This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into

consideration circumstances particular to MD Anderson,

including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

In patients with a high clinical suspicion of DVT/PE, in

the absence of contraindications it is recommended that Upper extremity DVT See Page 2
Clinical
treatment with anticoagulants be started while awaiting
Suspicion of Lower extremity DVT See Page 3
the outcome of diagnostic test(s).
VTE
For suspected PE consider obtaining ECHO, Troponin
Pulmonary embolism (PE) See Page 4
level, and BNP

APPENDIX A: Contraindications to Anticoagulation Therapy...Page 6

APPENDIX B: Contraindications to Thrombolysis...Page 6
APPENDIX C: Outpatient Treatment Criteria..Page 7
APPENDIX D: Recurrent VTE Anticoagulation Therapy Options ....Page 7
for patients currently on standard anticoagulant therapy
14
APPENDIX E: Anticoagulation Therapy Options for the Cancer Patients.Page 8-9
APPENDIX F: New Oral Anticoagulants Page 10-12
APPENDIX G: Thrombolytics..Page 13
Suggested Readings....Page 14
Development Credits......Page 15

Department of Clinical Effectiveness V5

Copyright 2015 The University of Texas MD Anderson Cancer Center
Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

Upper Extremity Consult Vascular Surgery or Interventional Radiology

DVT1 Consider catheter-directed thrombolysis if age of clot less than 30 days
Yes
2
Ultrasound/ Significant Maintain catheter and
Doppler extremity anticoagulate indefinitely
swelling?
No Is Yes while catheter is in place See Box A
catheter functional Page 5
.
Yes Yes and not infected?
No
Catheter Consider removal of catheter3
Acute DVT related?
confirmed? No
Yes No See Box A Page 5

First
occurrence? Continue evaluation of other causes of symptoms
Consider prophylaxis if clinically indicated (See VTE Prophylaxis Algorithm)
No

Continue current management

4
No new defect Consider post-thrombotic syndrome or other causes of symptoms
Consider applying sleeve compression if post-thrombotic syndrome
Ultrasound/
Doppler
New defect See Box A Page 5

1
In patients with a high clinical suspicion of DVT/PE, in the absence of contraindications it is recommended that treatment with anticoagulants be started while awaiting the outcome of diagnostic test(s).
2
Significant extremity swelling as evidenced by significant impact on performance status that affects quality of life, or is associated with phlegmasia or lymphedema
3
Anticoagulation after catheter removal can be stopped after 3 months.
4
Consider post-thrombotic syndrome if symptoms occur in same extremity as prior VTE

Department of Clinical Effectiveness V5

Copyright 2015 The University of Texas MD Anderson Cancer Center
Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

Lower Extremity Consult Vascular Surgery or Interventional Radiology

DVT1 Consider catheter-directed thrombolysis if age of clot is less than 30 days
Yes
Significant2
extremity
swelling? No
Yes See Box A Page 5
Ultrasound/ Acute DVT
Doppler confirmed?
No
Yes Continue evaluation of other causes of symptoms
Consider prophylaxis if clinically indicated (See VTE Prophylaxis Algorithm)
First
occurrence?

No

Continue current management

3
No new defect Consider post-thrombotic syndrome or other causes of symptoms
Consider applying compression stockings if post-thrombotic syndrome
Ultrasound/
Doppler
New defect See Box A on Page 5

1
In patients with a high clinical suspicion of DVT/PE, in the absence of contraindications it is recommended that treatment with anticoagulants be started while awaiting the outcome of diagnostic test(s).
2
Significant extremity swelling: significant impact on performance status that affects quality of life, or is associated with phlegmasia or lymphedema
3
Consider post-thrombotic syndrome when symptoms occur in site of prior VTE

Department of Clinical Effectiveness V5

Copyright 2015 The University of Texas MD Anderson Cancer Center Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

3
Submassive See Page 5
Pulmonary
Embolism (PE)1
Contra- Yes Consult Vascular Surgery
Massive
3 indications to
anticoagulation4 ? Follow-up
No Yes
Yes
Contra-
Treat with indications to
PE anticoagulant thrombolytics5? Yes
2 No
CT angiogram 3
confirmed ?
Systolic
Treat with systemic blood pressure
No
thrombolytics6 greater than
Yes 90 mmHg?
First No
occurrence of Continue evaluation of other causes of symptoms
PE? Consider prophylaxis if clinically indicated (See VTE Prophylaxis Algorithm)
No Consult
Vascular
No new defect Continue current management Surgery

2
CT angiogram
New defect See Box A on Page 5
1 4
In patients with a high clinical suspicion of DVT/PE, in the absence of contraindications it is recommended that treatment with anticoagulants be started while See Appendix A for Contraindications to Anticoagulation
awaiting the outcome of diagnostic test(s). For suspected PE, obtain the following: ECHO, Troponin level, BNP. 5
See Appendix B for Contraindications to Thrombolytics
2
If CT angiogram cannot be done, consider VQ scan 6
3 See Appendix F for Alteplase treatment and monitoring
Submassive pulmonary embolism (PE): Any PE that is not massive (see below).
Massive pulmonary embolism (PE):
Sustained hypotension (systolic blood pressure less than 90 mmHg for at least 15 minutes) or
Persistent bradycardia (Heart Rate less than 40 bpm with signs or symptoms of shock
Need for inotropic support
Department of Clinical Effectiveness V5
Copyright 2015 The University of Texas MD Anderson Cancer Center Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

Treatment for all VTE Upper extremity DVT Withhold anticoagulation and monitor

2
Temporary
2 Yes Retrievable IVC Filter
Lower extremity DVT
contraindication to
or PE
anticoagulant?
No Permanent IVC Filter
Yes
Contra-
indications to
1
anticoagulation ?
Select anticoagulants Monitor patient per selected anticoagulation
No Patient Yes
See Appendix D for management instructions therapy (see respective appendices)*
on current *For patients with VTE and cancer,
anticoagulation continue anticoagulant therapy
therapy? Select anticoagulants indefinitely, or until cancer
No
See Appendix E for management instructions resolves, or if no contraindication emerges
Does
patient meet
outpatient criteria for Yes
anticoagulation
treatment? (See Admit patient for evaluation and treatment or if already
Appendix No
inpatient, continue with evaluation and treatment
C)

1
See Appendix A for Contraindications to Anticoagulation
2
Criteria to consider for placement of a retrievable filter
If temporary/limited time (less than or equal to 2-3 months) of contraindication to anticoagulants place a retrievable IVC filter.
Greater than 6 months survival expected
Performance Status less than or equal to 1
Department of Clinical Effectiveness V5
Copyright 2015 The University of Texas MD Anderson Cancer Center
Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

APPENDIX A: Contraindications to Anticoagulation Therapy:

Absolute Contraindications: Relative Contraindications:

Cerebral hemorrhage, hemorrhage in the eye or vital organs or a drop in Brain metastases conferring risk of bleeding (renal, choriocarcinoma, melanoma, thyroid cancer)
hemoglobin of 2 gm/dL in 24 hours Spinal Procedure and/or epidural placement
Neurosurgery, ocular surgery or intracranial bleeding within past 10 days Major trauma or head trauma
Major abdominal surgery within 48 hours
Severe hypertension (Systolic BP greater then 200 mmHg, Diastolic BP greater than 120 mmHg)
Endocarditis/pericarditis
GI, GU bleeding within past 14 days
Preexisting coagulopathy
Thrombocytopenia less than 50,000/ul
Hypersensitivity to heparin, low molecular weight heparin (LMWH) or heparin induced
thrombocytopenia
Patient on active protocol that prohibits use of anticoagulation
Bleeding diathesis

APPENDIX B: Contraindications to Systemic Thrombolysis:

Absolute Relative
History of hemorrhagic stroke or stroke of unknown origin Pregnancy or first post-partum week
Intracranial tumor Non-compressible puncture sites
Ischemic stroke in previous 3 months Traumatic resuscitation
History of major trauma, surgery or head injury in previous 3 weeks Refractory hypertension (systolic pressure greater than 180 mmHg;
3
Platelet count below 100,000/mm diastolic blood pressure greater than 100)
Advanced liver disease
Infective endocarditis
Recent GI bleed (last 3 months)
Life expectancy less than or equal to 6 months

Department of Clinical Effectiveness V5

Copyright 2015 The University of Texas MD Anderson Cancer Center Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

APPENDIX C: Outpatient Treatment Criteria:

1. See Appendix A for contraindications
2. No co-morbidity requiring inpatient hospitalization
3. No clinical conditions requiring hospitalization
4. Likelihood of good compliance, ability to provide self-care and not at high-risk for falls
5. Adequate home support system and geographical accessibility for follow-ups
6. If pulmonary embolism, pulse oximetry greater then 95%; stable vital signs

APPENDIX D: Recurrent VTE Anticoagulation Therapy Options for patients currently on standard anticoagulant therapy

If patient is on sub-therapeutic warfarin, adjust dose to achieve a target INR of 2-3.

If INR is therapeutic, change warfarin to LMWH.
If patient is on a LMWH, check anti-factor Xa level 4 hours post injection.
1
If peak anti-factor Xa level is subtherapeutic (less than 0.5 anti-factor Xa units), adjust dose of the LMWH to achieve a peak anti-factor Xa of 0.5 1.5 units
If peak factor Xa level is within the therapeutic range, consider increasing dose of LMWH by 20% .
2

If peak factor Xa level is therapeutic and the VTE event is a symptomatic pulmonary embolism, place a permanent IVC filter.
Consider General Internal Medicine or Benign Hematology consult.

1
See recommendations for specific agents on Page 8.
2
Range may vary, based on specific institutional ranges.

Department of Clinical Effectiveness V5

Copyright 2015 The University of Texas MD Anderson Cancer Center Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

APPENDIX E: Anticoagulation Therapy Options for the Cancer Patients

LMWH1 Regimens for Treatment of Cancer Associated Thrombosis
DRUG DOSE / ROUTE / FREQUENCY MONITORING2 DOSE ADJUSTMENTS
Round to nearest International Units (IU) Consider reducing the daily dose by 50% when platelets are
Dalteparin (Fragmin)* dose, given subcutaneously daily Baseline CBC with between 20,000/mm3 - 50,000/mm3 and to 5,000 international units
Actual Body platelets, aPTT, PT and
*Preferred choice, FDA approved Month 1 Month 2-6 serum creatinine when platelets are less than 20,000/mm3
Weight (kg) 200 IU/kg 150 IU/Kg If creatinine clearance less than 30 mL/minute: adjust dose to obtain
for cancer patients For surgical patients,
Less than or equal to 56 10,000 IU 7,500 IU platelets every 3 days anti-Xa level of 0.5-1.5 International Units/mL (4-6 hours after
Use dalteparin with between days 4 and 14 fourth dose)
57-68 12,500 IU 10,000 IU after beginning LMWH
caution in patients with Obtain anti-Xa in patients weighing greater than 150 kg or less than
69-82 15,000 IU 12,500 IU then as clinically
platelets less than 50 kg, and adjust dose to obtain anti-Xa level of 1.5 International
83-98 18,000 IU 15,000 IU indicated
50,000 mm3 Units/mL (4-6 hours after fourth dose)
Greater than or equal to 99 Limited data suggests Dalteparin 200 IU/kg based on actual body weight (with no dose capping) in one or two divided doses.
An alternative option is Enoxaparin 1 mg/kg twice daily. Consider monitoring anti-Xa levels and adjust dose as needed.

Enoxaparin (Lovenox) If creatinine clearance less than 30 mL/minute: Use 50% of

total daily dose
1 mg/Kg subcutaneously every 12 hours or Same as above Obtain anti-Xa in patients with weight greater
Use enoxaparin with caution
in patients with platelets less 1.5 mg/Kg* subcutaneously daily in selected than 150 kg or less than 50 kg
than 100,000/mm3 patients a. For 1 mg/kg every 12 hour dosing regimen: adjust dose to
obtain anti-Xa level of 0.6 - 1.0 InternationalUnits/mL
(4-6 hours after fourth dose)
*Limited data suggest once per day dosing is b. For 1.5 mg/kg every 24 hour dosing regimen: adjust dose
inferior in cancer patients to obtain anti-Xa level of 1.0 - 1.5 International Units/mL
(4-6 hours after fourth dose)
1
NOTES: Low-Molecular Weight Heparins (LMWH) (preferred agents)
IfLMWHs are not accessible, consider switching to warfarin after 5 days of LMWH therapy. Heparin and Warfarin therapy should overlap 5 days during the acute
management of venous thrombosis. Appendix E Continued on Next Page
Patients who tolerate anticoagulation should be continued on it indefinitely or until active cancer resolves.
Patient should be observed closely for bleeding and signs and symptoms of neurological impairment if therapy is administered during or immediately following
diagnostic lumbar puncture, epidural anesthesia, or spinal anesthesia.
2
If lab results indicates Heparin Induced Thrombocytopenia, follow management guideline per Heparin Induced Thrombocytopenia (HIT) Algorithm.
Department of Clinical Effectiveness V5
Copyright 2015 The University of Texas MD Anderson Cancer Center Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

APPENDIX E continued: Anticoagulation Therapy Options for the Cancer Patients

Unfractionated Heparin (UFH)
TREATMENT MONITORING
If fixed dose, unmonitored subcutaneous UFH is chosen.
Initial dose: 333 units/Kg subcutaneously times one dose, followed by 250 units/Kg subcutaneously twice daily in addition to Baseline labs for heparin should be CBC with
warfarin for at least 5 days until the INR is greater than 2.0 for 24 hours. platelets, aPTT/PT, serum creatinine

Warfarin1 (Selected Vitamin K Antagonis) For Long-term Management

TREATMENT MONITORING
Overlap warfarin (2.5 5 mg PO) with induction therapy (LMWH, Factor Xa Inhibitor, or UFH-SC) beginning on Day 1 of INR Goal: 2-3
therapy Baseline CBC with platelet count, aPTT/PT,
Continue LMWH/Factor Xa Inhibitor subcutaneously until INR greater than or equal to 2 for two days, AND patient has liver function tests
received at least 4-5 days of induction therapy overlap Follow-up for PT/INR within 3-5 days, then
at least every month if not more frequently

Fondaparinux (Arixtra) (Factor Xa Inhibitor) Fondaparinux Dose Subcutaneously Daily

ACTUAL BODY FONDAPARNUX MONITORING
WEIGHT (Kg) If creatinine clearance is between 30 - 50 mL/minute: use with caution
DOSE
If creatinine clearance is less than 30 mL/minute: contraindicated
Less than 50 5 mg Requires baseline laboratory tests: CBC with Use fondaparinux with caution in patients with platelets less than 100,000/mm
3

50 100 7.5 mg platelets, aPTT/PT, serum creatinine

Greater than 100 10 mg

1
Use of warfarin in cancer patients has been shown to be less effective at preventing clot recurrence than LMWH.
Department of Clinical Effectiveness V5
Approved by The Executive Committee of the Medical Staff 06/30/2015
Copyright 2015 The University of Texas MD Anderson Cancer Center
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.
APPENDIX F: New Oral Anticoagulants (NOAC) (ATTENTION: Expert panels DO NOT RECOMMEND use of these drugs in patients with cancer.
A multidisciplinary consultation is strongly recommended with Benign Hematology, Cardiology, and/or General Internal Medicine). Each case needs to
be individually assessed prior to use of NOACs.
DABIGATRAN
DABIGATRAN DOSE MONITORING COMMENTS
After at least 5 days of induction therapy Routine monitoring of coagulation tests not required If creatinine clearance less than 30 mL/minute avoid use
(LMWH, Factor Xa Inhibitor, or UFH-SC), Baseline CBC with differential, renal function tests, Mild hepatic impairment no adjustment
begin dabigatran 150 mg PO twice daily after hepatic function tests, Anti-Factor Xa if clinically Moderate to severe hepatic impairment (Child Pugh class B or C)
last dose of Dalteparin, or indicated and available and patients with any hepatic disease associated with
12 hours after Enoxaparin, or coagulopathy avoid use
4 hours after UFH infusion is stopped Please be aware of drug interactions

RIVAROXABAN (Factor Xa Inhibitor)

RIVAROXABAN (Xarelto) DOSE
15 mg PO twice daily with food for 3 weeks
followed by 20 mg PO with food daily
MONITORING
Routine monitoring of coagulation tests not required
Baseline CBC with differential, renal function
tests, hepatic function tests, Anti-Factor Xa if
clinically indicated and available
COMMENTS
If creatinine clearance less than 30 mL/minute avoid use
Mild hepatic impairment no adjustment
Moderate to severe hepatic impairment (Child Pugh class B or C)
and patients with any hepatic disease associated with
coagulopathy avoid use
Please be aware of drug interactions

Note:
Reasons to avoid use of New Oral Anticoagulants (NOAC) in the cancer population:
Limited number of patients with cancer studied in NOAC clinical trials No reversal agents available
Lack of standardized testing for monitoring Complicated drug-drug interactions with chemotherapy agents

Appendix F Continued on Next Page

Department of Clinical Effectiveness V5

Approved by The Executive Committee of the Medical Staff 06/30/2015
Copyright 2015 The University of Texas MD Anderson Cancer Center
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

APPENDIX F: New Oral Anticoagulants (ATTENTION: Expert panels DO NOT RECOMMEND use of these drugs in patients with cancer. A
multidisciplinary consultation is strongly recommended with Benign Hematology, Cardiology, and/or General Internal Medicine). Each case needs to
be individually assessed prior to use of NOACs.
Reasons to avoid use of New Oral Anticoagulants (NOAC) in the cancer population:
Limited number of patients with cancer studied in NOAC clinical trials No reversal agents available
Lack of standardized testing for monitoring Complicated drug-drug interactions with chemotherapy agents

APIXABAN1 (Factor Xa Inhibitor)

APIXABAN1 DOSE MONITORING COMMENTS
Routine monitoring of coagulation If creatinine clearance less than 15 mL/minute avoid use
10 mg PO twice daily for 1 week followed
tests not required Mild hepatic impairment no adjustment
by 5 mg PO twice daily
Baseline CBC with differential,
Moderate to severe hepatic impairment (Child Pugh class B or C)
renal function tests, hepatic and patients with any hepatic disease associated with coagulopathy avoid use
function tests, Anti-Factor Xa if Please be aware of drug interactions
clinically indicated and available
EDOXABAN1 (Factor Xa Inhibitor)
EDOXABAN1 DOSE MONITORING COMMENTS

60 mg PO Daily started after at least 5 days
of treatment with a parenteral anticoagulant
If body weight less than or equal to 60 kg
dose reduce to 30 mg PO daily
Routine monitoring of coagulation
tests not required
Baseline CBC with differential,
renal function tests, hepatic
function tests, Anti-Factor Xa if
clinically indicated and available
If creatinine clearance less than 15 mL/minute avoid use
If creatinine clearance between 15-50mL/minute dose reduce to 30mg PO Daily
Hepatic Impairment Mild no adjustment required
Hepatic Impairment Moderate-Severe avoid use
If patient is on a concomitant P-glycoprotein inhibitors (quinidine, verapamil,
azithromycin, clarithromycin, erythromycin, itraconazole, and ketoconazole)
dose reduce to 30mg PO daily

1
Apixaban and Edoxaban are currently not on the MD Anderson formulary.

Department of Clinical Effectiveness V5

Copyright 2015 The University of Texas MD Anderson Cancer Center Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

APPENDIX G: Thrombolytics

ALTEPLASE

TREATMENT LEVEL OF CARE C2 or C3 with transfer to C1 MONITORING

C1: Critical Care, Emergency Department, Operating Room Utilization of a portable cardiac monitor with a
Alteplase 100 mg IV over 2 hours
C2: Monitored Intermediate Care physician/designee at bedside
C3: Acute Care Unit Neurologic exam to rule out intracranial bleeding
Vital signs per routine, based on level of care
HOLD ANTICOAGULATION while receiving
alteplase treatment

Department of Clinical Effectiveness V5

Copyright 2015 The University of Texas MD Anderson Cancer Center
Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

SUGGESTED READINGS
EINSTEIN Investigators, Bauersachs R, Berkowitz SD, et al. (2010). Oral rivaroxaban for symptomatic venous thromboembolism. N Engl J Med.; 363:24992510.
EINSTEINPE Investigators, Bller HR, Prins MH, et al. (2012). Oral rivaroxaban for the treatment of symptomatic pulmonary embolism. N Engl J Med.; 366:12871297.
Cohen AT, Spiro TE, Bller HR, et al; MAGELLAN Investigators. (2013). Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med.; 368: 513523.
Jaff, M., McMurty, S., Archer, S.L., et al. (2011). Management of massive and submassive pulmonary embolism, illiofemoral deep vein thrombosis, and chronic thromboembolic pulmonary
hypertension: A scientific statement from the American Heart Association. Circulation, 123, 1788-1830.
Khorana, A.A., Streiff, M.B., Farge, D., et al. (2009). Venous thromboembolism prophylaxis and treatment in cancer: a consensus statement of major guidelines panels and call to action. Journal
of Clinical Oncology, 2009 Oct 10, 27(29), 4919-26. Epub 2009 Aug 31.
Lee, AY. (2009). Anticoagulation in the treatment of established venous thromboembolism in patients with cancer. Journal of Clinical Oncology, 2009 Oct 10;27(29), 4895-901. Epub 2009 Sep
8. Review
Lee, AY, (2012). Treatment of established thrombotic events in patients with cancer. Thrombosis Research, 129 suppl, S146-S453.
Lee, AY, et al. (2003). CLOT Trial: fragmin study in cancer patients. New England Journal of Medicine, 349, 146-53.
Lee, AY. (2014) Prevention and treatment of venous thromboembolism in patients with cancer. Hematology. 2014(1) 312-317
Levine MN, Gu C, Liebman HA, et al. (2012). A randomized phase II trial of apixaban for the prevention of thromboembolism in patients with metastatic cancer. J Thromb Haemost.; 10:807814.
Lyman, G.H., Khorana, A.A., Falanga, A., et al. (2007). American Society of Clinical Oncology guideline: recommendations for venous thromboembolism prophylaxis and treatment in patients
with cancer. Journal of Clinical Oncology, (34), 5490-505. Epub 2007 Oct 29. Review.
Lyman, G.H., Khorana, A.A., Falanga, A., et al. (2013). Venous thromboembolism prophylaxis and treatment in patients with cancer; American Society of Clinical Oncololgy Practice Guideline
Update. Journal of Clinical Oncology, (31), 2189-2204.
Merli, G., Spiro, T.E., Olsson, C., et al. (2001). Subcutaneous enoxaparin once or twice daily compared with intravenous unfractionated heparin for treatment of VTE. Annals of Internal Medicine,
134, 191-202.
The NCCN Clinical Practice Guidelines in Oncology Venous Thromboembolic Disease (Version V.2.2014). 2014 National Comprehensive Cancer Network, Inc. Retrieved from NCCN.org.
Accessed [January 06, 2014].
Schulman S, Kearon C, Kakkar AK, et al. (2009). RE-COVER Study Group. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med.; 361:23422352.
Schulman S, Kearon C, Kakkar AK, et al. (2013). RE-MEDY Trial Investigators; RE-SONATE Trial Investigators. Extended use of dabigatran, warfarin, or placebo in venous thromboembolism.
N Engl J Med.; 368:709718.
Streiff, M.B. (2009). Diagnosis and initial treatment of venous thromboembolism in patients with cancer. Journal of Clinical Oncology, 27(29), 4889-94. Epub 2009 Sep 8. Review.
Department of Clinical Effectiveness V5
Copyright 2015 The University of Texas MD Anderson Cancer Center Approved by The Executive Committee of the Medical Staff 06/30/2015
 This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into consideration circumstances particular to MD Anderson,
including the following: MD Andersons specific patient population; MD Andersons services and structure; and MD Andersons clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers. This algorithm should not be used to treat pregnant or lactating women.

DEVELOPMENT CREDITS

This practice consensus algorithm is based on majority expert opinion of the VTE workgroup consisting of Faculty at the University of Texas MD Anderson
Cancer Center. It was developed using a multidisciplinary approach that included input from the faculty and staff. The core team included:

Jean-Bernard Durand, MD
Carmen Escalante, MD
Josiah Halm, MD
Steven Y. Huang, MD
Tam Thi Thanh Huynh, MD
Michael Kroll, MD
Tara Lech, PharmD, RPh
Deborah McCue, PharmD
Joseph L. Nates, MD
Cristhiam Rojas Hernandez, MD
Katy M. Toale, PharmD
S. Wamique Yusuf, MD
Ali Zalpour, PhramD

Department of Clinical Effectiveness V5

Approved by The Executive Committee of the Medical Staff 06/30/2015
Copyright 2015 The University of Texas MD Anderson Cancer Center