Direct oral anticoagulants versus low-molecular-weight heparin for venous thromboembolism in primary brain tumors: A TriNetX real-world analysis.

2054 Background: Venous thromboembolism (VTE) is a common complication in patients with primary brain tumors and is associated with poor outcomes. Although therapeutic anticoagulation is required for VTE treatment, its use in this population is challenging because of the increased risk of intracranial hemorrhage (ICH). Optimal anticoagulant selection remains uncertain, as concerns regarding ICH have limited randomized trial data in patients with primary brain tumors. Therefore, comparing ICH risk between direct oral anticoagulants (DOACs) and low-molecular-weight heparin (LMWH) is critical to optimizing anticoagulation in this high-risk group. Methods: This retrospective cohort study used the TriNetX Global Collaborative Network to identify adults (≥18 years) with primary malignant brain tumors who developed VTE within one year of tumor diagnosis. Patients with secondary malignant neoplasms were excluded. Cohorts included patients treated with DOACs (apixaban, rivaroxaban, edoxaban, or dabigatran) or LMWH (enoxaparin, dalteparin, or tinzaparin) after VTE diagnosis. The index date was defined by cohort entry criteria, and outcomes were assessed over 180 days. 1:1 propensity score matching was performed across demographic and clinical characteristics, including age, sex, race, cardiovascular disease, diabetes, kidney disease, coagulation disorders, obesity, and substance use. Intracranial hemorrhage and all-cause mortality were evaluated using risk estimates and Kaplan-Meier survival analyses. Results: After propensity score matching, 6,114 patients were included in each cohort. DOAC therapy was associated with a significantly lower risk of intracranial hemorrhage compared with LMWH over 180 days (3.9% vs 7.3%; risk ratio, 0.54; 95% CI, 0.46–0.64; p<0.001). In addition, all-cause mortality at 180 days was significantly lower in the DOAC cohort than in the LMWH cohort (24.8% vs 31.3%; risk ratio, 0.79; 95% CI, 0.75–0.84; p<0.001). These findings were consistent across the matched population, demonstrating improved safety and survival outcomes associated with DOAC use in patients with primary malignant brain tumors and VTE. Conclusions: In this large real-world cohort of adults with primary brain malignancy and VTE, DOAC treatment was associated with a lower intracranial hemorrhage risk and reduced mortality at 180 days compared with LMWH after propensity score matching. These findings support the safety of DOACs in patients with primary brain tumors and warrant further prospective evaluation of anticoagulant selection in this high-risk population.