Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer

Elie A. Akl, Lara Kahale, Francesca Sperati, Ignacio Neumann, Nawman Labedi, Irene Terrenato, Maddalena Barba, Elena V. Sempos, Paola Muti, Deborah Cook, Holger Schünemann

Research output: Contribution to journalArticle

32 Citations (Scopus)

Abstract

BACKGROUND: The choice of the appropriate perioperative thromboprophylaxis in patients with cancer depends on the relative benefits and harms of low molecular weight heparin (LMWH) and unfractionated heparin (UFH).

OBJECTIVES: To update a systematic review of the evidence for the relative efficacy and safety of LMWH and UFH for perioperative thromboprophylaxis in patients with cancer.

SEARCH METHODS: We performed a comprehensive search for trials of anticoagulation in patients with cancer including a February 2013 electronic search of: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. We also handsearched conference proceedings, reviewed reference list of included studies, used the 'related citations' feature in PubMed, and searched clinicaltrials.gov for ongoing studies.

SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled patients with cancer undergoing a surgical intervention and compared the effects of LMWH to UFH on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, or thrombocytopenia.

DATA COLLECTION AND ANALYSIS: Two review authors independently used a standardized form to extract in duplicate data on participants, interventions, outcomes of interest, and risk of bias. Where possible, we conducted meta-analyses using the random-effects model.

MAIN RESULTS: Of 9559 identified unique citations, we included 16 RCTs with 12,890 patients with cancer, all using preoperative prophylactic anticoagulation. We identified no new study with this update. The overall quality of evidence was moderate. The meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with UFH for the following outcomes: mortality (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.74 to 1.08), PE (RR 0.73; 95% CI 0.34 to 1.54), symptomatic DVT (RR 0.50; 95% CI 0.20 to 1.28), asymptomatic DVT (RR 0.81; 95% CI 0.66 to 1.01),major bleeding (RR 0.85; 95% CI 0.52 to 1.37), and minor bleeding (RR 0.92; 95% CI 0.47 to 1.79). LMWH was associated with lower incidence of wound hematoma (RR 0.68; 95% CI 0.52 to 0.88) but higher volume of intraoperative transfusion (mean difference (MD) 74 mL; 95% CI 47 to 102). The meta-analyses found no statistically significant differences for any of the following outcomes: reoperation for bleeding (RR 0.72; 95% CI 0.06 to 8.48) , intraoperative blood loss (MD= -6mL; 95% CI -87 to 74), postoperative transfusion (MD= 79mL; 95% CI -54 to 211), postoperative drain volume (MD= 27mL; 95% CI -44 to 98), and thrombocytopenia (RR 1.33; 95% CI 0.59 to 3.00).

AUTHORS' CONCLUSIONS: We found no difference between perioperative thromboprophylaxis with LMWH versus UFH in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding in patients with cancer. Further trials are needed to evaluate the benefits and harms of different heparin thromboprophylaxis strategies in this population more thoroughly.

Original languageEnglish
Pages (from-to)CD009447
JournalThe Cochrane database of systematic reviews
Volume6
DOIs
Publication statusPublished - 2014

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Low Molecular Weight Heparin
Heparin
Confidence Intervals
Odds Ratio
Neoplasms
Hemorrhage
Venous Thrombosis
Meta-Analysis
Pulmonary Embolism
Thrombocytopenia
Mortality
Randomized Controlled Trials
Reoperation
PubMed
MEDLINE
Hematoma

ASJC Scopus subject areas

  • Medicine(all)

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Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. / Akl, Elie A.; Kahale, Lara; Sperati, Francesca; Neumann, Ignacio; Labedi, Nawman; Terrenato, Irene; Barba, Maddalena; Sempos, Elena V.; Muti, Paola; Cook, Deborah; Schünemann, Holger.

In: The Cochrane database of systematic reviews, Vol. 6, 2014, p. CD009447.

Research output: Contribution to journalArticle

Akl, EA, Kahale, L, Sperati, F, Neumann, I, Labedi, N, Terrenato, I, Barba, M, Sempos, EV, Muti, P, Cook, D & Schünemann, H 2014, 'Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer', The Cochrane database of systematic reviews, vol. 6, pp. CD009447. https://doi.org/10.1002/14651858.CD009447.pub2
Akl, Elie A. ; Kahale, Lara ; Sperati, Francesca ; Neumann, Ignacio ; Labedi, Nawman ; Terrenato, Irene ; Barba, Maddalena ; Sempos, Elena V. ; Muti, Paola ; Cook, Deborah ; Schünemann, Holger. / Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer. In: The Cochrane database of systematic reviews. 2014 ; Vol. 6. pp. CD009447.
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abstract = "BACKGROUND: The choice of the appropriate perioperative thromboprophylaxis in patients with cancer depends on the relative benefits and harms of low molecular weight heparin (LMWH) and unfractionated heparin (UFH).OBJECTIVES: To update a systematic review of the evidence for the relative efficacy and safety of LMWH and UFH for perioperative thromboprophylaxis in patients with cancer.SEARCH METHODS: We performed a comprehensive search for trials of anticoagulation in patients with cancer including a February 2013 electronic search of: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. We also handsearched conference proceedings, reviewed reference list of included studies, used the 'related citations' feature in PubMed, and searched clinicaltrials.gov for ongoing studies.SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled patients with cancer undergoing a surgical intervention and compared the effects of LMWH to UFH on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, or thrombocytopenia.DATA COLLECTION AND ANALYSIS: Two review authors independently used a standardized form to extract in duplicate data on participants, interventions, outcomes of interest, and risk of bias. Where possible, we conducted meta-analyses using the random-effects model.MAIN RESULTS: Of 9559 identified unique citations, we included 16 RCTs with 12,890 patients with cancer, all using preoperative prophylactic anticoagulation. We identified no new study with this update. The overall quality of evidence was moderate. The meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with UFH for the following outcomes: mortality (risk ratio (RR) 0.89; 95{\%} confidence interval (CI) 0.74 to 1.08), PE (RR 0.73; 95{\%} CI 0.34 to 1.54), symptomatic DVT (RR 0.50; 95{\%} CI 0.20 to 1.28), asymptomatic DVT (RR 0.81; 95{\%} CI 0.66 to 1.01),major bleeding (RR 0.85; 95{\%} CI 0.52 to 1.37), and minor bleeding (RR 0.92; 95{\%} CI 0.47 to 1.79). LMWH was associated with lower incidence of wound hematoma (RR 0.68; 95{\%} CI 0.52 to 0.88) but higher volume of intraoperative transfusion (mean difference (MD) 74 mL; 95{\%} CI 47 to 102). The meta-analyses found no statistically significant differences for any of the following outcomes: reoperation for bleeding (RR 0.72; 95{\%} CI 0.06 to 8.48) , intraoperative blood loss (MD= -6mL; 95{\%} CI -87 to 74), postoperative transfusion (MD= 79mL; 95{\%} CI -54 to 211), postoperative drain volume (MD= 27mL; 95{\%} CI -44 to 98), and thrombocytopenia (RR 1.33; 95{\%} CI 0.59 to 3.00).AUTHORS' CONCLUSIONS: We found no difference between perioperative thromboprophylaxis with LMWH versus UFH in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding in patients with cancer. Further trials are needed to evaluate the benefits and harms of different heparin thromboprophylaxis strategies in this population more thoroughly.",
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TY - JOUR

T1 - Low molecular weight heparin versus unfractionated heparin for perioperative thromboprophylaxis in patients with cancer

AU - Akl, Elie A.

AU - Kahale, Lara

AU - Sperati, Francesca

AU - Neumann, Ignacio

AU - Labedi, Nawman

AU - Terrenato, Irene

AU - Barba, Maddalena

AU - Sempos, Elena V.

AU - Muti, Paola

AU - Cook, Deborah

AU - Schünemann, Holger

PY - 2014

Y1 - 2014

N2 - BACKGROUND: The choice of the appropriate perioperative thromboprophylaxis in patients with cancer depends on the relative benefits and harms of low molecular weight heparin (LMWH) and unfractionated heparin (UFH).OBJECTIVES: To update a systematic review of the evidence for the relative efficacy and safety of LMWH and UFH for perioperative thromboprophylaxis in patients with cancer.SEARCH METHODS: We performed a comprehensive search for trials of anticoagulation in patients with cancer including a February 2013 electronic search of: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. We also handsearched conference proceedings, reviewed reference list of included studies, used the 'related citations' feature in PubMed, and searched clinicaltrials.gov for ongoing studies.SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled patients with cancer undergoing a surgical intervention and compared the effects of LMWH to UFH on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, or thrombocytopenia.DATA COLLECTION AND ANALYSIS: Two review authors independently used a standardized form to extract in duplicate data on participants, interventions, outcomes of interest, and risk of bias. Where possible, we conducted meta-analyses using the random-effects model.MAIN RESULTS: Of 9559 identified unique citations, we included 16 RCTs with 12,890 patients with cancer, all using preoperative prophylactic anticoagulation. We identified no new study with this update. The overall quality of evidence was moderate. The meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with UFH for the following outcomes: mortality (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.74 to 1.08), PE (RR 0.73; 95% CI 0.34 to 1.54), symptomatic DVT (RR 0.50; 95% CI 0.20 to 1.28), asymptomatic DVT (RR 0.81; 95% CI 0.66 to 1.01),major bleeding (RR 0.85; 95% CI 0.52 to 1.37), and minor bleeding (RR 0.92; 95% CI 0.47 to 1.79). LMWH was associated with lower incidence of wound hematoma (RR 0.68; 95% CI 0.52 to 0.88) but higher volume of intraoperative transfusion (mean difference (MD) 74 mL; 95% CI 47 to 102). The meta-analyses found no statistically significant differences for any of the following outcomes: reoperation for bleeding (RR 0.72; 95% CI 0.06 to 8.48) , intraoperative blood loss (MD= -6mL; 95% CI -87 to 74), postoperative transfusion (MD= 79mL; 95% CI -54 to 211), postoperative drain volume (MD= 27mL; 95% CI -44 to 98), and thrombocytopenia (RR 1.33; 95% CI 0.59 to 3.00).AUTHORS' CONCLUSIONS: We found no difference between perioperative thromboprophylaxis with LMWH versus UFH in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding in patients with cancer. Further trials are needed to evaluate the benefits and harms of different heparin thromboprophylaxis strategies in this population more thoroughly.

AB - BACKGROUND: The choice of the appropriate perioperative thromboprophylaxis in patients with cancer depends on the relative benefits and harms of low molecular weight heparin (LMWH) and unfractionated heparin (UFH).OBJECTIVES: To update a systematic review of the evidence for the relative efficacy and safety of LMWH and UFH for perioperative thromboprophylaxis in patients with cancer.SEARCH METHODS: We performed a comprehensive search for trials of anticoagulation in patients with cancer including a February 2013 electronic search of: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. We also handsearched conference proceedings, reviewed reference list of included studies, used the 'related citations' feature in PubMed, and searched clinicaltrials.gov for ongoing studies.SELECTION CRITERIA: Randomized controlled trials (RCTs) that enrolled patients with cancer undergoing a surgical intervention and compared the effects of LMWH to UFH on mortality, deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding outcomes, or thrombocytopenia.DATA COLLECTION AND ANALYSIS: Two review authors independently used a standardized form to extract in duplicate data on participants, interventions, outcomes of interest, and risk of bias. Where possible, we conducted meta-analyses using the random-effects model.MAIN RESULTS: Of 9559 identified unique citations, we included 16 RCTs with 12,890 patients with cancer, all using preoperative prophylactic anticoagulation. We identified no new study with this update. The overall quality of evidence was moderate. The meta-analyses did not conclusively rule out either a beneficial or harmful effect of LMWH compared with UFH for the following outcomes: mortality (risk ratio (RR) 0.89; 95% confidence interval (CI) 0.74 to 1.08), PE (RR 0.73; 95% CI 0.34 to 1.54), symptomatic DVT (RR 0.50; 95% CI 0.20 to 1.28), asymptomatic DVT (RR 0.81; 95% CI 0.66 to 1.01),major bleeding (RR 0.85; 95% CI 0.52 to 1.37), and minor bleeding (RR 0.92; 95% CI 0.47 to 1.79). LMWH was associated with lower incidence of wound hematoma (RR 0.68; 95% CI 0.52 to 0.88) but higher volume of intraoperative transfusion (mean difference (MD) 74 mL; 95% CI 47 to 102). The meta-analyses found no statistically significant differences for any of the following outcomes: reoperation for bleeding (RR 0.72; 95% CI 0.06 to 8.48) , intraoperative blood loss (MD= -6mL; 95% CI -87 to 74), postoperative transfusion (MD= 79mL; 95% CI -54 to 211), postoperative drain volume (MD= 27mL; 95% CI -44 to 98), and thrombocytopenia (RR 1.33; 95% CI 0.59 to 3.00).AUTHORS' CONCLUSIONS: We found no difference between perioperative thromboprophylaxis with LMWH versus UFH in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding in patients with cancer. Further trials are needed to evaluate the benefits and harms of different heparin thromboprophylaxis strategies in this population more thoroughly.

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