EHA Guidelines on Management of Antithrombotic Treatments in Thrombocytopenic Patients With Cancer

Abstract

In cancer patients, thrombocytopenia can result from bone marrow infiltration or from anticancer medications and represents an important limitation for the use of antithrombotic treatments, including anticoagulant, antiplatelet, and fibrinolytic agents. These drugs are often required for prevention or treatment of cancer-associated thrombosis or for cardioembolic prevention in atrial fibrillation in an increasingly older cancer population. Data indicate that cancer remains an independent risk factor for thrombosis even in case of thrombocytopenia, since mild-to-moderate thrombocytopenia does not protect against arterial or venous thrombosis. In addition, cancer patients are at increased risk of antithrombotic drug-associated bleeding, further complicated by thrombocytopenia and acquired hemostatic defects. Furthermore, some anticancer treatments are associated with increased thrombotic risk and may generate interactions affecting the effectiveness or safety of antithrombotic drugs. In this complex scenario, the European Hematology Association in collaboration with the European Society of Cardiology has produced this scientific document to provide a clinical practice guideline to help clinicians in the management of patients with cancer and thrombocytopenia. The Guidelines focus on adult patients with active cancer and a clear indication for anticoagulation, single or dual antiplatelet therapy, their combination, or reperfusion therapy, who have concurrent thrombocytopenia because of either malignancy or anticancer medications. The level of evidence and the strength of the recommendations were discussed according to a Delphi procedure and graded according to the Oxford Centre for Evidence-Based Medicine.

Figure 1.

Management of anticoagulation in cancer patients with TP. *Stable grade 1–2 TP is defined as platelet counts, which are not expected to decrease to grade 3–4 TP in the coming days to weeks. †AF with arterial thromboembolism in the past 3 mo; AF with CHA2DS2-VASc ≥ 6; VTE in past 3 mo; mechanical heart valves where full-dose anticoagulation was not possible. ‡Stable grade 3 TP defined as platelet counts, which are not expected to decrease to grade 4 TP in the coming days to weeks. §VTE within the past 30 d. ¶Only in case of lower extremity DVT or pulmonary embolism. **This strategy can be used for a maximum of 14 d. AF = atrial fibrillation; DVT = deep vein thrombosis; INR = international normalized ratio; LAAO = left atrial appendage occlusion; LMWH = low-molecular weight heparin; TP = thrombocytopenia; Tx = transfusion; VKA = vitamin K antagonist; VTE = venous thromboembolism.

Figure 2.

Management of SAPT for secondary prevention in cancer patients with TP. §Refer to Table 4 for a nonexhaustive list of risk factors for major bleeding. ||Refer to Table 3 for a nonexhaustive list of patients with high-thrombotic risk. CV = cardiovascular; DDI = drug-drug interaction; NSAID = nonsteroidal anti-inflammatory drugs; SAPT = single antiplatelet therapy; TP = thrombocytopenia.

Figure 3.

Management of APT in patients with ACS and POST-PCI. §Refer to Table 4 for a nonexhaustive list of risk factors for major bleeding. ||Refer to Table 3 for a nonexhaustive list of patients with high-thrombotic risk. ACS = acute coronary syndrome; CV = cardiovascular; DDI = drug-drug interaction; DAPT = dual antiplatelet therapy; NSAID = nonsteroidal anti-inflammatory drugs; SAPT = single antiplatelet therapy; TP = thrombocytopenia.

Figure 4.

Reperfusion therapy in cancer patients with TP‡. †Recombinant tissue plasminogen activator (rt-PA, alteplase) or tenecteplase. ‡Platelets <100 × 10⁹/L. §Interventional procedures of thrombus removal including catheter-based thrombolysis or pharmacomechanical catheter-directed reperfusion techniques. AIS = acute ischemic stroke; LVO = large vessel occlusion; PE = pulmonary embolism; TP = thrombocytopenia.