Regresar

Systematic review and meta analysis of anticoagulant treatment in cancer-associated thrombosis. Implications about non-inferiority studies.

Abstract:

Cancer-associated thrombosis (CAT) is a frequent complication in cancer patients. There are three options for thromboprophilaxis: new direct oral anticoagulants (NOAC), low molecular weight heparins (LMWH) and anti-vitamin K (warfarin). The present systematic review was carried out to compare these alternatives on their effectiveness and safety under criteria of non-inferiority. Additionally, the use of NOAC and LMWH against a placebo was analyzed to show superiority. The primary event was deep venous thrombosis recurrence (DVTr) and for security, major bleeding. A total of 9353 patients were classified in four categories: NOAC vs warfarin (4 studies), NOAC vs LMWH (3 studies), LMWH vs. warfarin (3 studies) and NOAC or LMWH vs placebo (4 studies). The results show a superiority of NOAC over warfarin [RR; (95% CI) = 0.70; (0.58-0.87), p <0.001] and a non-inferiority of NOAC vs LMWH and LMWH vs. warfarin (RR; (95%CI) = 0.78;(0.59-1.03), p= 0.081 and 0.71; (0.44-1.14), p= 0.159 respectively]. Safety analysis for major bleeding showed superiority of LMWH over NOAC and warfarin [RR; (95%CI) = 1.69; (1.22-2.33), p <0.002 and 0.72;(0.56-0.93), p <0.001 respectively]. Studies showed superiority of NOAC / LMWH vs placebo, but the risk of bleeding was higher. It is concluded that the slight advantage of NOAC in the prevention and reduction of DVTr is questioned by the increased risk of bleeding. It is suggested that the choice of anticoagulant should be personalized, considering the risk of bleeding from the patient, the cancer site and the patient’s values and preferences.