Abstract Number: PB2116
Meeting: ISTH 2020 Congress
Theme: Venous Thromboembolism and Cardioembolism » Cancer Associated Thrombosis
Background: Low-molecular-weight heparin (LMWH) has been the standard anticoagulant in cancer patients with venous thromboembolism (VTE). Based on recent studies, direct oral anticoagulants (DOACs) represent an alternative, but limited data exists regarding the safety of DOACs in patients with brain cancer. Brain metastases are prevalent in specific cancer types, some of which have a high risk of intracranial hemorrhage (ICH). One retrospective single-center study of patients with brain metastases and VTE demonstrated no difference in ICH rates with DOACs (n=21) compared to LMWH (n=84).
Aims: To determine the incidence of ICH with DOACs and LMWH in patients with brain metastases receiving anticoagulation for VTE or atrial fibrillation.
Methods: A retrospective cohort study in two academic centers in Israel and the Netherlands. Follow-up started on the first day of concomitant anticoagulation and brain tumor diagnosis. At least two brain imaging studies were mandated. The primary endpoint was the cumulative incidence of any spontaneous ICH at 12-months follow-up with death as a competing risk. Major ICH was defined as spontaneous, ≥ 10 mL in volume, symptomatic or requiring surgical intervention. ICH imaging studies were reviewed by a neuroradiologist blinded for anticoagulant type.
Results: The cohort included 96 patients with brain metastases (41 DOAC, 55 LMWH). The 12-month cumulative incidence of any ICH was 10.1% in the DOAC-treated patients and 12.9% in those treated with LMWH (hazard ratio [HR] 0.77; 95% confidence interval [CI] 0.23-2.59, figure 1). When anticoagulation was analyzed as a time-varying covariate, neither the risk of any ICH nor the risk of major ICH differed between DOAC and LMWH treated patients (HR 0.98; 95% CI 0.28-3.40 and HR 0.57; 95% CI 0.12-2.87, respectively). Patient characteristics and outcomes are shown in Table 1.
Conclusions: This international multicenter study suggests comparable safety of LMWH and DOACs in patients with brain metastases, in line with a prior study.
| Characteristics | DOAC, n (%) N=41 | LMWH, n (%) N=55 | |
| Age (years), median [IQR] | 66 (58-74) | 64 (57-71) | |
| Male sex | 28 (68) | 28 (51) | |
| Cancer type | Lung cancer | 24 (59) | 31 (56) |
| Esophageal cancer | 7 (17) | 4 (7) | |
| Breast cancer | 1 (2) | 8 (15) | |
| Other | 9 (22) | 12 (22) | |
| Indication for anticoagulation | Venous thromboembolism * | 22 (54) | 49 (89) |
| Spontaneous ICH during follow-up | Any ICH [Major ICH] | 4 (10) [2 (5)] | 7 (13) [6 (11)] |
| Death [ICH-related] | 25 (61) [0 (0)] | 35 (64) [3 (6)] | |
[Table 1: Baseline patient characteristics and outcomes during 12-months follow-up. * The remainder had atrial fibrillation]
[Figure 1: 12-month cumulative incidence of any spontaneous ICH]
To cite this abstract in AMA style:
Leader A, Hamulyák EN, Carney BJ, Avrahami M, Knip JJ, Rozenblatt S, Beenen LFM, Yust-Katz S, Coppens M, Raanani P, Middeldorp S, Büller HR, Zwicker JI, Spectre G. Intracranial Hemorrhage with Direct Oral Anticoagulants in Patients with Brain Metastases [abstract]. Res Pract Thromb Haemost. 2020; 4 (Suppl 1). https://abstracts.isth.org/abstract/intracranial-hemorrhage-with-direct-oral-anticoagulants-in-patients-with-brain-metastases/. Accessed September 21, 2023.« Back to ISTH 2020 Congress
ISTH Congress Abstracts - https://abstracts.isth.org/abstract/intracranial-hemorrhage-with-direct-oral-anticoagulants-in-patients-with-brain-metastases/