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 |
OUTPATIENT THERAPY |
INPATIENT THERAPY |
|
< 45 kg |
Enoxaparin 1mg/kg SQ q12h
[or dalteparin 200 U/kg SQ q24h |
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 |
OUTPATIENT THERAPY |
INPATIENT THERAPY |
|
< 45 kg |
Enoxaparin 1.5mg/kg SQ q24h
[or dalteparin 150 U/kg SQ q24h |
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