Choice of thromboprophylaxis in patients with multiple myeloma

Our preferred thromboprophylaxis for patients receiving induction therapy for multiple myeloma depends on:

The baseline risk of VTE associated with a given regimen
The presence or absence of additional risk factors for thromboembolism, and
The risk of bleeding complications from VTE prophylaxis

Those already on therapeutic anticoagulation for another indication (eg, atrial fibrillation) should continue their prior anticoagulation. We reassess VTE risk, bleeding risk, and prophylaxis choice periodically. Patients may shift from one group to another if complications arise or treatment is de-escalated.

For those receiving an immunomodulatory drug as a single agent for maintenance therapy, including those post autologous transplantation, we suggest low dose aspirin prophylaxis (ie, 81 to 325 mg daily) rather than no prophylaxis or the use of other agents.

MM: multiple myeloma; VTE: venous thromboembolism; INR: international normalized ratio.

* If the IMPEDE VTE score is used for clinical VTE risk assessment, we propose using a cutoff of ≥8 points to designate high VTE risk. This cutoff predicts a VTE risk that is similar to that with a SAVED score of ≥2 points, and more clearly identifies patients who need prophylaxis that is more intensive than aspirin alone. Some other experts use an IMPEDE VTE score ≥4 points to designates high VTE risk.

¶ Clinical assessment of bleeding risk should take into account risk factors for bleeding such as bleeding history, platelet count, comorbidities (eg, coagulopathy), and need for indwelling catheters and/or interventional procedures.

Δ Choice of agent is individualized based on kidney function, concurrent medications, body weight, access, and patient preferences. Current or previous heparin-induced thrombocytopenia is a contraindication to LMWH.

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Choice of thromboprophylaxis in patients with multiple myeloma