Guidelines for Management of Cancer-Associated Thrombosis

Preamble

Several clinical trials have confirmed that in cancer-associated thrombosis, the use of low molecular weight heparin for the first 3-6 months of therapy instead of warfarin is associated with reduced rates of thromboembolic recurrence and bleeding complications, and may result in lower mortality in patients with non-metastatic disease . 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.

Obtain baseline labs

  • PT/aPTT
  • HCT
  • Platelets (and q2-3 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)

INPATIENT THERAPY

OUTPATIENT THERAPY

< 45 kg

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

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

46 -56

Dalteparin 10,000 units syringe SQ q24h

Dalteparin 10,000 units syringe SQ q24h

57-68

Dalteparin 12,500 units syringe SQ  q24h

Dalteparin 12,500 units syringe SQ q24h

69-82

Dalteparin 15,000 units syringe SQ q24h

Dalteparin 15,000 units syringe SQ q24h

83-98

Dalteparin 18,000 units syringe SQ q24h

Dalteparin 18,000 units syringe SQ q24h

>99 kg

Dalteparin 100 U/kg SQ q12h
(rounded to nearest 100 units drawn up
using 25,000 U/ml multidose vial))

Enoxaparin 1mg/kg SQ q12h

Clcr< 30 ml/min

IV heparin

Enoxaparin 1mg/kg SQ q24h

 

Subsequent therapy (month 2 through month 3-6)

TBW
(kg)

INPATIENT THERAPY

OUTPATIENT THERAPY

< 45 kg

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

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

46 -56

Dalteparin 7500 units SQ q24h

Dalteparin 7500 units SQ q24h

57-68

Dalteparin 10,000 units SQ q24h

Dalteparin 10,000 units SQ q24h

69-82

Dalteparin 12,500 units SQ q24h

Dalteparin 12,500 units SQ q24h

83-98

Dalteparin 15,000 units SQ q24h

Dalteparin 15,000 units SQ q24h

>99 kg

150 U/kg SQ q24h
rounded to nearest 100 units drawn up using 25,000 U/ml MDV

Enoxaparin 1mg/kg SQ q12h

Clcr<30 ml/min

IV heparin

Enoxaparin 1mg/kg SQ q24h

*Please refer to:

Guidelines for Management of Low Molecular Weight Heparin

Chronic Therapy (after the first 3-6 months)

  • Transition to warfarin at goal INR of 2-3
  • Routine INR monitoring according to standard practice

References

  • ACCP Guidelines: Kearon C et al et al. Antithrombotic therapy for venous thromboembolic disease. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).  Chest 2008; 133 (suppl 6):454-545.
  • 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