PMID- 29363105
OWN - NLM
STAT- MEDLINE
DCOM- 20180226
LR  - 20231006
IS  - 1469-493X (Electronic)
IS  - 1361-6137 (Linking)
VI  - 1
IP  - 1
DP  - 2018 Jan 24
TI  - Anticoagulation for the initial treatment of venous thromboembolism in people 
      with cancer.
PG  - CD006649
LID - 10.1002/14651858.CD006649.pub7 [doi]
LID - CD006649
AB  - BACKGROUND: Compared with people without cancer, people with cancer who receive 
      anticoagulant treatment for venous thromboembolism (VTE) are more likely to 
      develop recurrent VTE. OBJECTIVES: To compare the efficacy and safety of three 
      types of parenteral anticoagulants (i.e. fixed-dose low molecular weight heparin 
      (LMWH), adjusted-dose unfractionated heparin (UFH), and fondaparinux) for the 
      initial treatment of VTE in people with cancer. SEARCH METHODS: A comprehensive 
      search included a major electronic search of the following databases: Cochrane 
      Central Register of Controlled Trials (CENTRAL) (2018, Issue 1), MEDLINE (via 
      Ovid) and Embase (via Ovid); handsearching of conference proceedings; checking of 
      references of included studies; use of the 'related citation' feature in PubMed; 
      and a search for ongoing studies. This update of the systematic review was based 
      on the findings of a literature search conducted on 14 January 2018. SELECTION 
      CRITERIA: Randomized controlled trials (RCTs) assessing the benefits and harms of 
      LMWH, UFH, and fondaparinux in people with cancer and objectively confirmed VTE. 
      DATA COLLECTION AND ANALYSIS: Using a standardized form, we extracted data in 
      duplicate on study design, participants, interventions outcomes of interest, and 
      risk of bias. Outcomes of interested included all-cause mortality, symptomatic 
      VTE, major bleeding, minor bleeding, postphlebitic syndrome, quality of life, and 
      thrombocytopenia. We assessed the certainty of evidence for each outcome using 
      the GRADE approach. MAIN RESULTS: Of 15440 identified citations, 7387 unique 
      citations, 15 RCTs fulfilled the eligibility criteria. These trials enrolled 1615 
      participants with cancer and VTE: 13 compared LMWH with UFH enrolling 1025 
      participants, one compared fondaparinux with UFH and LMWH enrolling 477 
      participants, and one compared dalteparin with tinzaparin enrolling 113 
      participants. The meta-analysis of mortality at three months included 418 
      participants from five studies and that of recurrent VTE included 422 
      participants from 3 studies. The findings showed that LMWH likely decreases 
      mortality at three months compared to UFH (risk ratio (RR) 0.66, 95% confidence 
      interval (CI) 0.40 to 1.10; risk difference (RD) 57 fewer per 1000, 95% CI 101 
      fewer to 17 more; moderate certainty evidence), but did not rule out a clinically 
      significant increase or decrease in VTE recurrence (RR 0.69, 95% CI 0.27 to 1.76; 
      RD 30 fewer per 1000, 95% CI 70 fewer to 73 more; moderate certainty 
      evidence).The study comparing fondaparinux with heparin (UFH or LMWH) did not 
      exclude a beneficial or detrimental effect of fondaparinux on mortality at three 
      months (RR 1.25, 95% CI 0.86 to 1.81; RD 43 more per 1000, 95% CI 24 fewer to 139 
      more; moderate certainty evidence), recurrent VTE (RR 0.93, 95% CI 0.56 to 1.54; 
      RD 8 fewer per 1000, 95% CI 52 fewer to 63 more; moderate certainty evidence), 
      major bleeding (RR 0.82, 95% CI 0.40 to 1.66; RD 12 fewer per 1000, 95% CI 40 
      fewer to 44 more; moderate certainty evidence), or minor bleeding (RR 1.53, 95% 
      CI 0.88 to 2.66; RD 42 more per 1000, 95% CI 10 fewer to 132 more; moderate 
      certainty evidence)The study comparing dalteparin with tinzaparin did not exclude 
      a beneficial or detrimental effect of dalteparin on mortality (RR 0.86, 95% CI 
      0.43 to 1.73; RD 33 fewer per 1000, 95% CI 135 fewer to 173 more; low certainty 
      evidence), recurrent VTE (RR 0.44, 95% CI 0.09 to 2.16; RD 47 fewer per 1000, 95% 
      CI 77 fewer to 98 more; low certainty evidence), major bleeding (RR 2.19, 95% CI 
      0.20 to 23.42; RD 20 more per 1000, 95% CI 14 fewer to 380 more; low certainty 
      evidence), or minor bleeding (RR 0.82, 95% CI 0.30 to 2.21; RD 24 fewer per 1000, 
      95% CI 95 fewer to 164 more; low certainty evidence). AUTHORS' CONCLUSIONS: LMWH 
      is possibly superior to UFH in the initial treatment of VTE in people with 
      cancer. Additional trials focusing on patient-important outcomes will further 
      inform the questions addressed in this review. The decision for a person with 
      cancer to start LMWH therapy should balance the benefits and harms and consider 
      the person's values and preferences.
FAU - Hakoum, Maram B
AU  - Hakoum MB
AD  - Family Medicine, American University of Beirut, Beirut, Lebanon, 1107 2020.
FAU - Kahale, Lara A
AU  - Kahale LA
FAU - Tsolakian, Ibrahim G
AU  - Tsolakian IG
FAU - Matar, Charbel F
AU  - Matar CF
FAU - Yosuico, Victor Ed
AU  - Yosuico VE
FAU - Terrenato, Irene
AU  - Terrenato I
FAU - Sperati, Francesca
AU  - Sperati F
FAU - Barba, Maddalena
AU  - Barba M
FAU - Schunemann, Holger
AU  - Schunemann H
FAU - Akl, Elie A
AU  - Akl EA
LA  - eng
PT  - Journal Article
PT  - Meta-Analysis
PT  - Research Support, Non-U.S. Gov't
PT  - Review
PT  - Systematic Review
DEP - 20180124
PL  - England
TA  - Cochrane Database Syst Rev
JT  - The Cochrane database of systematic reviews
JID - 100909747
RN  - 0 (Anticoagulants)
RN  - 0 (Fibrinolytic Agents)
RN  - 0 (Heparin, Low-Molecular-Weight)
RN  - 0 (Polysaccharides)
RN  - 7UQ7X4Y489 (Tinzaparin)
RN  - 9005-49-6 (Heparin)
RN  - J177FOW5JL (Fondaparinux)
RN  - S79O08V79F (Dalteparin)
SB  - IM
UOF - Cochrane Database Syst Rev. 2014 Jun 19;(6):CD006649. PMID: 24945634
UIN - Cochrane Database Syst Rev. 2021 Dec 8;12:CD006649. PMID: 34878173
MH  - Anticoagulants/*therapeutic use
MH  - Dalteparin/therapeutic use
MH  - Fibrinolytic Agents/therapeutic use
MH  - Fondaparinux
MH  - Hemorrhage/chemically induced
MH  - Heparin/therapeutic use
MH  - Heparin, Low-Molecular-Weight/therapeutic use
MH  - Humans
MH  - Neoplasms/*complications
MH  - Polysaccharides/therapeutic use
MH  - Randomized Controlled Trials as Topic
MH  - Recurrence
MH  - Secondary Prevention
MH  - Tinzaparin
MH  - Venous Thromboembolism/*drug therapy/mortality
PMC - PMC6389339
COIS- HJS: panel member of the ASH VTE in cancer patients, Vice-Chair of the ASH VTE 
      guidelines and played various leadership roles from 1999 until 2014 with ACCP VTE 
      guidelines. EAA served on the executive committee the ACCP Antithrombotic Therapy 
      Guidelines published in 2016. All other review authors declare no conflicts of 
      interests.
EDAT- 2018/01/25 06:00
MHDA- 2018/02/27 06:00
PMCR- 2019/01/24
CRDT- 2018/01/25 06:00
PHST- 2018/01/25 06:00 [pubmed]
PHST- 2018/02/27 06:00 [medline]
PHST- 2018/01/25 06:00 [entrez]
PHST- 2019/01/24 00:00 [pmc-release]
AID - CD006649.pub7 [pii]
AID - 10.1002/14651858.CD006649.pub7 [doi]
PST - epublish
SO  - Cochrane Database Syst Rev. 2018 Jan 24;1(1):CD006649. doi: 
      10.1002/14651858.CD006649.pub7.