06/28/2017

NCCN has published updates to the NCCN Guidelines and NCCN Compendium® for Cancer-Associated Venous Thromboembolic Disease

NCCN has published updates to the NCCN Guidelines and NCCN Compendium^® for Cancer-Associated Venous Thromboembolic Disease. These NCCN Guidelines and are currently available as Version 1.2017. 

• Venous Thromboembolism (VTE) Prophylaxis
  • Initial prophylaxis for patients with cancer (VTE-1)
    • "Graduated compression stockings" were removed as an option for initial prophylaxis.
    • Footnote “d” referring to “Intermittent pneumatic compression (IPC)” was revised: “IPC device is preferred over CCS. Patient should be appropriately measured for stockings and monitored for adverse effects including skin ulcerations, especially in immobilized patients with peripheral neuropathy. See Contraindications to Mechanical Prophylaxis (VTE B). (CLOTS Trial Collaboration. Lancet 2009. 373:1958 1965.) In contrast to GCS, IPC significantly reduced DVT and was associated with a lower risk of skin complications. (CLOTS Trial Collaboration Dennis M, et al. Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial. Lancet 2013;382:516-524, and Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. Lancet 2009;373:1958-1965.)"

• Acute Superficial Vein Thrombosis (SVT) page was extensively revised. (SVT-1)
  
  
• Acute Deep Vein Thrombosis (DVT) page was extensively revised. (DVT-2)
  
  
• Catheter-Related DVT: Diagnosis and Treatment (DVT-3)
  • For patients receiving “Anticoagulation for at least 3 months”, footnote “l” was revised: “Anticoagulation without catheter removal is the preferred option for initial treatment, even for patients with symptomatic DVT, provided that the catheter is necessary, functional, and free of infection. There is very little clinical evidence regarding the appropriate duration of anticoagulation. The recommended duration of anticoagulation depends on patient tolerance of anticoagulation, response to anticoagulation, and catheter status. Consider longer duration anticoagulation in patients with poor flow, persistent symptoms, or unresolved thrombus. Consider shorter duration of anticoagulation if clot or symptoms resolve in response to anticoagulation and/or catheter removal.”

• Acute Pulmonary Embolism (PE) page was extensively revised. (PE-2)
  
  
• Heparin-Induced Thrombocytopenia (HIT)
  • Diagnosis and Treatment of HIT (HIT-1)
    • For patients with “Low” HIT Pre-test Probability (4T Score <4)
      • 1^st bullet was revised: “Weigh risks/benefits of heparin vs. parenteral direct thrombin inhibitor (DTI) or fondaparinux, and consider continuing heparin Continue UFH/LMWH"
      • A footnote was removed: "Data supporting use of fondaparinux is limited; however, among experienced clinicians it is commonly used for outpatient management in low-risk patients."

• VTE Risk Factors In Patients with Cancer (VTE-A, 1 of 3)
  • In the list under “High-risk outpatients on chemotherapy, based on combinations of the following risk factors”, the 2^nd bullet was revised: "Prechemotherapy platelet count > 300,000 350,000/mcL".
  • Under “Treatment-related risk factors”, for patients taking contraceptives, footnote "2" was added: "The following hormonal contraceptives are associated with an increased risk of VTE: progestin-only injectables and combined hormonal contraceptives (containing estrogen + progestin) administered orally, by transdermal patch or vaginal ring. Progestin-only contraceptives administered orally or via implants or IUDs have not been definitively shown to increase the risk of VTE in the general population, but may contribute to VTE risk in patients with multiple risk factors. (Tepper NK, et al. Nonoral combined hormonal contraceptives and thromboembolism: a systematic review. Contraception 2016;94:678-700)."

• Contraindications to Prophylactic or Therapeutic Anticoagulation Treatment (VTE-B)
  • Added footnote “1” referring to the absolute contraindication “Recent central nervous system (CNS) bleed, hemorrhagic CNS metastases”: “In general, brain metastases are a relative contraindication to anticoagulation except in cases where more caution is warranted due to the location of the metastases, tumor type, or presence of other comorbidities.”

• New page added: Management of Anticoagulation for VTE in Patients with Chemotherapy-Induced Thrombocytopenia (VTE-C)
  
  
• Therapeutic Anticoagulation for Venous Thromboembolism (VTE-E, 1 of 3)
  • Acute Management: At diagnosis or during diagnostic evaluation
    • 5^th bullet was revised: "Direct oral anticoagulants (DOACs) are not recommended (apixaban, dabigatran, edoxaban, and rivaroxaban require additional clinical experience and research to provide data regarding risks/benefits and guidance for their safe and effective use in cancer patients). For patients who refuse or have compelling reasons to avoid LMWH, the following direct oral anticoagulants (DOACs) are acceptable alternatives for acute management of VTE: apixaban and rivaroxaban. The choice of anticoagulant needs to incorporate specific considerations."
    • Footnote “6”, referring to low molecular weight heparin (LMWH) as a treatment option for management of VTE, was added: "Patients may refuse or be poor candidates for LMWH injections because they are painful, inconvenient, and expensive." (Also on VTE-E, 2 of 3)
  • Chronic management (VTE-E, 2 of 3)
    • 3rd bullet was revised: "DOAC are not recommended (apixaban, dabigatran, edoxaban, and rivaroxaban require additional clinical experience and research to provide data regarding risks/benefits and guidance for their safe and effective use in cancer patients). For patients who refuse or have compelling reasons to avoid LMWH, the following DOACs are acceptable alternatives as second-line agents for chronic management of VTE: apixaban, dabigatran, edoxaban, and rivaroxaban. The choice of anticoagulant needs to incorporate specific considerations."
    • Footnote “6” referring to patients who refuse or have compelling reasons to avoid LMWH, was added: “Patients may refuse or be poor candidates for LMWH injections because they are painful, inconvenient, and expensive. These factors may contribute to poor compliance with long-term LMWH treatment.”
    • Footnote “7” referring to DOACs, was added: “Unlike warfarin, concurrent administration with parenteral anticoagulants is not recommended when transitioning to apixaban, dabigatran, edoxaban, or rivaroxaban. See prescribing information for protocols for transitioning between agents.” 

• "Anticoagulant Options: Contraindications and Warnings" page for therapeutic anticoagulation for venous thromboembolism is new to the guidelines. (VTE-E, 3 of 3)
  
  
• Reversal of Anticoagulation in the Event of Life-Threatening Bleeding or Emergent Surgery (VTE-F 1 of 9). In lieu of repeating it throughout the table, the 2^nd bullet was added: "All anticoagulation reversal protocols are associated with a risk of thromboembolism."
  
  
• The following page was removed: Clinical Scenarios Warranting Consideration of Filter Placement (VTE-G).
  
  
• Therapeutic Anticoagulation Failure (VTE-H) page has been divided into 2 pages and extensively revised. 
  
  
• Thrombolytic Agents (VTE-I)
  • For thrombolysis of DVT, the following option was removed: "Tenecteplase 0.25-0.5 mg/h IV”
  • For the thrombolysis of PE, the following option was added: "Tenecteplase 0.25-0.5 mg/h IV (category 2B)"
  • Footnote “3” referring to alteplase was added: “Alteplase 50 mg may be appropriate for patients aged >75 years, recent surgery (within 1 mo), or high-risk of bleed."

• Perioperative Management of Anticoagulation and Antithrombotic Therapy (PMA)
  • Cancer patients on anticoagulants requiring surgery (PMA-1), patients undergoing non-emergent surgery
    • Since the “moderate” bleeding risk category was removed, the lower pathway after “bleeding risk assessment” was revised: " Very high, High and Low Risk"
  • Table 1: Bleeding Risk Assessment, Estimated Bleeding Risk of Various Surgical Procedures (PMA-A, 1 of 2)
    • Low Bleeding Risk Category
    • 7^th bullet was added: “GI endoscopy with biopsy”
    • "Major intra-abdominal surgery" and "major intra-thoracic surgery" were moved from "moderate" to the "high" bleeding risk category.
    • The “Moderate” bleeding risk category was removed.
    • The "Anticoagulation Recommendation" column was removed.
  • Table 1: Bleeding Risk Assessment, Estimated Bleeding Risk of Various Dental Procedures (PMA-A, 2 of 2)
    • A statement was added to the recommended procedures for patients with low and moderate bleeding risk: "Follow recommendations for very low risk surgical procedures. See (PMA-C)".
    • A statement was added to the recommended procedures for patients with high bleeding risk: "Follow recommendations for low risk surgical procedures. See (PMA-C)"
  • Perioperative Anticoagulation Management Guideline (PMA-C)
    • This section about perioperative anticoagulation management has been revised and extensively reformatted.