Efficacy and safety of Xa inhibitors for the treatment of cancer-associated venous thromboembolism

ABSTRACT

Introduction: Cancer patients with cancer-associated thrombosis (CAT) are at an elevated risk of recurrent venous thromboembolism (VTE) and of major bleeding while receiving treatment with anticoagulation. Recently, Xa inhibitors have been assessed in cancer patients for the treatment of CAT, providing clinicians and patients with more treatment options.

Areas covered: In this narrative review, the authors evaluate the evidence regarding the efficacy and safety of edoxaban, rivaroxaban, and apixaban in the treatment of CAT.

Expert opinion: Xa inhibitors are an effective, safe, and convenient option for the treatment of CAT. Overall, they may be associated with a lower risk of recurrent VTE in cancer patients. Certain subgroups of cancer patients may be at increased risk of major bleeding while on treatment with Xa inhibitors, when compared to low-molecular-weight-heparin (LMWH). The current published data suggests an increase in gastrointestinal (GI) major bleeding in patients with GI malignancies. Other patient, treatment, and cancer characteristics may also be associated with a higher risk of major bleeding. Therefore, when assessing the appropriateness of Xa inhibitors for the treatment of CAT, the clinician must take into consideration the known interactions of these drugs, the individualized bleeding risk, and the patient’s preferences, in order to make the best possible anticoagulation therapy recommendation.

KEYWORDS:

• Anticoagulants
• hemorrhage
• rivaroxaban
• apixaban
• edoxaban
• pulmonary embolism
• venous thromboembolism

Article highlights

• Cancer patients are at elevated risk of venous thromboembolism recurrence and major bleeding while receiving treatment for cancer-associated thrombosis.

• Recently, factor Xa inhibitors (edoxaban, rivaroxaban, and apixaban) have been compared to the standard of care of low-molecular-weight heparin for the treatment of cancer-associated thrombosis.

• Factor Xa inhibitors appear to be a safe and effective alternative for the treatment of cancer-associated thrombosis.

• Certain cancer patients, including those with gastrointestinal, genitourinary, or intracranial disease, may be at higher risk of bleeding complications when treated with factor Xa inhibitors.

• Contrary to low-molecular-weight heparins, clinicians must be cognizant of drug-drug interactions when prescribing a factor Xa inhibitor for the treatment of cancer-associated thrombosis.

• When choosing an anticoagulant for the treatment of cancer-associated thrombosis, patient preference and values must be taken into account.

This box summarizes key points contained in the article.

Declaration of interest

M Carrier has received research funding from Leo Pharma, Pfizer and Bristol Myers Squibb and honoraria from Pfizer, Bayer, Bristol Myers Squibb, Sanofi, Leo Pharma and Servier. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they are a site research collaborator for the Hokusai VTE Cancer trial (edoxaban vs dalteparin for the treatment of cancer-associated thrombosis) and the CASSINI trial (rivaroxaban vs control in ambulatory thromboprophylaxis in solid cancer patients receiving chemotherapy). All other peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

This paper was not funded.