背景:静脉血栓栓塞症(VTE)在癌症患者中非常普遍。最近的指南建议考虑直接口服抗凝剂(DOAC)治疗癌症相关血栓形成(CAT)。然而,缺乏DOAC之间的直接头对头比较,并且在CAT患者中几乎没有进行净临床获益(NCB)分析。方法:我们系统地搜索了PubMed,EMBASE,科克伦图书馆,和ClinicalTrials.gov用于报告复发性VTE的随机对照试验(RCT),大出血,或接受DOACs和低分子量肝素的CAT患者的临床相关出血事件。使用随机效应模型计算相对风险(RR)和95%置信区间(95%CIs)。计算累积排序曲线下的曲面(SUCRA)值,并进行了权衡分析来估计NCB。结果:总体而言,纳入4项RCTs,涉及2,894例患者.DOAC在降低复发性VTE的风险方面比达肝素更有效(RR:0.62,95%CI:0.44-0.87),大出血风险比较(RR:1.33,95%CI:0.84-2.11),临床相关出血风险增加(RR:1.45,95%CI:1.05-1.99).在复发性VTE和大出血方面,各个抗凝剂之间没有观察到显着差异。关于主要结局的每种抗凝剂的排名,edoxaban(SUCRA:69.2)比达肝素(SUCRA:60.7)更有效,利伐沙班(SUCRA:60.7),和阿哌沙班(SUCRA:25.5)减少VTE复发。对于大出血,阿皮沙班(SUCRA:76.3)的累积排名概率最高,其次是edoxaban(SUCRA:66.4),达肝素(SUCRA:28.8),和利伐沙班(SUCRA:28.5)。对于临床相关的出血观察到类似的结果。就利益和安全结果而言,DOAC,尤其是edoxaban,似乎赋予NCB比达肝素更好的配置文件。结论:DOAC是CAT患者的一种安全有效的替代治疗方法。其中,edoxaban可能会提供良好的风险-收益平衡。然而,由于缺乏面对面的研究,我们需要进一步调查以证实我们的发现。
Background: Venous thromboembolism (VTE) is highly prevalent in cancer patients. Recent guidelines recommend considering direct oral anticoagulants (DOACs) for the treatment of cancer-associated thrombosis (CAT). However, direct head-to-head comparisons among DOACs are lacking, and almost no net clinical benefit (NCB) analysis has been performed in patients with CAT. Methods: We systematically searched PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov for randomized controlled trials (RCTs) reporting on recurrent VTE, major bleeding, or clinically relevant bleeding events in patients with CAT who received DOACs and low-molecular-weight heparins. Relative risks (RRs) and 95% confidence intervals (95% CIs) were calculated using a random-effect model. Surface under the cumulative ranking curve (SUCRA) values were calculated, and a trade-off analysis was performed to estimate the NCB. Results: Overall, four RCTs involving 2,894 patients were enrolled. DOACs were more effective than dalteparin in reducing the risk of recurrent VTE (RR: 0.62, 95% CI: 0.44-0.87), with a comparative risk of major bleeding (RR: 1.33, 95% CI: 0.84-2.11) and an increased risk of clinically relevant bleeding (RR: 1.45, 95% CI: 1.05-1.99). No significant difference was observed among individual anticoagulants in terms of recurrent VTE and major bleeding. With respect to the ranking of each anticoagulant for the primary outcome, edoxaban (SUCRA: 69.2) was more effective than dalteparin (SUCRA: 60.7), rivaroxaban (SUCRA: 60.7), and apixaban (SUCRA: 25.5) in reducing VTE recurrence. For major bleeding, apixaban (SUCRA: 76.3) had the highest cumulative ranking probability, followed by edoxaban (SUCRA: 66.4), dalteparin (SUCRA: 28.8), and rivaroxaban (SUCRA: 28.5). Similar results were observed for clinically relevant bleeding. In terms of both benefit and safety outcomes, DOACs, especially edoxaban, seemed to confer a better NCB profile than dalteparin. Conclusions: DOACs are a safe and effective alternative therapy to dalteparin in patients with CAT. Among them, edoxaban might provide a good risk-to-benefit balance. However, because of the lack of head-to-head studies, further investigations are needed to confirm our findings.