尽管所有患有癌症相关血栓(CAT)的患者都有很高的发病率和死亡率风险,某些患者群体特别脆弱。这可能会使患者面临血栓复发或出血(或两者)的风险增加。抗凝治疗的获益-风险比可以修改。因此,需要谨慎选择治疗方法。这些弱势群体包括老年患者,肾功能损害或血小板减少症患者,体重过轻和肥胖的病人.然而,这些患者群体在临床试验中的代表性很低,限制治疗决策所依据的可用数据。对随机临床试验数据的荟萃分析表明,直接口服Xa因子抑制剂(DXIs)和低分子量肝素(LMWH)对大出血的相对治疗效果可能受高龄影响。在肾功能损害或低体重患者中,与LMWH相比,DXIs的相对风险-收益特征没有变化的证据。可用的,虽然有限,数据不支持基于肾损害或低体重限制TAC患者使用DXIs.在老年患者中,年龄本身并不是选择治疗的关键因素,但是脆弱就是这样一个因素。70岁以上的CAT患者在选择治疗前应进行系统的虚弱评估,并应解决可改变的出血风险因素。在肾功能损害的患者中,此后应定期评估和监测肌酸清除率.在eGFR小于30mL/min/1.72m2的患者中,可能需要调整抗凝治疗。同样,治疗前应评估血小板计数并定期监测.在3-4级患者中,应考虑使用减少剂量的LMWH治疗血小板减少症(小于50,000血小板/μL)。对于患有CAT和低体重的患者,标准抗凝治疗建议是适当的,而在肥胖患者中,阿哌沙班可能是首选。
Although all patients with cancer-associated thrombosis (CAT) have a high morbidity and mortality risk, certain groups of patients are particularly vulnerable. This may expose the patient to an increased risk of thrombotic recurrence or bleeding (or both), as the benefit-risk ratio of anticoagulant treatment may be modified. Treatment thus needs to be chosen with care. Such vulnerable groups include older patients, patients with renal impairment or thrombocytopenia, and underweight and obese patients. However, these patient groups are poorly represented in clinical trials, limiting the available data on which treatment decisions can be based. Meta-analysis of data from randomised clinical trials suggests that the relative treatment effect of direct oral factor Xa inhibitors (DXIs) and low molecular weight heparin (LMWH) with respect to major bleeding could be affected by advanced age. No evidence was obtained for a change in the relative risk-benefit profile of DXIs compared to LMWH in patients with renal impairment or of low body weight. The available, albeit limited, data do not support restricting the use of DXIs in patients with TAC on the basis of renal impairment or low body weight. In older patients, age is not itself a critical factor for choice of treatment, but frailty is such a factor. Patients over 70 years of age with CAT should undergo a systematic frailty evaluation before choosing treatment and modifiable bleeding risk factors should be addressed. In patients with renal impairment, creatine clearance should be assessed and monitored regularly thereafter. In patients with an eGFR less than 30mL/min/1.72m2, the anticoagulant treatment may need to be adapted. Similarly, platelet count should be assessed prior to treatment and monitored regularly. In patients with grade 3-4, thrombocytopenia (less than 50,000platelets/μL) treatment with a LMWH at a reduced dose should be considered. For patients with CAT and low body weight, standard anticoagulant treatment recommendations are appropriate, whereas in obese patients, apixaban may be preferred.