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NCCN Flash Updates™: NCCN Guidelines® & NCCN Compendium Updated®

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and the NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Cancer-Associated Venous Thromboembolic Disease. These NCCN Guidelines® are currently available as Version 1.2015.

  • Venous Thromboembolism
    • Inpatient Venous Thromboembolism Prophylaxis (VTE-1)
      • At risk population
        • First bullet modified: “Adult medical or surgical patient” (Also for VTE-2)
        • New bullet added: “Providers are encouraged to discuss VTE risk factors, VTE prevention, and the importance of patient adherence to care programs.” (Also for VTE-2)
      • Initial prophylaxis, Recommendation revised: “Prophylactic anticoagulation therapy (category 1) (Consider preoperative dosing with unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) for high-risk surgery [eg, abdominal/pelvic] patients)…
      • Footnote c revised: “Pharmacologic intervention. Discuss prevention and risks/benefits of VTE prophylactic anticoagulation by pharmacologic intervention. See Inpatient/Outpatient Prophylactic Anticoagulation Treatment (VTE-C).”
      • Footnote d revised: “IPC device is preferred over GCS. Patients should be …”
  • Deep or Superficial Vein Thrombosis (DVT-2)
    • Under DVT, Treatment, top pathway: “Contraindication persists or is likely to recur”
    • Treatment, Footnote h revised: “Consider permanent filters only for rare patients with permanent contraindications to anticoagulation or with chronic comorbidities.” This footnote change was also made on PE-2 and VTE-H.
  • Pulmonary Embolism (PE-2)
    • For patients with no contraindications to anticoagulation, and who are normal after acute management, “Consider outpatient management” was added as a treatment option.
  • Heparin-Induced Thrombocytopenia (HIT)
    • For patients with HIT antibody negative, recommendation revised: “Consider repeating HIT antibody test (ELISA) ± serotonin-release assay (SRA) if pre-test probability is moderate to high.” (HIT-2)
    • For patients with a pre-test probability score of moderate/high, the recommendation “Continue DTI or fondaparinux” was removed, and this patient population is now treated the same as the “HIT antibody positive” pathway. (HIT-2)
    • Therapeutic Options for HIT
      • Footnote “1” is new: “The NCCN Guidelines Panel encourages the development of protocols or order sets for HIT treatment that includes DTI dosing, adjustment in renal or hepatic dysfunction, nursing instructions, and monitoring parameters.” (HIT-B 1 of 2)
      • Regarding fondaparinux and renal concerns, revised statement and added recommendation: “For patients with Ccr 30->50 ml/min (clearance reduced by ≥40% lower): Use caution,” along with a new footnote: “Consider using a DTI” (HIT-B 2 of 2)
  • Inpatient/Outpatient Prophylactic Anticoagulation Treatment (VTE-C)
    • This page was reformatted into a table that now includes obesity dosing for body mass index (BMI) ≥40 kg/m2.
    • Footnote “4” is new: “Given the impact of renal insufficiency on clearance of enoxaparin and fondaparinux, UFH or dalteparin are recommended for obese patients with severe renal impairment (CCr<30 ml/min).”
  • Therapeutic Anticoagulation Treatment for Venous Thromboembolism (VTE-D)
    • Under “Acute Management” a new bullet was added: “Direct oral anticoagulants (DOAC) are not recommended (apixaban, dabigatran, edoxaban, and rivaroxaban require additional clinical experience and research to provide data regarding risks/benefits and guidance for their safe and effective use in cancer patients).” (Also added on VTE-D (2 of 2) under “Chronic Management”)
    • Duration of Anticoagulation as Recommended by Guideline (VTE-D 2 of 2)
      • Second bullet revised: “For non-catheter-associated DVT or PE, recommend indefinite anticoagulation if active cancer or persistent risk factors while cancer is active, under treatment, or if risk factors for recurrence persist.”
      • New bullet added: “Providers should continue to discuss with patients the risks/benefits of anticoagulation to determine the appropriate duration of therapy. (See Elements for Consideration in Decision Not to Treat [VTE-F]).
  • Reversal of Anticoagulation in the Event of Life-Threatening Bleeding or Emergent Surgery (VTE-E)
    • This section was revised extensively.
  • Therapeutic Anticoagulation Failure (VTE-H)
    • “Patient on LMWH” pathway, Recommendation revised: “Check anti-Xa level and/or Move to every 12-hour schedule or Increase dose.”
    • Footnote “6” is new: “Anti-Xa levels may be considered in patients who are underweight, obese, renally impaired, or for whom compliance is a concern.  Anti-Xa levels should be checked at their peak at 4 hours after dosing for both twice-daily or once-daily dosing regimens. Reference ranges are not clinically validated and can vary by facility. Suggested “therapeutic range” is usually 0.6-1.0 units/mL for twice-daily dosing or 1-2 units/mL for once-daily dosing.
  • Thrombolytic Agents (VTE-I)
    • Under “Pulmonary embolism” a new bullet was added: “Ultrasound-assisted catheter-directed thrombolysis,” with corresponding footnote: “Ultrasound-assisted catheter-directed thrombolysis is indicated for the treatment of PE in patients with ≥50% clot burden in one or both main pulmonary arteries or lobar pulmonary arteries, and evidence of right heart dysfunction based on right heart pressures (mean pulmonary artery pressure ≥25 mmHg) or echocardiographic evaluation. The panel recommends alteplase infusion at a rate of 1 mg/h per drug delivery catheter (2 mg/h for bilateral PE) with a total dose of 24 mg. The alteplase regimen is infused for 24 hours with one catheter and 12 hours for two catheters.”
  • Perioperative Management of Anticoagulation and Antithrombotic Therapy
    • Estimated Bleeding Risk of Various Dental Procedures (PMA-A 2 of 2)
      • This section was revised extensively.
  • Perioperative Anticoagulation Management Guideline (PMA-B)
    • Dosing for rivaroxaban and apixaban was revised.

For the complete updated versions of the NCCN Guidelines, the NCCN Compendium®, and the NCCN Chemotherapy Order Templates (NCCN Templates®), please visit NCCN.org.

To access the NCCN Biomarkers Compendium®, please visit NCCN.org/biomarkers.

To view the NCCN Guidelines for Patients®, please visit NCCN.org/patients.

Free NCCN Guidelines apps iPhone, iPad, and Android devices are now available! Visit NCCN.org/apps

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