Oral Anticoagulant Effective in Recurrent VTE Prevention in Cancer Patients

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Cancer patients with venous thromboembolism were randomly assigned 1:1 to either dalteparin, an LMWH, or rivaroxaban.
Cancer patients with venous thromboembolism were randomly assigned 1:1 to either dalteparin, an LMWH, or rivaroxaban.

University of Warwick researchers reported that once-daily rivaroxaban (Xarelto; Janssen) was found to lower recurrence of venous thromboembolism (VTE). The findings were published in the Journal of the American Society of Clinical Oncology

Currently, international guidelines recommend that cancer patients receive long-term daily subcutaneous low-molecular weight heparin (LMWH) for the treatment and prevention of recurrent VTE. Researchers aimed to determine if rivaroxaban, an oral factor Xa inhibitor, could serve as an alternative for treating VTE in patients with cancer. 

The SELECT-D trial (N=406) enrolled cancer patients with VTE (symptomatic pulmonary embolism [PE], incidental PE, or symptomatic lower-extremity proximal deep vein thrombosis [DVT]) of which 69% were receiving chemotherapy at the time of their VTE. 

Study patients were randomized 1:1 to either dalteparin, an LMWH, or rivaroxaban. The primary outcome was VTE recurrence over 6 months; safety was also assessed by major bleeding and clinically relevant non-major bleeding. 

Eighteen patients in the dalteparin group and 8 patients in the rivaroxaban group experienced recurrent VTE. At the end of 6 months, the rate of VTE recurrence was 4% among rivaroxaban patients vs 11% in the dalteparin arm (hazard ratio [HR] 0.43, 95% CI: 0.19 to 0.99). The cumulative rate of major bleeding was slightly lower in the dalteparin group vs rivaroxaban (4% vs 6%; HR 1.83, 95% CI: 0.68 to 4.96). The rate of clinically relevant non-major bleeding was also lower with dalteparin vs rivaroxaban (4% vs 13%; HR 3.76, 95% CI: 1.63 to 8.69). 

"The results of our trial provide evidence that rivaroxaban is an effective alternative to LMWH for the treatment of VTE in cancer. Rivaroxaban reduced the rate of recurrent VTE compared with LMWH, but at the cost of more bleeding," concluded lead author Professor Annie Young. While oral administration is more convenient vs injections, it should be used with caution in patients with esophageal cancer. In general, the authors stated that the patient's preference for an anticoagulant should be "based on a careful discussion between patient and physician about the benefits and risks of the treatment alternatives."

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