Peri-procedure management of antithrombotic agents and thrombocytopenia for common oncology procedures: Guidance from ISTH SSC

Key takeaway

The Hemostasis and Malignancy Subcommittee of SSC ISTH reviewed existing evidence and recommendations and provided useful practice guidance on periprocedural management of antithrombotic agents and thrombocytopenia in cancer patients.

Critical knowledge gaps seen in optimal peri-procedure management in cancer patients on anticoagulants, especially DOACs

• More high-quality studies needed for better practice guidance

Practice guidance provided to clinicians on:

• Management of antithrombotic agents with respect to procedure and bleeding risk 
• Management of thrombocytopenia with respect to platelet count and target platelet count goal according to bleeding risk

Why this matters

Cancer patients have increased risk of:

• Thrombosis 
• Bleeding 
• Thrombocytopenia
• Complicates decisions on periprocedural management of antithrombotic therapies
• Intensifies risks related to invasive procedures

Across guidelines, there is heterogeneity in classification of bleeding risks of procedures and associated recommendations for antithrombotic agent management

Hemostasis and Malignancy Subcommittee of ISTH SSC developed practical guidance to guide clinicians on peri-procedural management of antithrombotic agents and thrombocytopenia in cancer patients*

Key highlights

• Limited data exists on periprocedural management of antithrombotic agents and thrombocytopenia in cancer patients

For additional information on periprocedural management, please click on the hyperlink.

Isth ssc consensus guidance on management of antithrombotic agents*

• Recommends clinicians be aware of antiplatelet and/or anticoagulant presence before any procedure
• If needed, obtain blood work results: e.g., INR if on warfarin
• Recommends assessing risk-benefit ratio before each procedure:
  • Low thrombosis risk (e.g., remote or no thrombosis history):
    • Suggests withholding antiplatelets and/or anticoagulants before procedures
  • No to low thrombosis risk: Recommends evaluating bleeding risks of procedures as below

Suggests for management of low bleeding risk procedures, such as:

• Core biopsy (not deep tissue/organ)
• Fine needle aspiration
• Bone marrow biopsy
• Diagnostic or therapeutic draining procedures
• Central line insertion (at compressible sites)

1. If on monotherapy: Continue aspirin
2. If on other antiplatelets and/or anticoagulants:
   • Generally safe to continue monotherapy
   • Limited data exists to guide practice
3. If continuing antithrombotic agents:
   • Take other measures to lower bleeding risk, e.g.:
     • Maintain INR <3 when continuing warfarin
     • Delay DOAC morning dose until after procedure

Suggests interrupting antiplatelets or anticoagulants (except aspirin) for moderate bleeding risk procedures: 

• Deep tissue/organ biopsy 
• Implantable port placement 
• Central venous catheter in non-compressible site 
• Tunneled catheter 
• Large-bore drains

Suggests evaluating for acquired von Willebrand disease: 

• If present, in case of suspected or known MPN undergoing bone marrow biopsy, especially in extreme thrombocytosis (>1000 x 109/L), take steps to reduce hemorrhage risk by:
  • Cytoreduction or
  • Antithrombotic therapy interruption, if possible

Suggests withholding antiplatelets and anticoagulants for procedures with high morbidity risk from bleeding events: 

• Neuraxial procedures

Suggests the following duration of interruption when antiplatelets or anticoagulants are held: Warfarin: 

• 5 days LMWH: 
• 24 hours in patients with normal kidney function DOACs:
  • 2 days prior high-bleed-risk procedure
  • 1 day prior low/moderate-bleed risk procedure
  • 4 days if on dabigatran and CrCl <50 mL/min 
• If CrCl <30 mL/min: Need longer interruption time for LMWH and DOACs 
• Aspirin and clopidogrel: 5–7 days 
• Prasugrel: 7–10 days 
• Ticagrelor: 3–5 days

Suggests limiting exposure to single antithrombotic agent perioperatively whenever possible: 

• Combined antiplatelet and anticoagulation therapies exacerbate hemorrhage risks with surgical procedures

* Based on PubMed literature review and expert opinions. “Recommend” reflects strong guidance supported by high-quality evidence from clinical trials and “suggest” reflects weaker guidance statements based on lower quality evidence or expert opinion.

 

Isth ssc consensus guidance on management of thrombocytopenia

Suggests platelet count ≥20 x 109/L for lower bleeding risk procedures: 

• Fine needle aspiration 
• Central line placement 
• Paracenteses 
• Thoracentesis

Does not suggest specific target platelet threshold for bone marrow biopsy

If possible, suggests platelet count goal ≥50 x 109/L for higher bleeding risk procedures: 

• Percutaneous liver, kidney, transbronchial biopsies 
• Insertion of tunneled catheters and implantable ports or to non-compressible access sites 
• Neuraxial procedures

For additional details, refer the source publication Wang TF, et al.

* Provided guidance statements should not be considered absolute. Make adjustments after considering individual factors, preferences, and logistical constraints

Abbreviations

CrCl, Creatinine clearance; DOACs, Direct Oral Anticoagulants; FNA, Fine Needle Aspiration; INR, International Normalized Ratio; ISTH, International Society on Thrombosis and Hemostasis; LMWH, Low Molecular Weight Heparins; MPN, Myeloproliferative Neoplasms; SSC, Scientific and Standardization Committees.

Disclaimer: This content is not intended to supersede or replace any local/ country specific guidance or regulation around cancer-associated thrombosis that would be in place at the time of content generation.

MAT-IN-2301799-1.0-08/2023