Treatment Algorithm in Cancer-Associated Thrombosis: Updated Canadian Expert Consensus Related RAM: Khorana RAM

Figure 1. Patient risk stratification algorithm for anticoagulant therapy in cancer-associated thrombosis. ^a None of the DOACs are recommended for use in patients meeting criteria for Child-Pugh class C, with use of rivaroxaban being contraindicated in patients with hepatic disease (including Child-Pugh class B and C) associated with coagulopathy and having clinically relevant bleeding risk. Apixaban should be used with caution in patients with mild or moderate hepatic impairment (Child-Pugh class A or B), while these patients exhibited comparable pharmacokinetics and pharmacodynamics to healthy controls when treated with edoxaban. ^b Use of antiplatelet agents should be assessed, and discontinuation should be considered in the absence of a strong indication. Shared decision-making with other health care providers is warranted. ^c Currently, dalteparin, enoxaparin, and tinzaparin have randomized controlled trial evidence in cancerassociated thrombosis, with the evidence base being stronger for dalteparin and tinzaparin. Refer to the relevant product monograph for appropriate dosing. ^d Currently, apixaban, edoxaban, and rivaroxaban have randomized controlled trial evidence in cancer-associated thrombosis, with stronger evidence for apixaban and edoxaban. Refer to the relevant product monograph for appropriate dosing. DVT = deep vein thrombosis; PE = pulmonary embolism; GI = gastrointestinal; GU = genitourinary; DOAC = direct-acting oral anticoagulant; LMWH = low molecular weight heparin; VTE = venous thromboembolism.

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