Transcript
Announcer:
Welcome to CME on ReachMD. This episode is part of our MinuteCE curriculum. Prior to beginning the activity, please be sure to review the faculty and commercial support disclosure statements as well as the learning objectives.
Dr. Lopes:
Hello, this is CME on ReachMD, and I’m Dr. Renato Lopes. Here with me today is Dr. Ander Cohen.
Welcome. I understand you have a patient case that you'd like to present to us.
Dr. Cohen:
Yes, I have, Renato. And great to see you.
I'd like to talk about a patient with GI malignancy and upon re-embolus. And this is a 68-year-old man who had a DVT 2 years ago that was treated, and he’s now off treatment but he’s developed a GI malignancy. He’s had definitive therapy, and he's become short of breath, and a PE is diagnosed. And the real question is, what anticoagulant would you use in this patient? Because he's not only high risk of thrombosis, he's also high risk of bleeding. And we know from some research that we've done of over 15,000 cases, that GI cancers, particularly upper GI cancers but other cancers as well, brain cancers, bladder cancers, prostate cancers, and kidney and cervical cancers are all high risk of bleeding. So we really need to work out what's best. And if we look to the literature, we can see that in the CARAVAGGIO study, which was the study that compared apixaban with the low-molecular-weight heparin dalteparin, that there was no increased risk of bleeding when apixaban was compared to low-molecular-weight heparin in patients with GI cancer. But what we didn’t have up until more recently was real-world data that extrapolates what we find in the clinical trials and is consistent with the clinical trials. And I think we now have real-world data that shows that these patients with GI cancer do seem to do very well with the DOACs, and in particular apixaban, not just with respect to bleeding, but also to reducing recurrences of venous thrombosis.
So I thought I'd just have a chat with you about this case, Renato.
Dr. Lopes:
Well, that’s a great case and so common, right? We see these patients every day in our practice. But let me ask you a question. Because you said the patient had VTE or DVT 2 years ago. But was the patient still on an anticoagulant when he presented with this PE or he got treated for 6 months to 12 months and then the anticoagulation was stopped? Because I think that's an important point, right?
Dr. Cohen:
Yes, it is. And the answer is the latter, that this patient, that was their first venous thrombosis 2 years ago. They received 6 months of therapy and stopped. So then they had the GI cancer diagnosis, the definitive treatment with chemotherapy and surgery, and then developed a PE. So this is an interesting case because we don’t know whether the previous DVT was related to early cancer or whether it was just a propensity to develop venous thrombosis.
But the key here, I think, Renato, is choosing the right anticoagulant. And DOACs seem to be the right anticoagulant because they reduce thrombosis by 30% to 40%. But in the case of apixaban, they don't seem to increase major bleeding, which was not apparent with some of the other DOACs.
Dr. Lopes:
No, I think you're spot on in terms of the choice of the anticoagulation for this patient population. Because I think the first good news that we had with the NOACs is we can use for VTEs, overall, that we can use also when VTEs are associated with cancer. But some concerns were about GI cancers, GI bleeds, and I think CARAVAGGIO came to really say that, yes, we can still use low-molecular-weight heparin for these patients, but we have an alternative of, like, apixaban, as you said, that will not increase GI bleeding compared to low-molecular-weight heparin, again, which is not the case with other NOACs. So I think, overall, good news to the treatment of this challenging group of patients.
Dr. Cohen:
Yeah. No, I think that's an excellent summary, Renato. And thanks very much for discussing this with me today, and thanks to everyone for tuning in and hearing us have this brief conversation.
Dr. Lopes:
Great. Thanks everyone. Thanks for listening.
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