{"id":12943,"date":"2021-11-11T14:11:44","date_gmt":"2021-11-11T14:11:44","guid":{"rendered":"https:\/\/jurmed.ro\/medici\/?p=12943"},"modified":"2021-11-11T14:11:44","modified_gmt":"2021-11-11T14:11:44","slug":"anticoagularea-pacientului-oncologic","status":"publish","type":"post","link":"https:\/\/jurmed.ro\/medici\/anticoagularea-pacientului-oncologic\/","title":{"rendered":"Anticoagularea pacientului oncologic"},"content":{"rendered":"
\"\"<\/a>
Dr. Corina Georgiana Toader Medic specialist Oncologie Medicala Centrul Medical Neolife, Bucuresti<\/em><\/figcaption><\/figure>\n

Tromboza asociat\u0103 cancerului este o cauz\u0103 major\u0103 de morbiditate \u0219i mortalitate asociat\u0103 bolii neoplazice. Pacien\u021bii oncologici prezint\u0103 risc de 4 p\u00e2n\u0103 la 7 ori mai mare de a dezvolta un trombembolism venos (TEV) fa\u021b\u0103 de pacientii non-oncologici; \u00een plus acesti pacien\u021bi au un risc de 3 ori mai mare de trombembolism venos recurent, de 2 ori mai mare de s\u00e2ngerare asociat\u0103 anticoagularii si un risc de 10 ori mai mare de deces fa\u021b\u0103 de pacien\u021bii far\u0103 boal\u0103 oncologic\u0103\u00b9.<\/p>\n

Un pacient oncologic poate avea multiple cauze bine cunoscute pentru statusul de hipercoagulabilitate: imbobilizare prelungit\u0103, infec\u021bii, interven\u021bii chirurgicale, chimioterapie, cancerele cu risc crescut de TEV\u00b2. Factori de risc lega\u021bi de pacient pot include si insuficien\u021ba cardiac\u0103 cronic\u0103, obezitatea, mai ales la pesoanele peste 75 de ani\u00b3.<\/p>\n

O parte din medicamentele folosite in terapia oncologic\u0103 cresc riscul de dezvoltare a unui TEV, terapia antiangiogenic\u0103, factorii de stimulare ai eritropoezei, s\u0103rurile de platin\u0103, tratamentul hormonal si thalidomida\u2074.<\/p>\n

\u00a0Netratat\u0103, tromboza venoas\u0103 profund\u0103 are un risc de 50% de a determina trombembolism pulmonar la cca 3 luni de la dezvoltarea acesteia, cu un risc de deces de 25%\u2075.<\/p>\n

\u00a0Cele mai comune localiz\u0103ri ale tumorilor primare diagnosticate \u00een timpul unui episod de trombembolim venos sunt cancerul pulmonar (17%), cancerul de pancreas (10%), colo-rectal (8%), renal (8%) \u0219i de prostata (7%)\u2076. Inciden\u021ba trombembolismului venos la pacien\u021bii deja diagnostica\u021bi este usor diferit\u0103, cea mai mare fiind la pacien\u021bii diagnostica\u021bi cu cancer pancreatic (8,1%), rinichi (5.6 %), ovar (5.6%), pl\u0103m\u00e2n (5.1%) \u0219i stomac (4.9%)\u2077.<\/p>\n

Managementul TEV la pacien\u021bii cu cancer include at\u00e2t identificarea pacien\u021bilor care pot s\u0103 beneficieze de profilaxie farmacologic\u0103 precum \u0219i tratamentul eficient pentru reducerea riscului de recuren\u021b\u0103 \u0219i mortalitate a TEV.<\/p>\n

ASCO a publicat pentru prima dat\u0103 un ghid privind aceste subiecte \u00een 2007\u2078, cu actualiz\u0103ri repetate. Actualizarea actual\u0103 revizuie\u0219te c\u00e2teva recomand\u0103ri anterioare. Mai ales, anticoagulante orale au fost ad\u0103ugate ca op\u021biuni pentru profilaxia \u0219i tratamentul trombembolismului venos.<\/p>\n

Actualul ghid r\u0103spunde urmatoarelor \u00eentrebari:\u00a0<\/strong><\/p>\n

    \n
  1. Pacien\u021bii spitaliza\u021bi cu cancer ar trebui s\u0103 primeasc\u0103 anticoagulare pentru profilaxia TEV?<\/li>\n
  2. Pacien\u021bii trata\u021bi ambulator ar trebui s\u0103 primeasc\u0103 anticoagulare pentru profilaxia TEV \u00een timpul chimioterapiei sistemice?<\/li>\n
  3. \u00cen cazul \u00een care pacien\u021bii sunt supu\u0219i unei interven\u021bii chirurgicale ei primesc profilaxie perioperatorie?<\/li>\n
  4. Care este cel mai bun tratament pentru pacien\u021biii cu cancer pentru a preveni recuren\u021ba trombembolismului venos?<\/li>\n
  5. \u00cen cazul \u00een care pacien\u021bii cu cancer primesc anticoagulante \u00een absen\u021ba unui trombembolism diagnostic, poate cre\u0219te supravie\u0163uirea?<\/li>\n
  6. Ce se \u0219tie despre predic\u021bia riscului \u0219i con\u0219tientizarea TEV \u00een r\u00e2ndul pacien\u021bilor cu cancer?<\/li>\n<\/ol>\n

    \u00a0Ultimul ghid de practic\u0103 clinic\u0103 ASCO vine cu urm\u0103toarele recomandari:<\/strong><\/p>\n

    1.1. Pacien\u021bi spitaliza\u021bi, cu criz\u0103 visceral\u0103 si alte comorbidit\u0103\u021bi sau mobilitate redus\u0103, trebuie s\u0103 primeasc\u0103 tromboprofilaxiei farmacologic\u0103 \u00een absen\u021ba s\u00e2nger\u0103rilor sau a altor contraindica\u021bii.<\/p>\n

    1.2. Pacien\u021bii spitaliza\u021bi care prezint\u0103 criz\u0103 visceral\u0103, f\u0103r\u0103 al\u021bi factori de risc suplimentari pot s\u0103 primeasc\u0103 tromboprofilaxie farmacologic\u0103 \u00een absen\u021ba s\u00e2nger\u0103rilor sau a altor contraindica\u021bii.<\/p>\n

    1.3. Pacien\u021bii interna\u021bi nu ar trebui s\u0103 primeasc\u0103 tromboprofilaxie farmacologic\u0103 de rutin\u0103 \u00een scopul exclusiv al procedurilor minore sau al perfuziei de chimioterapie \u0219i nici pacien\u021bii supu\u0219i transplantului de celule stem \/ m\u0103duv\u0103 osoas\u0103.<\/p>\n

    2.1. Tromboprofilaxia farmacologic\u0103 de rutin\u0103 nu trebuie oferit\u0103 tuturor pacien\u021bilor trata\u021bi ambulator.<\/p>\n

    2.2. Pacien\u021bii trata\u021bi \u00een ambulator, cu risc crescut (scor Khorana de 2 sau mai mare \u00eenainte de a \u00eencepe un nou schem\u0103 de chimioterapie sistemic\u0103) li se poate oferi tromboprofilaxie cu apixaban, rivaroxaban sau cu heparin\u0103 \u00een greutate (LMWH) cu condi\u021bia s\u0103 nu existe factori de risc semnificativi pentru s\u00e2ngerare \u0219i nici interac\u021biuni medicamentoase. Luarea \u00een considerare a unei astfel de terapii ar trebui s\u0103 fie \u00eenso\u021bit\u0103 de o discu\u021bie cu pacientul despre beneficii \u0219i daune relative, costul medicamentelor \u0219i durata profilaxiei \u00een acest cadru.<\/p>\n

    2.3. Pacien\u021bii cu mielom multiplu c\u0103rora li s-au administrat regimuri pe baz\u0103 de talidomid\u0103 sau lenalidomid\u0103 cu chimioterapie \u0219i \/ sau dexametazon\u0103 ar trebui s\u0103 li se ofere tromboprofilaxie farmacologic\u0103 cu oricare dintre acestea: aspirin\u0103 sau LMWH pentru pacien\u021bii cu risc mai redus \u0219i LMWH pentru pacien\u021bii cu risc mai mare.<\/p>\n

    3.1. To\u021bi pacien\u021bii cu boal\u0103 malign\u0103 supu\u0219i unei interven\u021bii chirurgicale majore ar trebui s\u0103 primeasc\u0103 tromboprofilaxie farmacologic\u0103 fie cu heparin\u0103 nefrac\u021bionat\u0103 (UFH), fie cu LMWH, cu excep\u021bia cazului \u00een care contraindicat din cauza s\u00e2nger\u0103rii active, sau a riscului ridicat de s\u00e2ngerare sau a altor contraindica\u021bii.<\/p>\n

    3.2. Profilaxia trebuie \u00eenceput\u0103 preoperator.<\/p>\n

    3.3 Metodele mecanice pot fi ad\u0103ugate tromboprofilaxiei farmacologice, dar ar trebui s\u0103 nu se utilizeaze ca monoterapie pentru prevenirea TEV, cu excep\u021bia cazului \u00een care metodele farmacologice sunt contraindicate din cauza s\u00e2nger\u0103rii active sau a riscului crescut de s\u00e2ngerare.<\/p>\n

    3.4. Un regim combinat de profilaxie farmacologic\u0103 \u0219i mecanic\u0103 poate \u00eembun\u0103t\u0103\u021bi eficacitatea, mai ales la pacien\u021bii cu cel mai mare risc.<\/p>\n

    3.5. Tromboprofilaxia farmacologic\u0103 la pacien\u021bii supu\u0219i unei interven\u021bii chirurgicale majore pentru cancer trebuie continuat\u0103 timp de cel pu\u021bin 7-10 zile. Profilaxia extins\u0103 cu LMWH timp de p\u00e2n\u0103 la 4 s\u0103pt\u0103m\u00e2ni postoperator este recomandat\u0103 pacien\u021bilor supu\u0219i unei interven\u021bii chirurgicale abdominale sau pelvine majore deschise sau laparoscopice pentru cancer, \u00a0care prezint\u0103 caracteristici cu risc ridicat, cum ar fi mobilitatea restric\u021bionat\u0103, obezitatea, antecedentele de TEV sau alte condi\u021bii cu factori de risc. \u00cen interven\u021biile chirurgicale cu risc mai mic, decizia cu privire la durata adecvat\u0103 a tromboprofilaxiei se face de la caz la caz.<\/p>\n

    4.1. Anticoagularea ini\u021bial\u0103 poate implica LMWH, UFH, fondaparinux sau rivaroxaban. Pentru pacien\u021bii care au ini\u021biat tratamentul cu anticoagulare parenteral\u0103, LMWH este preferat\u0103 fa\u021b\u0103 de UFH \u00een perioada ini\u021bial\u0103 5 p\u00e2n\u0103 la 10 zile de anticoagulare pentru pacientul cu cancer cu TEV nou diagnosticat, care nu are insuficien\u021b\u0103 renal\u0103 sever\u0103 (definit\u0103 ca clearance-ul creatininei mai mic de 30 ml \/ min).<\/p>\n

    4.2. Pentru anticoagulare pe termen lung, LMWH, edoxaban sau rivaroxaban timp de cel pu\u021bin 6 luni sunt preferat datorit\u0103 eficacit\u0103\u021bii \u00eembun\u0103t\u0103\u021bite fa\u021b\u0103 de antagoni\u0219tii vitaminei K (VKA). VKA sunt inferioari, dar pot fi utilizati dac\u0103 LMWH sau anticoagulantele orale directe (DOAC) nu sunt accesibile. Exist\u0103 o cre\u0219tere a riscului major de s\u00e2ngerare cu DOAC, observate \u00een special la nivel gastrointestinal \u0219i poten\u021bial malignit\u0103\u021bi genito-urinare. Aten\u021bie cu DOAC este de asemenea, justificat \u00een alte situa\u021bii cu risc crescut de s\u00e2ngerare a mucoasei. Ar trebui verificat\u0103 interac\u021biunea medicamentelor \u00eenainte de a utiliza un DOAC.<\/p>\n

    4.3. Anticoagularea cu LMWH, DOAC sau VKA dup\u0103 primele 6 luni ar trebui s\u0103 fie oferit\u0103 anumitor pacien\u021bi cu cancer, cum ar fi cei cu boal\u0103 metastatic\u0103 sau cei care primesc chimioterapie. Anticoagularea peste 6 luni trebuie evaluat\u0103 pe o baz\u0103 intermitent\u0103 pentru a se asigura un profil risc-beneficiu favorabil continuu.<\/p>\n

    4.4. Pe baza opiniei exper\u021bilor, \u00een absen\u021ba datelor randomizate ale studiilor, beneficiile pe termen scurt fiind incerte \u0219i dovezi numeroase de r\u0103ni cauzate de filtrele montate pe termen lung, filtrele de ven\u0103 cav\u0103 nu ar trebui s\u0103 se introduc\u0103 pacien\u021bilor cu tromboz\u0103 stabil\u0103 sau cronic\u0103 (diagnostic de TEV cu mai mult de 4 s\u0103pt\u0103m\u00e2ni \u00een urm\u0103), nici pacien\u021bilor cu contraindica\u021bii temporare la terapia anticoagulant\u0103 (de exemplu, interven\u021bii chirurgicale). De asemenea, nu exist\u0103 un rol pentru inser\u021bia filtrului pentru prevenirea primar\u0103 sau profilaxia emboliei pulmonare (PE) sau a trombozei venoase profunde din cauza riscului de r\u0103nire pe termen lung. Poate fi oferit pacien\u021bilor cu contraindica\u021bii absolute la anticoagulant, terapie \u00een cadrul tratamentului acut (diagnostic de TEV \u00een ultimele 4 s\u0103pt\u0103m\u00e2ni) dac\u0103 sarcina trombului a fost considerat\u0103 amenin\u021b\u0103toare de via\u021b\u0103. Sunt necesare cercet\u0103ri suplimentare.<\/p>\n

    4.5. Introducerea unui filtru de vena cava poate fi oferit ca adjuvant la anticoagulare la pacien\u021bi cu progresie a trombozei (TEV recurent\u0103 sau extinderea trombului existent) \u00een ciuda optimului de terapie anticoagulant\u0103. Acest lucru se bazeaz\u0103 pe opinia exper\u021bilor comisiei, av\u00e2nd \u00een vedere absen\u021ba unei \u00eembun\u0103t\u0103\u021biri a supravie\u021buirii, un beneficiu limitat pe termen scurt, dar dovezi numeroase ale riscului crescut pe termen lung pentru TEV.<\/p>\n

    4.6 Pentru pacien\u021bii cu tumori maligne primare sau metastatice ale SNC \u0219i cu TEV stabilit, anticoagularea a\u0219a cum este descris\u0103 pentru al\u021bi pacien\u021bi cu cancer, ar trebui oferit\u0103, de\u0219i r\u0103m\u00e2n incertitudini despre alegerea agen\u021bilor \u0219i selec\u021bia pacien\u021bilor cel mai probabil s\u0103 beneficieze.<\/p>\n

    4.7. Embolismul pulmonar (TEP) accidental \u0219i tromboza venoas\u0103 profund\u0103 trebuie tratate \u00een acela\u0219i mod ca TEV simptomatic, av\u00e2nd \u00een vedere rezultatele lor clinice similare comparativ cu pacien\u021bii cu cancer cu evenimente simptomatice.<\/p>\n

    4.8. Tratamentul TEP subsegmental izolat sau trombi veno\u0219i splahnici sau viscerali diagnostica\u021bi incidental ar trebui s\u0103 fie oferite de la caz la caz, lu\u00e2nd \u00een considerare poten\u021bialele beneficii \u0219i riscuri ale anticoagul\u0103rii.<\/p>\n

    5. Nu se recomand\u0103 utilizarea anticoagulantelor pentru a \u00eembun\u0103t\u0103\u021bi supravie\u021buirea la pacien\u021bii cu cancer f\u0103r\u0103 VTE.<\/p>\n

    6.1. Exist\u0103 o varia\u021bie substan\u021bial\u0103 a riscului de a dezvolta TEV \u00eentre pacien\u021bii cu cancer \u0219i localizarea tumorii. Pacien\u021bii cu cancer ar trebui s\u0103 fie evalua\u021bi ini\u021bial \u0219i periodic dup\u0103 risc pentru TEV, \u00een special la \u00eenceperea terapiei antineoplazice sistemice sau \u00een momentul spitaliz\u0103rii. Factorii de risc individuali, inclusiv biomarkerii sau locul cancerului, nu identific\u0103 \u00een mod fiabil pacien\u021bii cu cancer cu risc crescut de a dezvolta TEV. \u00cen setarea ambulatorie, la pacien\u021bii cu tumori solide trata\u021bi cu terapie sistemic\u0103, evaluarea riscului poate s\u0103 se desf\u0103\u0219oare pe baza unui instrument validat de evaluare a riscurilor.<\/p>\n

    6.2. Oncologii \u0219i membrii echipei de oncologie ar trebui s\u0103 educe pacien\u021bii cu privire la TEV, \u00een special \u00een condi\u021bii care cresc riscul, cum ar fi interven\u021bii chirurgicale majore, spitalizare \u0219i \u00een timpul tratamentului sistemic.<\/p>\n

    \u00cen ciuda asocierii bine cunoscute a TEV \u0219i cancer, con\u0219tientizarea pacientului cu privire la risc \u0219i semnele de avertizare ale TEV r\u0103m\u00e2ne sc\u0103zut, subliniind necesitatea educa\u021biei medicale \u0219i con\u0219tientizarea pacientului. Oncologii \u0219i echipele lor ar trebui s\u0103 se asigure, cel pu\u021bin, c\u0103 pacien\u021bii au o recunoa\u0219tere de baz\u0103 a semnelor de avertizare VTE. Mai departe educa\u021bia poate ajuta pacien\u021bii s\u0103 disting\u0103 \u00eentre simptomele secundare bolii lor de baz\u0103, tratament, \u0219i alte cauze poten\u021biale\u2079.<\/p>\n

    \n

    Bibliografie:<\/p>\n

      \n
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    5. O’Connell CL, Boswell WD, Duddalwar V, Caton A, Mark LS, Vigen C and Liebma n HA: Unsuspected pulmonary emboli in cancer patients: Clinical correlates and relevance. J Clin Oncol. 24:4928\u20134932. 2006. View Article : Google Scholar : Pub Med\/NCBI<\/li>\n
    6. S\u00f8rensen HT, Mellemkjaer L, Olsen JH and Baron JA: Prognosis of cancers associated with venous thromboembolism. N Engl J Med. 343:1846\u20131850. 2000<\/li>\n
    7. Stein PD, Beemath A, Meyers FA, Skaf E, Sanchez J and Olson RE: Incidence of venous thromboembolism in patients hospitalized with cancer. Am J Med. 119:60\u201368. 2006<\/li>\n
    8. Lyman GH, Khorana AA, Falanga A, et al: American Society of Clinical Oncology guideline: Recommendations for venous thromboembolism prophylaxis and treatment in patients with cancer. J Clin Oncol 25:5490-5505, 2007<\/li>\n
    9. Gilligan T, Coyle N, Frankel RM, et al: Patient-clinician communication: American Society of Clinical Oncology consensus guideline. J Clin Oncol 35: 3618-3632, 2017<\/li>\n<\/ol>\n

      \n

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      Tromboza asociat\u0103 cancerului este o cauz\u0103 major\u0103 de morbiditate \u0219i mortalitate asociat\u0103 bolii neoplazice. 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