内容紹介
Management of Venous Thromboembolism in Cancer Patients
Summary
The clinical relevance of the association between venous thromboembolism(VTE)and cancer is well documented. VTE is one of the leading causes of death in cancer patients. It would be an advantage to have knowledge on predictive parameters for the development of thrombosis and to be able to select cancer patients individually according to their risk profiles. An elevated platelet count is associated with an increased risk of VTE in cancer patients. The biomarkers including D-dimer have been identified and used to extend the existing risk stratification. Treatment of VTE in cancer patients is complicated due to a high rate of recurrence in addition to a higher risk of bleeding during anticoagulation therapy. Current guidelines recommend low-molecular-weight heparin(LMWH)monotherapy over vitamin K antagonist(VKA)for the treatment of cancer-associated VTE. However, recent clinical study could not show any superior efficacy of LMWH over VKA in preventing VTE recurrence or overall mortality. The direct oral anticoagulants(DOACs)may be an effective treatment for VTE in cancer patients, although the risk reduction for recurrent VTE with the DOACs compared to LMWH has not been well assessed. Physicians should frequently re-evaluate the risk-benefit ratio of ongoing anticoagulation therapy in individual patient, in views of the overall clinical conditions including their quality of life and life expectancy.
要旨
静脈血栓塞栓症(venous thromboembolism: VTE)は,がん患者における重篤な合併症である。がんは,その進展や転移に際して宿主の血液凝固機構を巧みに利用する。血小板数や凝固線溶系の指標であるD-dimerは,VTEの発症リスクを評価する上で有用なマーカーである。がん患者の周術期におけるVTE予防には,ワルファリンよりも低分子量ヘパリンなどの非経口抗凝固療法が推奨される。VTEを発症したがん患者に対して少なくとも3～6か月間にわたり低分子量ヘパリンによる治療が行われるが,生命予後の改善に必ずしもつながらない。“active cancer”病変をもつ患者では,予防用量の低分子量ヘパリンや経口抗凝固薬を初期治療から投与期間を延長して使用すべきであろう。本邦のように低分子量ヘパリンの自己注射が困難であるような状況がある場合には,直接型経口抗凝固薬(direct oral anticoagulants: DOACs)の適否を考慮すべきであろう。VTEのマネジメントは,治療プロトコール,併存疾患やADL,原病による生命予後の予測などに加えて患者自身の意思を十分に考慮した上でプランニングされるべきである。
目次
Summary
The clinical relevance of the association between venous thromboembolism(VTE)and cancer is well documented. VTE is one of the leading causes of death in cancer patients. It would be an advantage to have knowledge on predictive parameters for the development of thrombosis and to be able to select cancer patients individually according to their risk profiles. An elevated platelet count is associated with an increased risk of VTE in cancer patients. The biomarkers including D-dimer have been identified and used to extend the existing risk stratification. Treatment of VTE in cancer patients is complicated due to a high rate of recurrence in addition to a higher risk of bleeding during anticoagulation therapy. Current guidelines recommend low-molecular-weight heparin(LMWH)monotherapy over vitamin K antagonist(VKA)for the treatment of cancer-associated VTE. However, recent clinical study could not show any superior efficacy of LMWH over VKA in preventing VTE recurrence or overall mortality. The direct oral anticoagulants(DOACs)may be an effective treatment for VTE in cancer patients, although the risk reduction for recurrent VTE with the DOACs compared to LMWH has not been well assessed. Physicians should frequently re-evaluate the risk-benefit ratio of ongoing anticoagulation therapy in individual patient, in views of the overall clinical conditions including their quality of life and life expectancy.
要旨
静脈血栓塞栓症(venous thromboembolism: VTE)は,がん患者における重篤な合併症である。がんは,その進展や転移に際して宿主の血液凝固機構を巧みに利用する。血小板数や凝固線溶系の指標であるD-dimerは,VTEの発症リスクを評価する上で有用なマーカーである。がん患者の周術期におけるVTE予防には,ワルファリンよりも低分子量ヘパリンなどの非経口抗凝固療法が推奨される。VTEを発症したがん患者に対して少なくとも3～6か月間にわたり低分子量ヘパリンによる治療が行われるが,生命予後の改善に必ずしもつながらない。“active cancer”病変をもつ患者では,予防用量の低分子量ヘパリンや経口抗凝固薬を初期治療から投与期間を延長して使用すべきであろう。本邦のように低分子量ヘパリンの自己注射が困難であるような状況がある場合には,直接型経口抗凝固薬(direct oral anticoagulants: DOACs)の適否を考慮すべきであろう。VTEのマネジメントは,治療プロトコール,併存疾患やADL,原病による生命予後の予測などに加えて患者自身の意思を十分に考慮した上でプランニングされるべきである。