Improving clinical outcomes of Venous Thromboprophylaxis in Multiple Myeloma

Aims The risk of thrombosis in multiple myeloma is significantly increased in the context of combination chemotherapy with anti-angiogenic agents. This study aimed to determine and improve the practice of thromboprophylaxis in patients with multiple myeloma. Methods Patient, disease and treatment characteristics of 50 patients with multiple myeloma were recorded in 2007 and practice compared with the ASCO guideline on venous thromboprophylaxis and treatment in patients with cancer. Results 87.5% of all hospitalised patients with myeloma received appropriate thromboprophylaxis., 73.2% of all patients without contraindications to thromboprophylaxis receiving thalidomide or lenalidomide plus chemotherapy or dexamethasone received anticoagulation, 23.3% of all anticoagulated patients received LMWH at the prophylactic dose or adjusted dose Warfarin, 90.9% of all ambulatory patients receiving other chemotherapy were not anticoagulated. There were no significant bleeding episodes but 6% patients suffered a thromboembolic event. The recommendations were subsequently revised: all patients receiving anti-angiogenic agents in combination with steroids, chemotherapy or, 2 or more risk factors should be anticoagulated , all patients that are anticoagulated should receive LMWH at the prophylactic dose or adjusted dose warfarin to INR of 2-3, the target INR should be documented , patients on warfarin should be referred to anticoagulation clinic, anticoagulation should be stopped with cessation of thalidomide/lenolidamide. The practice was re-audited to the revised standards in 2009. There were no thrombotic events but 1 gastro-intestinal bleed. Conclusion Treatment of myeloma with anti-angiogenic agents requires careful consideration of thromboprophylaxis especially in patients with other pro-thrombotic risk factors, and careful monitoring to optimise the risk: benefit.