Direct oral anticoagulants in the treatment of venous thromboembolic disease associated with cancer. Evidence and recommendations

A review (PubMed/Medline) is carried out until March 31, 2021, looking for the available evidence on the treatment of venous thromboembolic disease (VIE) with direct oral anticoagulants (DOA) in cancer patients. It includes 15 randomized and controlled trials, 26 systematic reviews and meta-analyzes, and 6 clinical practice guidelines. In cancer patients, DOAs as treatment (initial and long-term) of VTE are an effective and safe option compared to low-molecular-weight heparins (LMWH). The risk of recurrent VTE is lower with DOA, without significantly increasing the risk of major bleeding. Compared with LMWH, the risk of non-major but clinically relevant bleeding is higher. The increased risk of bleeding in patients treated with DOA appears to be related to excess upper gastrointestinal bleeding. In addition to gastrointestinal cancer, other high-risk characteristics associated with bleeding complications are urothelial cancer, drug interactions, and the use of anticancer drugs associated with gastrointestinal toxicity. Therefore, DOAs should be used with caution in cancer patients and high risk of bleeding. Individual preferences are another relevant aspect when indicating DOA.