116 Letters to the Editor
Disclosure of Conflict of Interests The author states that he has no conflict of interest. References 1 Carrier M, Khorana A, Zwicker J, Noble S, Lee A, The subcommittee on Haemostasis Malignancy for the SSC of the ISTH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 2013; 1: 1–9.
2 Red Cross Issues Emergency Call for Blood and Platelet Donors. http://www.redcross.org/news/article/Red-Cross-Issues-EmergencyCall-for-Blood-and-Platelet-Donors. Accessed 26 August 2013. 3 Yuan S, Goldfinger D. Clinical and laboratory aspects of platelet transfusion therapy. www.uptodate.com. Accessed 26 August 2013. 4 Pemmaraju N, Kroll MH, Afshar-Kharghan V, Oo TH. Bleeding risk in thrombocytopenic cancer patients with venous thromboembolism (VTE) receiving anticoagulation. https://ash.confex.com/ ash/2012/webprogram/Paper47208.html. Accessed 26 August 2013. 5 Soff GA. Pathophysiology and management of thrombosis in cancer: 150 years of progress. J Thromb Thrombolysis 2013; 35: 346– 351.
Management of challenging cases of patients with cancerassociated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH: a reply to a rebuttal M . C A R R I E R , * A . A . K H O R A N A , † J . I . Z W I C K E R , ‡ S . N O B L E , § A . Y . Y . L E E ¶ and O N B E H A L F O F T H E SUBCOMMITTEE ON HAEMOSTASIS AND MALIGNANCY FOR THE SSC OF THE ISTH *Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; †Department of Solid Tumor Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA; ‡Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; §Royal Gwent Hospital, Newport, UK; and ¶Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
To cite this article: Carrier M, Khorana AA, Zwicker JI, Noble S, Lee AYY, on behalf of the Subcommittee on Haemostasis and Malignancy for the SSC of the ISTH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH: a reply to a rebuttal. J Thromb Haemost 2014; 12: 116–7. See also Carrier M, Khorana A, Zwicker J, Noble S, Lee A; the subcommittee on Haemostasis Malignancy for the SSC of the ISTH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 2013; 11: 1760–5 and Oo TH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH: a rebuttal. This issue, pp 115–6.
. e thank Dr Oo for his interesting comments on the W management of patients with acute cancer-associated thrombosis (CAT) and thrombocytopenia (< 50 9 109 L–1). As discussed in our article, the guidance statement specifically addresses challenging clinical situations without high-quality evidence, with the aim of providing expert opinions and pragmatic approaches regarding the management of anticoagulation in individual cancer patients with these therapeutic challenges [1]. It is beyond the Correspondence: Agnes Y. Y. Lee, Division of Hematology, University of British Columbia, 2775 Laurel Street 10th floor, Vancouver, BC, V5Z 1M9, Canada. Tel.: +1 604 875 4952; fax: +1 604 875 4696. E-mail: [email protected]
scope of this article to anticipate and address specific national variations in practice (e.g. regional shortage of blood and platelet donors) or hospital-specific restrictions on the use of blood products. Therefore, clinicians need to interpret the Guidance Statement within their local context. As shown in many previous studies, the risk of recurrent venous thromboembolism and its associated casefatality rates are highest during the first month following the index event, and the risks associated with inadequate anticoagulation are therefore substantial [2–6]. Therefore, we recommend full therapeutic doses of anticoagulation with platelet transfusion for the management of acute CAT (i.e. ≤ 1 month) and thrombocytopenia (< 50 9 109 L–1) [1]. However, we agree with Dr Oo that platelet transfusion might not always be possible or successful in achieving a platelet count of ≥ 50 9 109 L–1, and might
DOI: 10.1111/jth.12444 © 2013 International Society on Thrombosis and Haemostasis
Letters to the Editor 117
even be contraindicated. In such cases, insertion of a retrievable filter along with the use of reduced doses of low molecular weight heparin (50%) if the platelet count is between 25 9 109 L–1 and 50 9 109 L–1 is a reasonable approach. As already stated in the Guidance Statement, the retrievable filter should be removed and therapeutic anticoagulation should be initiated when the platelet count recovers [1]. Disclosure of Conflict of Interests The authors state that they have no conflict of interest. References 1 Carrier M, Khorana A, Zwicker J, Noble S, Lee A; the subcommittee on Haemostasis Malignancy for the SSC of the ISTH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 2013; 11: 1760–5.
© 2013 International Society on Thrombosis and Haemostasis
2 Brandjes DP, Heijboer H, B€ uller HR, de Rijk M, Jagt H, ten Cate JW. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis. N Engl J Med 1992; 19: 1485–9. 3 Pinede L, Ninet J, Duhaut P, Chabaud S, Demolombe-Rague S, Durieu I, Nony P, Sanson C, Boissel JP; Investigators of the ‘Duree Optimale du Traitement AntiVitamines K’ (DOTAVK) Study. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation 2001; 22: 2453–60. 4 The van Gogh Investigators. Idraparinux versus standard therapy for venous thromboembolic disease. N Engl J Med 2007; 357: 1094–104. 5 Hull RD, Pineo GF, Brant RF, Mah AF, Burke N, Dear R, Wong T, Cook R, Solymoss S, Poon MC, Raskob G. Long-term low-molecular-weight heparin versus usual care in proximal-vein thrombosis patients with cancer. Am J Med 2006; 119: 1062–72. 6 Lee AYY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, Rickles FR, Julian JA, Haley S, Kovacs MJ, Gent M. Lowmolecular-weight heparin versus a coumadin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003; 349: 146–53.
Disclosure of Conflict of Interests The author states that he has no conflict of interest. References 1 Carrier M, Khorana A, Zwicker J, Noble S, Lee A, The subcommittee on Haemostasis Malignancy for the SSC of the ISTH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 2013; 1: 1–9.
2 Red Cross Issues Emergency Call for Blood and Platelet Donors. http://www.redcross.org/news/article/Red-Cross-Issues-EmergencyCall-for-Blood-and-Platelet-Donors. Accessed 26 August 2013. 3 Yuan S, Goldfinger D. Clinical and laboratory aspects of platelet transfusion therapy. www.uptodate.com. Accessed 26 August 2013. 4 Pemmaraju N, Kroll MH, Afshar-Kharghan V, Oo TH. Bleeding risk in thrombocytopenic cancer patients with venous thromboembolism (VTE) receiving anticoagulation. https://ash.confex.com/ ash/2012/webprogram/Paper47208.html. Accessed 26 August 2013. 5 Soff GA. Pathophysiology and management of thrombosis in cancer: 150 years of progress. J Thromb Thrombolysis 2013; 35: 346– 351.
Management of challenging cases of patients with cancerassociated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH: a reply to a rebuttal M . C A R R I E R , * A . A . K H O R A N A , † J . I . Z W I C K E R , ‡ S . N O B L E , § A . Y . Y . L E E ¶ and O N B E H A L F O F T H E SUBCOMMITTEE ON HAEMOSTASIS AND MALIGNANCY FOR THE SSC OF THE ISTH *Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada; †Department of Solid Tumor Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA; ‡Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; §Royal Gwent Hospital, Newport, UK; and ¶Division of Hematology, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
To cite this article: Carrier M, Khorana AA, Zwicker JI, Noble S, Lee AYY, on behalf of the Subcommittee on Haemostasis and Malignancy for the SSC of the ISTH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH: a reply to a rebuttal. J Thromb Haemost 2014; 12: 116–7. See also Carrier M, Khorana A, Zwicker J, Noble S, Lee A; the subcommittee on Haemostasis Malignancy for the SSC of the ISTH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 2013; 11: 1760–5 and Oo TH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH: a rebuttal. This issue, pp 115–6.
. e thank Dr Oo for his interesting comments on the W management of patients with acute cancer-associated thrombosis (CAT) and thrombocytopenia (< 50 9 109 L–1). As discussed in our article, the guidance statement specifically addresses challenging clinical situations without high-quality evidence, with the aim of providing expert opinions and pragmatic approaches regarding the management of anticoagulation in individual cancer patients with these therapeutic challenges [1]. It is beyond the Correspondence: Agnes Y. Y. Lee, Division of Hematology, University of British Columbia, 2775 Laurel Street 10th floor, Vancouver, BC, V5Z 1M9, Canada. Tel.: +1 604 875 4952; fax: +1 604 875 4696. E-mail: [email protected]
scope of this article to anticipate and address specific national variations in practice (e.g. regional shortage of blood and platelet donors) or hospital-specific restrictions on the use of blood products. Therefore, clinicians need to interpret the Guidance Statement within their local context. As shown in many previous studies, the risk of recurrent venous thromboembolism and its associated casefatality rates are highest during the first month following the index event, and the risks associated with inadequate anticoagulation are therefore substantial [2–6]. Therefore, we recommend full therapeutic doses of anticoagulation with platelet transfusion for the management of acute CAT (i.e. ≤ 1 month) and thrombocytopenia (< 50 9 109 L–1) [1]. However, we agree with Dr Oo that platelet transfusion might not always be possible or successful in achieving a platelet count of ≥ 50 9 109 L–1, and might
DOI: 10.1111/jth.12444 © 2013 International Society on Thrombosis and Haemostasis
Letters to the Editor 117
even be contraindicated. In such cases, insertion of a retrievable filter along with the use of reduced doses of low molecular weight heparin (50%) if the platelet count is between 25 9 109 L–1 and 50 9 109 L–1 is a reasonable approach. As already stated in the Guidance Statement, the retrievable filter should be removed and therapeutic anticoagulation should be initiated when the platelet count recovers [1]. Disclosure of Conflict of Interests The authors state that they have no conflict of interest. References 1 Carrier M, Khorana A, Zwicker J, Noble S, Lee A; the subcommittee on Haemostasis Malignancy for the SSC of the ISTH. Management of challenging cases of patients with cancer-associated thrombosis including recurrent thrombosis and bleeding: guidance from the SSC of the ISTH. J Thromb Haemost 2013; 11: 1760–5.
© 2013 International Society on Thrombosis and Haemostasis
2 Brandjes DP, Heijboer H, B€ uller HR, de Rijk M, Jagt H, ten Cate JW. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis. N Engl J Med 1992; 19: 1485–9. 3 Pinede L, Ninet J, Duhaut P, Chabaud S, Demolombe-Rague S, Durieu I, Nony P, Sanson C, Boissel JP; Investigators of the ‘Duree Optimale du Traitement AntiVitamines K’ (DOTAVK) Study. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation 2001; 22: 2453–60. 4 The van Gogh Investigators. Idraparinux versus standard therapy for venous thromboembolic disease. N Engl J Med 2007; 357: 1094–104. 5 Hull RD, Pineo GF, Brant RF, Mah AF, Burke N, Dear R, Wong T, Cook R, Solymoss S, Poon MC, Raskob G. Long-term low-molecular-weight heparin versus usual care in proximal-vein thrombosis patients with cancer. Am J Med 2006; 119: 1062–72. 6 Lee AYY, Levine MN, Baker RI, Bowden C, Kakkar AK, Prins M, Rickles FR, Julian JA, Haley S, Kovacs MJ, Gent M. Lowmolecular-weight heparin versus a coumadin for the prevention of recurrent venous thromboembolism in patients with cancer. N Engl J Med 2003; 349: 146–53.
