• Benjamin Planquette, Laurent Bertoletti, Anaïs Charles-Nelson, Silvy Laporte, Claire Grange, Isabelle Mahé, Gilles Pernod, Antoine Elias, Francis Couturaud, Nicolas Falvo, Marie Antoinette Sevestre, Valérie Ray, Alexis Burnod, Nicolas Brebion, Pierre-Marie Roy, Miruna Timar-David, Sandro Aquilanti, Joel Constans, Alessandra Bura-Rivière, Dominique Brisot, Gilles Chatellier, Olivier Sanchez, Guy Meyer, Philippe Girard, Patrick Mismetti, and CASTA DIVA Trial Investigators.
• Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, APHP, Université de Paris, Paris, France; INSERM UMR_S1140, Innovations Thérapeutiques en Hémostase, Laboratoire de Chirurgie expérimentale, Fondation Alain Carpentier, Paris, France; F-CRIN INNOVTE Network, Saint-Etienne, France.
• Chest. 2022 Mar 1; 161 (3): 781-790.

BackgroundDirect oral anticoagulants (DOACs) are an alternative to low-molecular-weight heparin for treating cancer-associated VTE.Research QuestionIs rivaroxaban as efficient and safe as dalteparin to treat patients with cancer-associated VTE?Study Design And MethodsIn a randomized open-label noninferiority trial, patients with active cancer who had proximal DVT, pulmonary embolism (PE), or both were assigned randomly to therapeutic doses of rivaroxaban or dalteparin for 3 months. The primary outcome was the cumulative incidence of recurrent VTE, a composite of symptomatic or incidental DVT or PE, and worsening of pulmonary vascular or venous obstruction at 3 months.ResultsOf 158 randomized patients, 74 and 84 patients were assigned to receive rivaroxaban and dalteparin, respectively. Mean age was 69.4 years, and 115 patients (76.2%) had metastatic disease. The primary outcome occurred in 4 and 6 patients in the rivaroxaban and dalteparin groups, respectively (both the intention-to-treat and per-protocol populations: cumulative incidence, 6.4% vs 10.1%; subdistribution hazard ratio [SHR], 0.75; 95% CI, 0.21-2.66). Major bleeding occurred in 1 and 3 patients in the rivaroxaban and dalteparin groups, respectively (cumulative incidence, 1.4% vs 3.7%; SHR, 0.36; 95% CI, 0.04-3.43). Major or clinically relevant nonmajor bleeding occurred in 9 and 8 patients in the rivaroxaban and dalteparin groups, respectively (cumulative incidence, 12.2% vs 9.8%; SHR, 1.27; 95% CI, 0.49-3.26). Overall, 19 patients (25.7%) and 20 patients (23.8%) died in the rivaroxaban and dalteparin groups, respectively (hazard ratio, 1.05; 95% CI, 0.56-1.97).InterpretationIn this trial comparing rivaroxaban and dalteparin in the treatment of cancer-associated VTE, the number of patients was insufficient to reach the predefined criteria for noninferiority, but efficacy and safety results were consistent with those previously reported with DOACs. An updated meta-analysis of randomized trials comparing DOACs with low-molecular-weight heparin in patients with cancer-associated VTE is provided.Trial RegistryClinicalTrials.gov; No.: NCT02746185; URL: www.Clinicaltrialsgov.Copyright © 2021 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

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