title: Prevention of thalidomide- and lenalidomide-associated thrombosis in myeloma.
abstract: The incidence of venous thromboembolism (VTE) is more than 1 per thousand annually in the general population and increases further in cancer patients. The risk of VTE is higher in multiple myeloma (MM) patients who receive thalidomide or lenalidomide, especially in combination with dexamethasone or chemotherapy. Various VTE prophylaxis strategies, such as low-molecular-weight heparin (LMWH), warfarin or aspirin, have been investigated in small, uncontrolled clinical studies. This manuscript summarizes the available evidence and recommends a prophylaxis strategy according to a risk-assessment model. Individual risk factors for thrombosis associated with thalidomide/lenalidomide-based therapy include age, history of VTE, central venous catheter, comorbidities (infections, diabetes, cardiac disease), immobilization, surgery and inherited thrombophilia. Myeloma-related risk factors include diagnosis and hyperviscosity. VTE is very high in patients who receive high-dose dexamethasone, doxorubicin or multiagent chemotherapy in combination with thalidomide or lenalidomide, but not with bortezomib. The panel recommends aspirin for patients with < or = 1 risk factor for VTE. LMWH (equivalent to enoxaparin 40 mg per day) is recommended for those with two or more individual/myeloma-related risk factors. LMWH is also recommended for all patients receiving concurrent high-dose dexamethasone or doxorubicin. Full-dose warfarin targeting a therapeutic INR of 2-3 is an alternative to LMWH, although there are limited data in the literature with this strategy. In the absence of clear data from randomized studies as a foundation for recommendations, many of the following proposed strategies are the results of common sense or derive from the extrapolation of data from many studies not specifically designed to answer these questions. Further investigation is needed to define the best VTE prophylaxis.
authors: Division of Hematology, University of Turin, Azienda Ospedaliera S. Giovanni Battista, Torino, Italy. appalumbo@yahoo.com
authors: A
authors: A
authors: Palumbo
authors: S V
authors: SV
authors: Rajkumar
authors: M A
authors: MA
authors: Dimopoulos
authors: P G
authors: PG
authors: Richardson
authors: J
authors: J
authors: San Miguel
authors: B
authors: B
authors: Barlogie
authors: J
authors: J
authors: Harousseau
authors: J A
authors: JA
authors: Zonder
authors: M
authors: M
authors: Cavo
authors: M
authors: M
authors: Zangari
authors: M
authors: M
authors: Attal
authors: A
authors: A
authors: Belch
authors: S
authors: S
authors: Knop
authors: D
authors: D
authors: Joshua
authors: O
authors: O
authors: Sezer
authors: H
authors: H
authors: Ludwig
authors: D
authors: D
authors: Vesole
authors: J
authors: J
authors: Bladé
authors: R
authors: R
authors: Kyle
authors: J
authors: J
authors: Westin
authors: D
authors: D
authors: Weber
authors: S
authors: S
authors: Bringhen
authors: R
authors: R
authors: Niesvizky
authors: A
authors: A
authors: Waage
authors: M
authors: M
authors: von Lilienfeld-Toal
authors: S
authors: S
authors: Lonial
authors: G J
authors: GJ
authors: Morgan
authors: R Z
authors: RZ
authors: Orlowski
authors: K
authors: K
authors: Shimizu
authors: K C
authors: KC
authors: Anderson
authors: M
authors: M
authors: Boccadoro
authors: B G
authors: BG
authors: Durie
authors: P
authors: P
authors: Sonneveld
authors: M A
authors: MA
authors: Hussein
mesh_terms: D000970:Antineoplastic Agents / Q000009:adverse effects; D001241:Aspirin / Q000627:therapeutic use; D006495:Heparin, Low-Molecular-Weight / Q000627:therapeutic use; D006801:Humans; D019934:International Normalized Ratio; D000077269:Lenalidomide; D009101:Multiple Myeloma / Q000150:complications* / Q000188:drug therapy; D011292:Premedication / Q000379:methods*; D018570:Risk Assessment; D012307:Risk Factors; D013792:Thalidomide / Q000009:adverse effects* / Q000031:analogs & derivatives*; D013927:Thrombosis / Q000139:chemically induced* / Q000517:prevention & control*; D054556:Venous Thromboembolism / Q000139:chemically induced / Q000517:prevention & control; D014859:Warfarin / Q000627:therapeutic use
chemical_list: D000970:Antineoplastic Agents; D006495:Heparin, Low-Molecular-Weight; D013792:Thalidomide; D014859:Warfarin; D000077269:Lenalidomide; D001241:Aspirin