A Large Retrospective Analysis [J].J Clin Oncol.2011,29(25):3466-73. 2.Venous thromboembolism in the cancer outpatient setting: contemporary rates and predictors in the
4. Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism:
a pooled analysis of the EINSTEIN-DVT and PE randomized studies[J]. Thromb J 2013; 11:21. 5. Direct oral anticoagulants in patients with VTE and cancer: a systematic review and meta-analysis[J].
虽然LMWH能够降低VTE的复发风险，但因其花费较
高且需要皮下注射，因此肿瘤患者合并VTE时长期治疗选择
LMWH还是华法林应综合评估患者的风险和获益，以及患 者的选择倾向。
新型口服抗凝药与传统抗凝治疗的比较
4.Oral rivaroxaban versus standard therapy for the treatment of symptomatic venous thromboembolism: a pooled analysis of the EINSTEIN-DVT and PE randomized studies. Thromb J 2013; 11:21.
Long term treatment
• LMWH is preferred. • Indefinite anticoagulation in patients with active cancer or persistent risk factors. extended anticoagulant therapy (no scheduled stop date) over 3 months of therapy (1B), or have a high bleeding risk, we suggest extended anticoagulant therapy (no scheduled stop date) over 3 months of therapy (2B)
肿瘤患者VTE指南推荐治疗方案总结 肿瘤患者发生VTE时起始治疗各指南均推荐LMWH。
长期治疗药物选择方面除ASCO指南说明无法使用
LMWH时可选择VKA，其余均说明LMWH优于
VKA。
活动性肿瘤或血栓诱因持续存在时，疗程不确定，长 期抗凝优于短期抗凝（3个月）。
肿瘤患者VTE长期治疗LMWH VS华法林
1.0mg/kg bid序贯华法林或香豆素类抗凝药）。统计患者3、6、12个
月VTE复发及出血情况。预设的非劣效性边缘值为1.75。
Table 2 Efficacy and safety outcomes and net clinical benefit in all patients and selected patient subgroups
5.Direct oral anticoagulants in patients with VTE and cancer: a systematic review and meta-analysis. Chest. 2015; 147(2): 475-484.
Table 2 Efficacy and safety outcomes and net clinical benefit in all patients and selected patient subgroups
结果：共有8282名患者纳入该研究，其中一些关键的亚组，如骨折、 肿瘤(利伐沙班组232人，5.6%，标准治疗组198人，4.8%)、具有大的 血栓和既往有VTE复发使的患者，利伐沙班与标准治疗组间安全性和 有效性相似。
54 full-text articles excluded,with reasons; 14=unavailable data for cancer subgroup;1=case series;15=review;4=retrospective study;2=protocol;6=observational study;4=nonrandomizedtrial;4=no cancer patients included;1=only one cancer patient included;2=no relevant outcome; 1=different durations of intervention
65 full-text articles assessed for eligibility
10 studies included in qualitative synthesis(11 reports) 10 studies included in qualitative synthesis(meta-analysis)
前 言
目前已经证实恶性肿瘤与VTE之间关系密切，恶性肿瘤 患者通常处于高凝 状态，与非恶性肿瘤患者相比，其发生VTE的风险更高。血栓栓塞事件已经成 为肿瘤患者的第二大死因。 肿瘤患者发生VTE通常初始使用低分子肝素（LMWH）进行抗凝治疗，长期 抗凝是否可转换为华法林？亦或更换为新型抗凝药？
主要内容
肿瘤患者VTE治疗方案选择
211ESMO
2014ASCO
2016ACCP
2016NCCN
2011EMSO
肿瘤患者VTE治疗方案选择
Initial treatment
• LMWH is recommended for the initial 5 to 10 days of treatment of VTE as well as for long-term secondary prophylaxis for at least 6 months.
LMWH VS华法林生VTE复发
VTE复发：使用时间-事件资料，采用pooled analysis方法，对两篇已发表，一篇从作者
处获得的原始资料进行分析。
结 果：LMWH与VKA间有统计学差异 HR0.47；95% CI 0.32-0.71；I2=0%

LMWH VS华法出血事件间无统计学差异
文献小结
01
02
肿瘤患者VTE初始治疗方案 肿瘤患者VTE长期治疗肝素VS华法林
03
04
肿瘤患者VTE长期治疗DOACs VS华法林 总结
参 考文 献
1.High Incidence of Thromboembolic Events in Patients Treated With Cisplatin-Based Chemotherapy:
United States[J]. Cancer. 2013 ,119(3):648-55.
3. Anticoagulation for the long-term treatment of venous thromboembolism in patients with cancer[J]. Cochrane Database Syst Rev ,2014,8(7).
Chest. 2015;147(2):475-484.
6. Pros and cons of new oral anticoagulants in the treatment of venous thromboembolism in patients with cancer[J].Inter Emerg Med.2015,10(6):651-656.
流行病学
1.High Incidence of Thromboembolic Events in Patients Treated With Cisplatin-Based Chemotherapy: A Large
流行病学
2.Venous thromboembolism in the cancer outpatient setting: contemporary rates and predictors in the United States[J]. Cancer. 2013 ,119(3):648-55.
• 75%-80% of the initial dose for 6 months of LMWH is safe and more effective than VKA.(I,A)
Use of novel oral anticoagulants is not currently recommended for patients with malignancy and VTE.
3. Anticoagulation for the long-term treatment of venous thromboembolism in patients with cancer. Cochrane Database Syst Rev ,2014,8(7).
LMWH VS华法林生存率及全因死亡率
生存率：使用时间-事件资料，采用pooled analysis方法， 对两篇已发表，一篇从作者处获得的原始资料进行分析。 结 果：LMWH与VKA间无统计学差异 HR0.96；95% CI 0.81-1.14；I2=0%
全因死亡率：采用pooled analysis方法，分析6个月时 的全因死亡率。 结 果：LMWH与VKA间无统计学差异 RR0.97；95% CI 0.88-1.10；I2=0%
10,033 records identified through database searching 55 additional record identified through other sources