Logo

Log In Sign Up |  An official publication of: American College of Emergency Physicians
Navigation
  • Home
  • Multimedia
    • Podcasts
    • Videos
  • Clinical
    • Airway Managment
    • Case Reports
    • Critical Care
    • Guidelines
    • Imaging & Ultrasound
    • Pain & Palliative Care
    • Pediatrics
    • Resuscitation
    • Trauma & Injury
  • Resource Centers
    • mTBI Resource Center
  • Career
    • Practice Management
      • Benchmarking
      • Reimbursement & Coding
      • Care Team
      • Legal
      • Operations
      • Quality & Safety
    • Awards
    • Certification
    • Compensation
    • Early Career
    • Education
    • Leadership
    • Profiles
    • Retirement
    • Work-Life Balance
  • Columns
    • ACEP4U
    • Airway
    • Benchmarking
    • Brief19
    • By the Numbers
    • Coding Wizard
    • EM Cases
    • End of the Rainbow
    • Equity Equation
    • FACEPs in the Crowd
    • Forensic Facts
    • From the College
    • Images in EM
    • Kids Korner
    • Medicolegal Mind
    • Opinion
      • Break Room
      • New Spin
      • Pro-Con
    • Pearls From EM Literature
    • Policy Rx
    • Practice Changers
    • Problem Solvers
    • Residency Spotlight
    • Resident Voice
    • Skeptics’ Guide to Emergency Medicine
    • Sound Advice
    • Special OPs
    • Toxicology Q&A
    • WorldTravelERs
  • Resources
    • ACEP.org
    • ACEP Knowledge Quiz
    • Issue Archives
    • CME Now
    • Annual Scientific Assembly
      • ACEP14
      • ACEP15
      • ACEP16
      • ACEP17
      • ACEP18
      • ACEP19
    • Annals of Emergency Medicine
    • JACEP Open
    • Emergency Medicine Foundation
  • About
    • Our Mission
    • Medical Editor in Chief
    • Editorial Advisory Board
    • Awards
    • Authors
    • Article Submission
    • Contact Us
    • Advertise
    • Subscribe
    • Privacy Policy
    • Copyright Information

Should You Use Direct Oral Anticoagulants for Cancer-Associated VTE?

By Ken Milne, MD | on January 13, 2019 | 1 Comment
Skeptics' Guide to EM
  • Tweet
  • Click to email a link to a friend (Opens in new window) Email
Print-Friendly Version
Table 1: Secondary Outcomes
Table 1: Secondary Outcomes

The Case

A 73-year-old man currently undergoing chemotherapy for colon cancer presents to the emergency department with a swollen right leg. His vital signs are all stable, and his leg does not look like it has cellulitis. The ultrasound confirms your suspicion of a deep-vein thrombosis (DVT). The patient is being prepared for outpatient management, but does not want to be on injections for the next six to 12 months. He asks if there are any other treatments besides low-molecular-weight heparin (LMWH). 

You Might Also Like
  • Restarting Antithrombotics After Gastrointestinal Bleeding Tied to Better Outcomes
  • Low Risk of Brain Hemorrhage in Ground-Level Fall with Antiplatelets, Anticoagulants
  • New Developments in Direct Oral Anticoagulant Safety and Indications
Explore This Issue
ACEP Now: Vol 38 – No 01 – January 2019

Background

Cancer increases the risk of venous thromboembolism (VTE). Patients with cancer can be difficult to manage due to the higher risk of bleeding and the higher rate of thrombosis recurrence. The CLOT trial established LMWH as the standard therapy for symptomatic and asymptomatic VTE.1

Direct oral anticoagulants (DOACs) like rivaroxaban have been shown to be effective treatments for VTE without causing increased bleeding complication rates in non-cancer patients. A trial by Bean et al suggested it was safe and effective to dry start DOACs (no LMWH needed) in certain patients with VTE.2

Although DOACs are frequently used in the treatment of cancer-associated VTE, there is little evidence to support this practice. The SELECT-D trial was a small open-label pilot trial looking at the use of rivaroxaban. It showed a lower hazard ratio (HR) for VTE with wide confidence intervals and a higher clinically relevant non-major bleeding rate.3

Clinical Question

In cancer-associated VTE, is edoxaban non­inferior to LMWH?

Reference

Raskob GE, van Es N, Verhamme P, et al. Edoxaban for the treatment of cancer-associated venous thromboembolism. N Engl J Med. 2018;378(7):615-624.

  • Population: Adult patients with active cancer or cancer diagnosed within the previous two years with acute symptomatic or asymptomatic VTE.
    • Exclusions: See the article’s supplementary appendix.
    • Intervention: LMWH for five days followed by oral edoxaban 60 mg daily for at least six months.
  • Comparison: Subcutaneous (SQ) dalteparin 200 IU/kg daily (maximum 18,000 IU) for one month followed by 150 IU/kg daily for at least five months.
  • Outcome: 
    • Primary: Composite of recurrent VTE or major bleeding during 12-month follow-up.
    • Secondary: Clinically relevant non-major bleeding (CRNB), event-free survival, VTE-related death, all-cause mortality, recurrent DVT, recurrent pulmonary embolism. (The complete list is in the article’s supplementary appendix.)

Authors’ Conclusions

“Oral edoxaban was noninferior to subcutaneous dalteparin with respect to the composite outcome of recurrent venous thromboembolism or major bleeding. The rate of recurrent venous thromboembolism was lower but the rate of major bleeding was higher with edoxaban than with dalteparin.”

Pages: 1 2 3 | Single Page

Topics: AnticoagulantsCancerCancer-Associated Venous ThromboembolismDeep Vein ThrombosisDirect Oral AnticoagulantsVenous Thromboembolism

Related

  • Anticoagulant Selection Is Cornerstone of Pulmonary Embolism Treatment

    March 11, 2025 - 1 Comment
  • Grant Program Funds Venous Thromboembolism Management Projects

    March 9, 2025 - 1 Comment
  • New Bedside Tools Available for Stroke and Cancer Complications

    September 8, 2022 - 0 Comment

Current Issue

ACEP Now: June 2025 (Digital)

Read More

About the Author

Ken Milne, MD

Ken Milne, MD, is chief of emergency medicine and chief of staff at South Huron Hospital, Ontario, Canada. He is on the Best Evidence in Emergency Medicine faculty and is creator of the knowledge translation project the Skeptics Guide to Emergency Medicine.

View this author's posts »

One Response to “Should You Use Direct Oral Anticoagulants for Cancer-Associated VTE?”

  1. January 20, 2019

    Gregg Chesney Reply

    Thanks for this review! I had this exact debate last week (but enoxaparin vs rivaroxaban) with our ED pharmacist, the patient’s oncologist and his general surgeon for a patient with an acute DVT 2 weeks post-op from a resection of a colonic adenocarcinoma. I hadn’t seen the new article in the NEJM yet, and the 2016 ACCP VTE guidelines are still recommending LMWH. I had originally ordered enoxaparin but the oncologist decided he wanted to manage him on rivaroxaban, citing new data that DOACs are noninferior in these patients, which I hadn’t had a chance to look for yet, so thanks for filling me in!

Leave a Reply Cancel Reply

Your email address will not be published. Required fields are marked *


*
*

Wiley
  • Home
  • About Us
  • Contact Us
  • Privacy
  • Terms of Use
  • Advertise
  • Cookie Preferences
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 2333-2603