Table 4.

Role of the Direct Oral Anticoagulants in the Acute Treatment of Cancer-Associated Thrombosis in Recent Guidelines

Guideline	Recommendations Regarding DOACs
ISTH 2018,85	DOACs (edoxaban, rivaroxaban) suggested as first line for CAT treatment in patients at low bleeding risk and no interfering drugs. DOACs (edoxaban, rivaroxaban) suggested as acceptable alternative to LMWH for CAT treatment in patients at high bleeding risk (eg, luminal gastrointestinal cancers or other gastrointestinal mucosal diseases, genitourinary cancers at high bleeding risk).
ASCO 2020,4	DOAC (rivaroxaban) or LMWH/UFH/fondaparinux recommended for initial anticoagulation. DOACs (edoxaban, rivaroxaban) or LMWH recommended for long-term anticoagulation for at least 6 months. Caution with DOACs in patients with gastrointestinal/genitourinary malignancies, or other diseases at high risk of mucosal bleeding. Check drug-drug interactions. DOACs or LMWH/VKA after the initial 6 months should be offered to selected patients with active cancer (eg, metastatic disease, or receiving chemotherapy).
ACCP 2021,86	DOACs (apixaban, edoxaban, rivaroxaban) recommended over LMWH for initiation (5–21 days) and treatment (up to 3 months) phases of anticoagulation. Apixaban or LMWH preferred for patients with luminal gastrointestinal tumours, since edoxaban and rivaroxaban might increase the risk of gastrointestinal major bleeding.
ASH 2021,5	DOACs (apixaban, rivaroxaban) or LMWH suggested for initial treatment (first week) of CAT. DOACs (apixaban, edoxaban, rivaroxaban) suggested over LMWH/VKA for the short-term treatment (initial 3–6 months). DOACs or LMWH suggested for the long-term treatment (>6 months).
ITAC 2022,87	DOACs (apixaban or rivaroxaban started immediately, edoxaban started after parenteral anticoagulation) can be used, as an alternative to LMWH, for the initial treatment of CAT (first 10 days) in patients without high risk of gastrointestinal or genitourinary bleeding. DOACs (apixaban, edoxaban, rivaroxaban) or LMWH suggested for the early (up to 6 months) and long-term (>6 months) treatment of CAT. The DOACs should be considered in patients without renal insufficiency (CrCl ≥ 30 ml/min), drug interactions or gastrointestinal absorption impairment. Caution if gastrointestinal malignancies.

Abbreviations: ACCP, American College of Chest Physicians; ASCO, American Society of Clinical Oncology; ASH, American Society of Hematology; CAT, cancer-associated thromboembolism; CrCl, creatinine clearance; DOACs, direct oral anticoagulants; ISTH, International Society on Thrombosis and Haemostasis; ITAC, International Initiative on Thrombosis and Cancer; LMWH, low molecular weight heparin; UFH, unfractionated heparin; VKA, vitamin K antagonist.