1/ Tweetorial: DOACs in cancer
The risk of venous thromboembolism (VTE) is up to 7 x higher in patients with cancer, and contributes to morbidity and mortality

Overall prognosis is worse in patients with cancer and VTE, compared to those with cancer and no VTE
2/ The treatment of VTE in cancer is complex due to concerns around;

-Interactions with anti-cancer treatment 💊
-Timing of surgery and procedures 🪚 (no scalpel emoji)
-Low platelet counts due to treatment 🩸
-Higher risk of bleeding related to some cancers 🩹
3/ LMWH was traditionally the treatment of choice, with data from the CLOT study (2003) showing improved efficacy vs warfarin & no ⬆️ bleeding risk

It is a useful option as no monitoring (usually) required, less interactions and short T1/2. It is however given by injection...
4/ Several studies have investigated DOAC use in cancer.
These showed;

Edoxaban (Hokusai VTE)-⬇️ VTE recurrence compared to LMWH. ⬆️ major bleeding, esp GI tract

Rivaroxaban (SELECT D)-⬇️ VTE recurrence compared to LMWH. ⬆️ clinically relevant non-major bleeding

Apixaban (ADAM VTE and Caravaggio)- superior to LMWH for VTE recurrence with similar rates of major bleeding, except for a subgroup of patients over the age of 75 who had more with apixaban
6/ A common concern in these studies was increased rates of bleeding, some major, in patients with GI/GU cancers on DOACs 🩸

The ISTH subsequently advised caution in using DOACs in patients with malignancies of the GI/GU tract
7/ In summary, DOACs should be considered for many, but not all patients with cancer and VTE. Caution should be exercised in those with high bleeding risk (e.g. GI cancers) and elderly patients (> 75). As always, individualised decisions should be made with the patient’s input
8/ If you want to put some of this new knowledge into practice, our friends at @TeamHaem are running a case about DOACs in cancer

It’s like a Marvel crossover of the haematology Twitter world 😋

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More from @BukuHaematology

16 Sep 20
1/ Antidote news! There has been promise recently regarding antidotes being developed for DOACs. Before we get onto that, a quick summary of what we have so far...
2/ In the case of bleeding while on warfarin, this should be stratified by severity. Usual rule is if life/limb/sight threatening bleeding, prothrombin complex concentrate + vit K is used. If not, vitamin K +- pause/cessation of warfarin is advised.
3/ Warfarin works by inhibiting vitamin K-dependent clotting factor production. These factors are II, VII, IX and X. The 'antidote' is prothrombin complex concentrate (e.g beriplex) which is a concentrated 'soup' of factors II, VII, IX and X (and some protein C and S)
Read 11 tweets
17 Feb 20
1/19. When considering whether a patient is at risk of bleeding before a procedure/surgery or if a patient is bleeding and you want to assess if there are any 'correctable' clotting abnormalities, a thorough approach is needed to ensure all factors are identified.
2/19. The patient might have a PT of 19 seconds but this will probably make little/no difference in terms of bleeding risk, but the clopidogrel they have continued to take without telling the nurses/medical staff really will. I.e the coagulation screen isn't the whole picture..
3/19. The 3 main elements are platelets, fibrinogen and clotting factors.
Platelet function depends on platelet number and function. Count can be reduced by many causes. Major surgery can occur with a platelet count of 50x10^9 or more (BSH guidelines. Note neurosurgery >100)
Read 19 tweets
15 Jan 20
1/7. Prothrombin time (PT) measures the extrinsic coagulation cascade. The only 'major' clotting factor in the extrinsic pathway is factor VII. This is the clotting factor with the shortest half life, and explains why the PT is so often prolonged in unwell patients
2/7. It also makes a long PT relatively easy to investigate and manage. The absolute majority of patients with a long PT will either be vitamin K deficient, have factor VII deficiency due to consumption in sepsis/bleeding or liver disease.
3/7. Warfarin and the DOACS (to a varying degree) will represent most of the rest of prolonged PT results. Factor VII deficiency is incredibly rare, and will have been present from birth, therefore if the patient has had a normal PT in the past...
Read 7 tweets

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