Anticoagulation for thrombosis prophylaxis in cancer patients with central venous catheters
Sübutlu məlumatların xülasələri
30.08.2018 • Sonuncu dəyişiklik 30.08.2018
Editors
Low-molecular-weight heparin (LMWH) appears to reduce catheter-related venous thromboembolism compared to no LMWH in cancer patients with central venous catheter.
Comment: The quality of evidence is downgraded by study limitations (unclear allocation concealment and lack of blinding).
Summary
Summary
A Cochrane review included 13 studies with a total of 3 420 subjects with cancer with a central venous catheter. Seven studies compared low-molecular-weight heparin (LMWH) to no LMWH (6 in adults and 1 in children), 6 studies compared vitamin K antagonists (VKA) to no VKA (5 in adults and 1 in children), and 3 studies compared LMWH to VKA in adults.
Prophylactic dose LMWH compared to no LMWH: LMWH decreased incidence of symptomatic catheter-related venous thromboembolism (VTE) up to 3 months of follow-up compared to no LMWH in adults (RR 0.43, 95% CI 0.22 to 0.81; 5 studies, n=1 089), but there was no difference in mortality at 3 months of follow-up (RR 0.82, 95% CI 0.53 to 1.26; 5 studies, n=1 236). No statistically significant differencfes were observed in major bleeding (RR 1.49, 95% CI 0.06 to 36.28; 4 studies, n=1 018), minor bleeding (RR 1.35, 95% CI 0.62 to 2.92; 2 studies, n=544), and thrombocytopenia (RR 1.03, 95% CI 0.80 to 1.33; 4 studies, n=1 002).
Low-dose VKA compared to no VKA: There were no differences between low-dose VKA compared to no VKA in mortality (RR 0.99, 95% CI 0.64 to 1.55; 4 studies, n=701), symptomatic catheter-related VTE (RR 0.61, 95% CI 0.23 to 1.64; 4 studies, n=1 271), major bleeding (RR 7.14, 95% CI 0.88 to 57.78; 2 studies, n=1 026), minor bleeding (RR 0.69, 95% CI 0.38 to 1.26; 2 studies, n=1 026), premature catheter removal (RR 0.82, 95% CI 0.30 to 2.24; 1 study, n=88), and catheter-related infection (RR 1.17, 95% CI 0.74 to 1.85; 1 study, n=88) in adults.
LMWH compared to VKA: There were no differences between LMWH and VKA in mortality (RR 0.94, 95% CI 0.56 to 1.59; 3 studies, n=561), symptomatic catheter-related VTE (RR 1.83, 95% CI 0.44 to 7.61; 2 studies, n=327), pulmonary embolism (RR 1.70, 95% CI 0.74 to 3.92; 2 studies, n=327), major bleeding (RR 3.11, 95% CI 0.13 to 73.11; 2 studies, n=289), or minor bleeding (RR 0.95, 95% CI 0.20 to 4.61; 1 study, n=234) in adults. LMWH increased the risk of thrombocytopenia compared to VKA at 3 months of follow-up (RR 1.69, 95% CI 1.20 to 2.39; 2 studies, n=327).
Clinical comment
Patients with cancer with CVCs considering anticoagulation should balance the possible benefit of reduced thromboembolic complications with the possible harms and burden of anticoagulants.
A Cochrane review
included 12 studies with a total of 2823 subjects. Two of the RCTs included children. Of the 10 RCTs including 2564 adults, one compared prophylactic dose heparin with low-dose VKA. Three RCTs compared VKA with no VKA and four RCTs compared heparin with no heparin. Two additional trials had three separate arms comparing heparin, VKA, and no intervention.
Prophylactic-dose heparin, compared with no heparin, was associated with a statistically significant reduction in symptomatic DVT (risk ratio (RR) 0.48; 95% confidence interval (CI) 0.27 to 0.86; moderate-quality evidence). However, results did not confirm or exclude a beneficial or detrimental effect of heparin on mortality (RR 0.82; 95% CI 0.53 to 1.26; moderate-quality evidence), major bleeding (RR 0.49; 95% CI 0.03 to 7.84; low-quality evidence), infection (RR 1.00; 95% CI 0.54 to 1.85; moderate-quality evidence); thrombocytopenia (RR 1.03; 95% CI 0.80 to 1.33; moderate-quality evidence), or minor bleeding (RR 1.35; 95% CI: 0.62 to 2.92). Low-dose VKAs, compared with no VKAs, were associated with a statistically significant reduction in asymptomatic DVT (RR 0.43; 95% CI 0.30 to 0.62). Results did not confirm or exclude a beneficial or detrimental effect of VKAs on mortality (RR 1.04; 95% CI 0.89 to 1.22; low-quality evidence), symptomatic DVT (RR 0.51; 95% CI 0.21 to 1.22; low-quality evidence), major bleeding (RR 7.60; 95% CI 0.94 to 61.49; very-low-quality evidence), or minor bleeding (RR 3.14; 95% CI 0.14 to 71.51). The use of heparin, compared with VKA was associated with a statistically significant increase in thrombocytopenia (RR 3.73; 95% CI 2.26 to 6.16; low-quality evidence) and asymptomatic DVT (RR 1.74; 95% CI 1.20 to 2.52). Clinical comment: Patients with cancer with CVCs considering anticoagulation should balance the possible benefit of reduced thromboembolic complications with the possible harms and burden of anticoagulants.
Ədəbiyyat
- Kahale LA, Tsolakian IG, Hakoum MB et al. Anticoagulation for people with cancer and central venous catheters. Cochrane Database Syst Rev 2018;(6):CD006468. .