Direct Oral Anticoagulants for Treatment of Venous Thromboembolism Associated with Cancer: A Systematic Review and Meta-Analysis

There is uncertainty about the choice of anticoagulation therapy in patients with malignancy and venous thromboembolism (VTE). While low-molecular weight heparin (LMWH) remains the current standard, direct oral anticoagulants (DOACs) have emerged as an appealing alternative option. The primary objective of this analysis was to compare the efficacy and safety of DOACs versus LMWH in patients with malignancy and VTE. The secondary objective was to compare the safety and efficacy of the different DOACs. An online search of PubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov from inception until April 2020 was conducted. Four RCTs encompassing 2,907 patients, (50.5% men and mean age of 65.7 ± 10.5) were selected. At a mean follow up of 12 months, moderate certainty evidence showed no differences between DOAC and LMWH in VTE recurrence (HR, 0.54 [CI 0.23 to 1.28], I2 = 56%, p=0.23), in major bleeding (HR, 1.38 [CI 0.45 to 4.22], I2 = 33%, p=0.21) or clinically relevant non-major bleeding (CRNMB) (HR, 1.77 [CI 0.49 to 6.40], I2 = 73.9%, p=0.087). There was no difference between the DOACs when compared to each other. In conclusion, DOACs are an acceptable alternative to LMWHs for the treatment of VTE in patients with malignancy.