Table 3.

Clinical considerations for selection of anticoagulation

DOAC	Optimal	Patient without GI malignancy33,34 Low risk of major bleedinga Ease of treatment for patient is a priority31 No strong drug-–drug interactions
Avoid	Active GI malignancy33,34 History of GI bleeding33,34 Extremes of weight (<50 kg or >150 kg)b Renal insufficiency/fluctuating renal status61
LMWH	Optimal	Frequent emetogenic chemotherapy, nausea and vomiting, difficulty with oral intake Concerns for GI absorption (feeding tubes, gastric or bowel resections) Drug-–drug interactions with DOAC or VKA Motivated patient willing to use for extended durations31 Known increased bleeding risk Recurrent cancer-associated VTE while on anticoagulantsc88–90
Avoid	Strong aversion to injectable therapy31 Renal insufficiency/fluctuating renal status23 Extremes of weight (<50 kg or >150 kg)b
VKA	Optimal	Any situation in which close anticoagulant monitoring is necessary (eg, multiple prior bleeds) or concern about absorption and metabolism Advanced chronic kidney disease Extremes of weight (<50 kg or >150 kg)b
Avoid	Lack of access to dedicated anticoagulation monitoring service with experience caring for cancer patients91

Notes: ^aIf a DOAC reversal agent is not readily available, LMWH may be preferred for patients with increased risk of bleeding at baseline. ^bPrescribing information for factor Xa inhibitors and LMWH recommend against use in extremes of weight, although a 2018 study suggests that DOACs may be appropriate for obese patients.⁹² cUsing twice-daily dosing of enoxaparin, given at 120–125% of standard twice-daily dosing. No data for DOACs in this setting are available, and how to increase the DOAC dose with limited pill strengths is not known. Please note: This is not an exhaustive list. Anticoagulant choices may be appropriate in some patients not meeting “optimal” criteria. Reproduced from Al-Samkari H, Connors JM. The role of direct oral anticoagulants in treatment of cancer-associated thrombosis. Cancers (Basel). 2018;10 (8).  Creative Commons license and disclaimer available from: http://creativecommons.org/licenses/by/4.0/legalcode. ¹

Abbreviations: GI, gastrointestinal; DOAC, direct oral anticoagulant; VKA, vitamin K antagonist; VTE, venous thromboembolism; LMWH, low molecular weight heparin.