Guidelines for Management of Cancer-Associated Thrombosis

As of June 2018, current guidelines from the American College of Chest Physicians (ACCP) and the National Comprehensive Cancer Network (NCCN) recommend LMWH for the first 3-6 months of treatment for cancer-associated thrombosis, and long-term anticoagulation for as long as malignancy is present. Ongoing clinical trials comparing LMWH to DOAC therapy for intial treatment of cancer-associated thrombosis may alter these guidelines in the future. 

OBTAIN BASELINE LABS

  • PT/aPTT
  • HCT
  • Platelets (and q2-5 days during the first 2 weeks of LMWH therapy)
  • Serum creatinine

OBTAIN PATIENT'S TOTAL BODY WEIGHT (TBW) IN KG

CALCULATE CREATININE CLEARANCE

  • Male: [(140-age) x TBW] / 72 x Scr
  • Female: CrCl (male) x 0.85

INITIAL THERAPY (FIRST MONTH)

TBW
(kg)

OUTPATIENT THERAPY

INPATIENT THERAPY

< 45 kg

Enoxaparin 1mg/kg SQ q12h

[or dalteparin 200 U/kg SQ q24h
(rounded to nearest 500 units using 10,000 U/ml graduated syringe)]

 

Enoxaparin 1mg/kg SQ q12h

 

46 -56

Enoxaparin 1mg/kg SQ q12h

[or dalteparin 10,000 units syringe SQ q24h]

57-68

Enoxaparin 1mg/kg SQ q12h

[or dalteparin 12,500 units syringe SQ q24h]

69-82

Enoxaparin 1mg/kg SQ q12h

[or dalteparin 15,000 units syringe SQ q24h]

83-98

Enoxaparin 1mg/kg SQ q12h

[or dalteparin 18,000 units syringe SQ q24h]

>99 kg

Enoxaparin 1mg/kg SQ q12h

CrCl 30-60 ml Enoxaparin 0.85mg/kg SQ q12h Enoxaparin 0.85mg/kg SQ q12h

CrCl < 30 ml/min

Enoxaparin 1mg/kg SQ q24h

IV heparin

 

SUBSEQUENT THERAPY (MONTH 2 THROUGH MONTH 3-6)

TBW
(kg)

OUTPATIENT THERAPY

INPATIENT THERAPY

< 45 kg

Enoxaparin 1.5mg/kg SQ q24h

[or dalteparin 150 U/kg SQ q24h
(rounded to nearest 500 units
using 10,000 U/ml graduated syringe)]

 

 

 

 

Enoxaparin 1.5mg/kg SQ q24h

46 -56

Enoxaparin 1.5mg/kg SQ q24h
OR
[or dalteparin 7500 units SQ q24h]

57-68

Enoxaparin 1.5mg/kg SQ q24h

[or dalteparin 10,000 units SQ q24h]

69-82

Enoxaparin 1.5mg/kg SQ q24h
OR
[or dalteparin 12,500 units SQ q24h]

83-98

Enoxaparin 1.5mg/kg SQ q24h
OR
[or dalteparin 15,000 units SQ q24h]

>99 kg

Enoxaparin 1mg/kg SQ q12h

Enoxaparin 1mg/kg SQ q12h

CrCl 30-60 ml/min Enoxaparin 0.85mg/kg SQ q12h or 1.5mg/kg SQ q24h Enoxaparin 0.85mg/kg SQ q12h or 1.5mg/kg SQ q24h

CrCl <30 ml/min

Enoxaparin 1mg/kg SQ q24h

IV heparin

 

CHRONIC THERAPY (AFTER THE FIRST 3-6 MONTHS)

  • Transition to warfarin (goal INR of 2-3) 
  • OR  continue LMWH based on pt preference 
  • OR consider DOAC therapy as long as patient is not receiving potentially interacting concurrent therapies

REFERENCES

  • ACCP Guidelines: Kearon C et al et al. Antithrombotic therapy for venous thromboembolic disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th Edition:  American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (suppl 2):419-94.
  • Hull R, et al. A randomised trial evaluating long-term low-molecular-weight heparin therapy for three months vs. intravenous heparin followed by warfarin sodium in patients with current cancer [abstract]. Thromb Haemost 2003;(suppl),P137a
  • 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.
  • Lee AY et al. Randomized comparison of low molecular weight heparin and coumarin derivatives on the survival of patients with cancer and venous thromboembolism. J Clin Oncol. 2005 Apr 1;23(10):2123-9.
  • Meyer G, et al. Comparison of low-molecular-weight heparin and warfarin for the secondary prevention of venous thromboembolism in patients with cancer: a randomized controlled study. Arch Intern Med. 2002 Aug 12-26;162(15):1729-35.
  • NCCN guidelines: http://www.nccn.org/professionals/physician_gls/default.asp