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Cancer-Associated VTE — ABIM Board MCQ

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HardHematologyCancer-Associated VTEABIM Board

A 58-year-old man with metastatic lung adenocarcinoma receiving pembrolizumab undergoes surveillance CT, which incidentally demonstrates an acute segmental pulmonary embolism. He is hemodynamically stable and has no active bleeding. His platelet count is 190,000/mm3, and creatinine clearance is 78 mL/min. He has no gastrointestinal or genitourinary tumor and takes no strong P-glycoprotein or CYP3A4 modifier. He prefers oral treatment. Which initial anticoagulation strategy is guideline-concordant and can be started without a parenteral anticoagulant lead-in?

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Correct answer: C — Apixaban 10 mg orally twice daily for 7 days, followed by 5 mg twice daily

Apixaban is an appropriate first-line treatment for cancer-associated VTE in a patient without active bleeding, severe renal impairment, a high-risk luminal gastrointestinal or genitourinary lesion, or a major drug interaction. It can be initiated directly at 10 mg twice daily for 7 days and then reduced to 5 mg twice daily. Incidentally detected segmental PE in a patient with active cancer generally warrants therapeutic anticoagulation. Dalteparin is effective and remains appropriate, but it is injectable and is not required for every patient. Warfarin is less preferred and must overlap with a rapidly acting parenteral anticoagulant when used for acute VTE. Aspirin is not adequate treatment, and observation is inappropriate for this acute segmental PE.

Reference: Key NS, et al. Venous Thromboembolism Prophylaxis and Treatment in Patients With Cancer: ASCO Guideline Update (Treatment of VTE recommendations). J Clin Oncol. 2023;41:3063-3071. https://pubmed.ncbi.nlm.nih.gov/37075273/