USA: The Hemostasis and Malignancy Subcommittee of the International Society on Thrombosis and Haemostasis (ISTH) has issued guidance on peri-procedure management of antithrombotic agents and thrombocytopenia around the time of common procedures in cancer patients.
Cancer patients are at an increased thrombosis risk requiring antiplatelet agents and/or anticoagulants, and they can also get thrombocytopenia due to cancer therapies or cancer itself. They undergo many procedures such as placement of central access lines, tissue or bone marrow biopsies, lumbar puncture, diagnostic or therapeutic draining procedures, and more. Management of thrombocytopenia or antithrombotic agents around the time of these procedures is highly variable.

The guidance, published in the Journal of Thrombosis and Haemostasis, aims to provide useful practice guidance in the management of antithrombotic agents and thrombocytopenia around the time of common procedures in patients with cancer.
Based on the literature review and expert opinions, the panel proposes the below guidance statements:
Guidance for antithrombotic agents
It is recommended that clinicians be aware of the presence of anticoagulants and/or antiplatelet agents prior to any procedures and obtain results of appropriate blood work if required.
An assessment for risk and benefit ratio is recommended prior to each procedure
In patients with low risk of thrombosis, the authors suggest withholding anticoagulation and/or antiplatelet agents prior to procedures.
In all other patients (no to low risk of thrombosis), the authors recommend evaluating the bleeding risks of procedures as below
The following management us suggested for procedures considered as low risk of bleeding: core biopsy (not deep tissue/organ), FNA, bone marrow biopsy, diagnostic or therapeutic draining procedures, or central line insertion (at compressible sites):
ASA can be continued if monotherapy.
For other antiplatelet agents and/or anticoagulation, there are limited data to guide practice, but it is generally considered safe to continue monotherapy.
Other precautions can be taken to reduce the bleeding risk when AT agents are continued, such as ensuring INR <3 when warfarin is continued, delay morning dose of DOAC until after procedure.
Interruption of respective anticoagulants or antiplatelet agents (except for ASA) is suggested for procedures considered as moderate risk of bleeding: biopsy of deep tissue/organ, placement of an implantable port, a central venous catheter in a non-compressible site or a tunneled catheter, and/or large-bore drains.
In patients with suspected or known MPN undergoing bone marrow biopsy, particularly in the setting of extreme thrombocytosis (>1000 x 109/L), evaluation for acquired von Willebrand disease is suggested and, if present, steps to minimize hemorrhage risk.
For procedures associated with high risk of morbidity from bleeding events such as neuraxial procedures, withholding anticoagulation, and antiplatelet agents is suggested.
The following duration of interruption is suggested when anticoagulation or antiplatelet agents are held
Warfarin: 5 days
LMWH: 24 h in patients with normal kidney function
DOACs: 2 days before a high-bleed-risk and 1 day before a low/moderate-bleed-risk (4 days if taking dabigatran and CrCl <50 ml/min) procedure
In patients with CrCl <30 ml/min, longer interruption time will be needed for LMWH and DOACs
ASA and clopidogrel: 5–7 days; prasugrel: 7–10 days; ticagrelor (reversible P2Y12 inhibitor): 3–5 days
For combined antiplatelet and anticoagulation therapies, the authors suggest limiting exposure to a single antithrombotic agent whenever possible peri-operatively, as combined therapies exacerbate risks of hemorrhage with surgical procedures.
Guidance for thrombocytopenia
For lower bleeding risk procedures (such as FNA or insertion of central lines in compressible areas), a platelet count ≥20 x 109/L is suggested.
For bone marrow biopsy, a specific target platelet threshold is not suggested.
For procedures associated with higher risk of bleeding, including biopsies of deep tissues/organs such as percutaneous liver, kidney, transbronchial biopsies, insertion of tunneled catheters and implantable ports or to non-compressible access sites, or neuraxial procedures, the authors suggest a goal platelet count of ≥50 x 109/L, if feasible.
The authors acknowledge the limited data supporting firm guidance on the management of antiplatelet agents, anticoagulation, and thrombocytopenia before invasive procedures in patients with cancer. Considering that these issues arise on a daily basis, the guidance statements by ISTH SSC provide a framework for clinical decision-making.
"The statements should not be considered absolute, and adjustments should be made after taking into consideration patient factors, preferences, and logical constraints," the authors wrote. "We identified critical knowledge gaps in the optimal peri-procedure management in patients with cancer on anticoagulants, especially DOACs, and antiplatelet agents other than ASA. There is a desperate need for more high-quality studies in this area to provide better practice guidance."
Reference:
Wang TF, Sanfilippo KM, Douketis J, Falanga A, Karageorgiou J, Maraveyas A, Ortel TL, Soff G, Vedantham S, Zwicker JI. Peri-procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH. J Thromb Haemost. 2022 Sep 26. doi: 10.1111/jth.15896. Epub ahead of print. PMID: 36217296.