American Society of Hematology 2021 guidelines for management of venous thromboembolism: prevention and treatment in patients with cancer

TLDR

Venous thromboembolism is a frequent and deadly complication in cancer patients, markedly increasing morbidity and mortality. These ASH guidelines aim to aid clinicians and patients in deciding how to prevent and treat VTE in cancer patients. The guidelines were developed by a multidisciplinary panel using updated systematic reviews and the GRADE framework to assess evidence. Recommendations cover mechanical and pharmacologic prophylaxis for hospitalized, surgical, and ambulatory patients, and anticoagulation strategies for initial, short‑term, and long‑term VTE treatment, with strong advice against prophylaxis in low‑risk ambulatory chemotherapy and for LMWH as initial therapy, and conditional guidance on prophylaxis in hospitalized and surgical patients and on LMWH/DOAC use in high‑risk ambulatory and for various treatment durations.

Abstract

Background: Venous thromboembolism (VTE) is a common complication among patients with cancer. Patients with cancer and VTE are at a markedly increased risk for morbidity and mortality. Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in their decisions about the prevention and treatment of VTE in patients with cancer. Methods: ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The guideline development process was supported by updated or new systematic evidence reviews. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess evidence and make recommendations. Results: Recommendations address mechanical and pharmacological prophylaxis in hospitalized medical patients with cancer, those undergoing a surgical procedure, and ambulatory patients receiving cancer chemotherapy. The recommendations also address the use of anticoagulation for the initial, short-term, and long-term treatment of VTE in patients with cancer. Conclusions: Strong recommendations include not using thromboprophylaxis in ambulatory patients receiving cancer chemotherapy at low risk of VTE and to use low-molecular-weight heparin (LMWH) for initial treatment of VTE in patients with cancer. Conditional recommendations include using thromboprophylaxis in hospitalized medical patients with cancer, LMWH or fondaparinux for surgical patients with cancer, LMWH or direct oral anticoagulants (DOAC) in ambulatory patients with cancer receiving systemic therapy at high risk of VTE and LMWH or DOAC for initial treatment of VTE, DOAC for the short-term treatment of VTE, and LMWH or DOAC for the long-term treatment of VTE in patients with cancer.