NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) and NCCN Drugs & Biologics Compendium (NCCN Compendium®) for Cancer-Associated Venous Thromboembolic Disease. These NCCN Guidelines® are currently available as Version 1.2016.

• FLASCO
• August 8, 2016
• News

• Venous Thromboembolism Prophylaxis
  • VTE Prophylaxis Following Discharge and for Ambulatory Cancer Patients at Risk (VTE-2)
    • For medical oncology patients in other outpatient settings (ie, those without multiple myeloma), the following footnote was removed: “Consider patient conversation about risks and benefits of VTE prophylaxis in patients with a Khorana score ≥3. (See Khorana Predictive Model [VTE-A 3 of 3]).”
  • Deep or Superficial Vein Thrombosis (DVT/SVT) was divided into two new pages: “Acute Deep Vein Thrombosis (DVT)” and “Acute Superficial Vein Thrombosis (SVT)”
  • Acute Deep Vein Thrombosis
    • The “Incidental DVT” bullet was removed from “Diagnosis”, and a new pathway for “Unsuspected DVT” was added to clarify that workup/imaging studies are recommended only if not already performed.
    • Catheter-related DVT: Diagnosis and Treatment (DVT-3)
      • For patients with DVT and no contraindication to anticoagulation, the first bullet under “Treatment” was revised: “Anticoagulation for at least 3 months or as long as CVAD is in place”
      • For patients receiving anticoagulation for DVT, footnote “k” was added: “Consider longer duration anticoagulation in patients with poor flow, persistent symptoms, or unresolved thrombus.”
    • Acute Pulmonary Embolism
      • Diagnosis and Evaluation (PE-1)
        • The “Incidental PE” bullet was removed from “Diagnosis”, and a new pathway for “Unsuspected PE” was added, along with the revised footnote “c”: “Repeat imaging and diagnostic studies are not routinely needed in patients with incidental PE. Consider outpatient management for these patients.”
      • Heparin-Induced Thrombocytopenia
        • Diagnosis and Treatment of HIT (HIT-1)
          • For patients with “Low” HIT Pre-test Probability (4T Score <4):
            • The following bullet was removed: “Consider HIT antibody test (enzyme-linked immunosorbent assay [ELISA]) for select patients (See HIT antibody test results HIT-2)”.
            • Footnote “c” was revised: “A ‘low’ pre-test probability score combined with a negative antibody test is useful in ruling out a diagnosis of HIT; a positive test increases the suspicion for HIT. Patients with 4T scores <4 are very unlikely to have HIT, so routine HIT antibody testing in these patients is probably not advisable. In non-cancer patients with 4T scores of 1–3, the risk of HIT is small but not zero, but this has not been validated in cancer patients. Based on clinical judgment HIT antibody testing may be warranted in select patients of concern.”
          • Therapeutic Options for HIT (HIT-B, 2 of 2)
            • The fondaparinux recommendation was revised: “For patients with C_Cr 30–50 mL/min (clearance reduced by 40%): Consider using a DTI”
          • Reversal of Anticoagulation in the Event of Life-Threatening Bleeding or Emergent Surgery
            • The recommendations for reversal of dabigatran were revised as follows (VTE-E, 6 of 9):
              • New bullet added: “Administer idarucizumab, 5 g IV”
              • 3rd bullet was revised: “ For special situations with slow or incomplete clearance (eg, renal dysfunction or failure), consider adding to idarucizumab:…”
              • Statement was removed: “May be helpful based on in vitro or animal models: aPCC (anti-inhibitor coagulant complex, vapor heated 25–50 units/kg IV) rhFVIIa 90 mcg/kg IV”
              • Precautions/Additional Considerations, 3rd bullet revised: “In patients with renal failure/severe renal insufficiency, dialysis may be helpful in addition to idarucizumab.”
            • New page added with recommendations for reversal of edoxaban anticoagulation in the event of life-threatening bleeding or emergent surgery. (VTE-E, 8 of 9)
          • A new list of indications for thrombolysis was added (VTE-J):“Limb-threatening/life-threatening acute proximal DVT, Symptomatic ileal femoral thrombosis, Massive/life-threatening PE, Intestinal SPVT with high risk of ischemia”
          • “Pomalidomide” was added to “thalidomide/lenalidomide” as appropriate throughout the guidelines.

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.