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A Summary of Guidelines for the Treatment of Cancer-Associated Thrombosis 07
Long term Optimal Incidental/
Guideline Initial Anticoagulation Anticoagulation Duration Recurrent VTE
International Once-daily LMWH regimen (or twice DOACs or LMWH 6 months Recurrent VTE:
Initiative on daily if required). (grade 1A)
Thrombosis and (a) increase LMWH by
Cancer 2019 6 Rivaroxaban or edoxaban (after 20%–25% or switch to DOAC
initial LMWH/UFH for 5 days if CrCl
≥30 mL/min and patient is not at (b) for DOACs, switch to LMWH
high risk of GI or GU bleeding (grade
1B)) (c) for VKAs, switch to LMWH or
DOAC.
UFH (when LMWH or DOACs are
contraindicated or not available
(grade 2C))
Fondaparinux (if CrCl ≥30 mL/min
(grade 2D)).
National Rivaroxaban (category 2A) At least Incidental PE: Treated similarly
Comprehensive (preferred over LMWH for patients 3 months of to symptomatic PE (category
Cancer Network without GI malignancies) therapy or for 2A).
2020 7 as long as the
Apixaban (category 1) cancer is Recurrent VTE on UFH: HIT,
active or antiphospholipid syndrome
Edoxaban after at least 5 days of undergoing (check UFH anti-Xa level),
parenteral anticoagulation treatment, increase dose of UFH, or switch
(category 1), whichever is to LMWH or DOAC (category
longer 2B).
LMWH (dalteparin category 1)
(preferred over DOACs in patients Recurrent VTE on LMWH: HIT,
with GI malignancies) switch to twice-daily injections
or increase dose, or switch to
UFH (category 2B) (preferred for fondaparinux or DOAC
patients with CrCl <30 mL/min) (category 2B).
Recurrent VTE on fondaparinux:
HIT or switching to UFH, LMWH,
or DOAC (category 2B).

Recurrent VTE on warfarin:
Switch to LMWH, UFH,
fondaparinux, or DOAC
(category 2B).

Recurrent VTE on DOAC: Switch
to LMWH or fondaparinux
(category 2B).

Spanish Society Rivaroxaban (if bleeding risk is low DOACs and 6 months Incidental VTE: Treated similarly
of Medical and no significant drug-drug LMWH to symptomatic VTE (grade 1B).
Oncology 2018 8 interactions)(grade 1B).
Recurrent VTE in patients on
LMWH (grade 1B). VKA or prophylactic or
intermediate doses of LMWH
UFH and fondaparinux (grade 1B). (grade 2B): Therapeutic LMWH

Recurrent VTE on therapeutic
LMWH: Increase LMWH dose
25% or switch to DOAC (grade
2B).

Recurrent VTE on DOAC: Switch
to LMWH or increase DOAC
dose to therapeutic dose if
subtherapeutic doses were
being used (grade 3C).

Abbreviations: CrCl, creatinine clearance; DOAC, direct oral anticoagulant; GI, gastrointestinal; GU, genitourinary; HIT, heparin-induced thrombocytopenia; IVC, inferior vena
cava; LMWH, low-molecular-weight heparin; PE, pulmonary embolism; UFH, unfractionated heparin; ULN, upper limit of normal range; VKA, vitamin K antagonist;
VTE, venous thromboembolism