo for ambulatory patients with cancer who have no therapeutic or prophylactic indication for anticoagulation
OutcomeRelative effect (95% CI)Assumed risk - placeboCorrespondding risk - heparin (95% CI)Participants (studies)
Mortality at 12 monthsRR 0.97
(0.92 to 1.01)472 per 1000458 per 1000
(434 to 477)7 013 (13 studies)
Symptomatic VTERR 0.56
(0.42 to 0.74)55 per 100031 per 1000
(23 to 41)6 809 (13 studies)
Major bleedingRR 1.14
(0.7 to 1.85)19 per 100021 per 1000
(13 to 35)7 363 (15 studies)
Minor bleedingRR 1.32
(1.02 to 1.71)30 per 100040 per 1000
(31 to 51)6 884 (13 studies)
Ədəbiyyat
- ."?>Akl EA, Kahale LA, Hakoum MB et al. Parenteral anticoagulation in ambulatory patients with cancer. Cochrane Database Syst Rev 2017;(9):CD006652.