Table 2.

Management of challenging cases of cancer-associated thrombosis16

Recurrent VTE despite anticoagulation

  • If on warfarin, switch to therapeutic LMWH.

  • If already on LMWH, increase dose by 25% or increase back up to therapeutic weight adjusted dose if they are receiving non-therapeutic dosing.

  • If no symptomatic improvement use peak anti-Xa level to estimate next dose escalation.

Management of CAT in thrombocytopenia

  • For platelet count >50 x10 9 L -1 give full therapeutic dose LMWH.

  • For acute CAT and platelet count <50 x 10 9 L -1:

  1. full anticoagulation with platelet transfusion to maintain platelet count >50 x 10 9 L -1
  2. if platelet transfusion is not possible consider retrievable IVC filter.

  • For subacute or chronic CAT and thrombocytopaenia (platelet count <50 x 10 9 L -1):

  1. reduce therapeutic dose by 50% or use prophylacitic dose for platelet count 25–50 x 10 9 L -1
  2. omit LMWH if platelet count <25 x 10 9 L -1.
Bleeding while anticoagulated

  • Assess each bleeding episode to identify bleeding source, severity, impact and reversibility.

  • Provide supportive measures to stop bleeding, including transfusion where indicated.

  • For a major or life-threatening bleeding episode, withhold anticoagulation:

  1. consider IVC filter insertion in patients with acute or subacute CAT with a major or life-threatening bleeding episode
  2. do not consider IVC filter insertion in patients with chronic CAT
  3. once bleeding resolves, remove retrievable filter (if inserted) and resume/initiate anticoagulation.

  • CAT = cancer-associated thrombosis; IVC = inferior vena cava; LMWH = low molecular weight heparin; VTE = venous thromboembolism.