1
|
Zou P, Zahir H, Duggal A, Pandya G, Jin J, Leil TA. Pharmacokinetics, Pharmacodynamics, and Safety of Edoxaban in Pediatric Subjects: A Phase I Single-Dose Study. Clin Pharmacol Ther 2024. [PMID: 38369608 DOI: 10.1002/cpt.3196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/14/2024] [Indexed: 02/20/2024]
Abstract
This was an open-label, single-dose, phase I study to characterize the pharmacokinetics (PKs), pharmacodynamics (PDs), and safety of edoxaban in pediatric subjects from birth to 18 years at risk for venous thromboembolism (VTE). Children requiring anticoagulant therapy were enrolled into 5 age cohorts (0 to < 6 months (N = 12), 0.5 to < 2 years (N = 13), 2 to < 6 years (N = 13), 6 to < 12 years (N = 13), and 12 to < 18 years (N = 15)) receiving tablet or oral suspension of edoxaban at doses expected to be equivalent to 30 or 60 mg once daily (q.d.) in adult subjects with VTE. Sixty-six pediatric subjects were enrolled and completed the study. Edoxaban plasma concentration peaked between 1 and 3 hours and declined rapidly until 4-8 hours. The range of mean total apparent clearance across 5 age cohorts at low and high doses was 0.47 to 1.11 L/h/kg. The ranges of mean volume of central compartment and apparent peripheral volume were 2.31 to 3.59 L/kg and 1.92 to 4.14 L/kg, respectively. Across all age groups, the estimated median exposures were within the 0.5- to 1.5-fold of the median area under the plasma drug concentration-time curve (AUC) in adult subjects receiving corresponding doses (30 mg q.d. for low dose and 60 mg q.d. for high dose). In all age groups, PD parameters (prothrombin time, activated partial thromboplastin time, and anti-Factor Xa activity) showed a linear PK-PD relationship and were in line with previous adult data. The results support further evaluation of the pediatric doses in larger pivotal trials.
Collapse
Affiliation(s)
- Peng Zou
- Daiichi Sankyo Inc., Basking Ridge, New Jersey, USA
| | | | - Anil Duggal
- Daiichi Sankyo Inc., Basking Ridge, New Jersey, USA
| | | | - James Jin
- Daiichi Sankyo Inc., Basking Ridge, New Jersey, USA
| | - Tarek A Leil
- Daiichi Sankyo Inc., Basking Ridge, New Jersey, USA
| |
Collapse
|
2
|
Salem AM, Smith T, Wilkes J, Bailly DK, Heyrend C, Profsky M, Yellepeddi VK, Gopalakrishnan M. Pharmacokinetic Modeling Using Real-World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement-Clinical Outcomes Relationship. J Clin Pharmacol 2024; 64:30-44. [PMID: 37565528 DOI: 10.1002/jcph.2333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
Unfractionated heparin (UFH) is a commonly used anticoagulant for pediatric patients undergoing extracorporeal membrane oxygenation (ECMO), but evidence is lacking on the ideal dosing. We aimed to (1) develop a population pharmacokinetic (PK) model for UFH, measured through anti-factor Xa assay; (2) optimize UFH starting infusions and dose titrations through simulations; and (3) explore UFH exposure-clinical outcomes relationship. Data from 218 patients admitted to Utah's Primary Children's Hospital were retrospectively collected. A 1-compartment PK model with time-varying clearance (CL) adequately described UFH PK. Weight on CL and volume of distribution and ECMO circuit change on CL were significant covariates. The typical estimates for initial CL and first-order rate constant to reach steady-state CL were 0.57 L/(h·10 kg) and 0.02/h. Comparable to non-ECMO patients, the typical steady-state CL was 0.81 L/(h·10 kg). Simulations showed that a 75 IU/kg UFH bolus dose followed by starting infusions of 25 and 20 IU/h/kg for patients aged younger than 6 years and 6 years or older, respectively, achieved the therapeutic target in 56.6% of all patients, whereas only 3.1% exceeded the target. The proposed UFH titration schemes achieved the target in more than 90% of patients while less than 0.63% were above the target after 24 and 48 hours of treatment. The median intensive care unit survival time in patients within and below the target at 24 hours was 136 and 66 hours, respectively. In conclusion, PK model of UFH was developed for pediatric patients on ECMO. The proposed UFH dosing scheme attained the anti-factor Xa target rapidly and safely.
Collapse
Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Trey Smith
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Pediatric Analytics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - David K Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Caroline Heyrend
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Michael Profsky
- Mechanical Circulatory Support, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Venkata K Yellepeddi
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
| |
Collapse
|
3
|
Visser C, Yousefi A, Nierman MC, Huisman MV, Gulpen AJW, van Ommen CH, Kruip MJHA. The effect of COVID-19 vaccination on anticoagulation stability in adolescents and young adults using vitamin K antagonists. Thromb Res 2023; 228:121-127. [PMID: 37321159 PMCID: PMC10258126 DOI: 10.1016/j.thromres.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/21/2023] [Accepted: 06/05/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION The European Medicine Agency has authorized COVID-19 vaccination in adolescents and young adults (AYAs) from 12 years onwards. In elderly vitamin K antagonist (VKA) users, COVID-19 vaccination has been associated with an increased risk of supra- and subtherapeutic INRs. Whether this association is also observed in AYAs using VKA is unknown. Our aim was to describe the stability of anticoagulation after COVID-19 vaccination in AYA VKA users. MATERIALS AND METHODS A case-crossover study was performed in a cohort of AYAs (12-30 years) using VKAs. The most recent INR results before vaccination, the reference period, were compared with the most recent INR after the first and, if applicable, second vaccination. Several sensitivity analyses were performed in which we restricted our analysis to stable patients and patients without interacting events. RESULTS 101 AYAs were included, with a median age [IQR] of 25 [7] years, of whom 51.5 % were male and 68.3 % used acenocoumarol. We observed a decrease of 20.8 % in INRs within range after the first vaccination, due to an increase of 16.8 % in supratherapeutic INRs. These results were verified in our sensitivity analyses. No differences were observed after the second vaccination compared to before and after the first vaccination. Complications after vaccination occurred less often than before vaccination (9.0 vs 3.0 bleedings) and were non-severe. CONCLUSIONS the stability of anticoagulation after COVID-19 vaccination was decreased in AYA VKA users. However, the decrease might not be clinically relevant as no increase of complications nor significant dose adjustments were observed.
Collapse
Affiliation(s)
- Chantal Visser
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Arjen Yousefi
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Melchior C Nierman
- Department of Thrombosis and Anticoagulation, Atalmedial Medical Diagnostics Centers, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Anouk J W Gulpen
- Department of Internal Medicine, The Elkerliek Hospital, Helmond, the Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Marieke J H A Kruip
- Department of Hematology, Erasmus MC, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands; Thrombosis Service Star-shl, Rotterdam, the Netherlands.
| |
Collapse
|
4
|
Direct oral anticoagulants versus standard anticoagulation in children treated for acute venous thromboembolism. Pediatr Res 2022; 93:1491-1498. [PMID: 36071237 DOI: 10.1038/s41390-022-02294-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/07/2022] [Accepted: 08/18/2022] [Indexed: 11/09/2022]
Abstract
Direct oral anticoagulants (DOACs) are widely used to treat venous thromboembolism (VTE) in adults. Little attention is given to pediatric VTE (PVTE). The objective of this study is to study the efficacy and safety of DOACs in published PVTE randomized control trials (RCTs). PubMed, Embase, China National Knowledge Infrastructure, the Cochrane Library, SinoMed, and ClinicalTrials.gov were searched until 2021, to identify RCTs that enrolled patients with VTE <18 years of age who received DOACs versus standard anticoagulation. Outcomes were evaluated using the Mantel-Haenszel method of random-effects model. Our study evaluated seven RCTs that included 1139 cases of PVTE, which had a low risk of publication and assessment bias. Compared with standard anticoagulation, patients receiving DOACs presented a lower rate of recurrent VTE (relative risk [RR], 0.42 [confidence interval {CI}, 0.20 to 0.89]), similar mortality rate (RR, 0.50 [CI, 0.07 to 3.57]), major bleeding (RR, 0.46 [CI, 0.14 to 1.57]), and higher clinically relevant nonmajor bleeding (RR, 2.71 [CI, 1.05 to 7.02]) with low heterogeneity. Limiting to subgroups, dabigatran and rivaroxaban yielded similar findings, except for a higher incidence of nonmajor bleeding during rivaroxaban use. DOACs could be an alternative to standard anticoagulation in PVTE. Dabigatran and rivaroxaban have similar effects. IMPACT: In venous thromboembolism (VTE), direct oral anticoagulants (DOACs) are widely used as a substitution for standard anticoagulation in most situations for adults; however, little attention is paid to the pediatric population. For pediatric VTE, previous meta-analyses have emphasized the epidemiology, risk factors, and the use of traditional anticoagulants, and seldom reported the use of novel oral anticoagulants. This is the first meta-analysis of randomized controlled trials that focuses on the efficacy outcomes and safety endpoints of DOACs compared with standard anticoagulation in pediatric VTE.
Collapse
|
5
|
Halimeh S, Male C, Nowak-Goettl U. New Anticoagulants in Neonates, Children, and Adolescents. Hamostaseologie 2022; 42:123-130. [PMID: 35488165 DOI: 10.1055/a-1740-7080] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Thrombotic events are an increasing challenge in pediatrics. Standard-of-care anticoagulants for pediatric thrombosis have several disadvantages which could be overcome by using direct oral anticoagulants (DOACs). Until recently, there was not enough evidence from clinical trials to recommend for or against the use of any of the four DOACs in children with thrombosis. In this literature review, we looked at the latest clinical trials in this field. On clinicaltrials.gov, we found 13 current studies with published results. For two of the four DOACs, namely dabigatran and rivaroxaban, we found successful phase III studies which led to the approval for the use in children. The results of these pivotal phase III studies allow to finally recommend rivaroxaban and dabigatran for the prophylaxis and treatment of thrombotic events in children.
Collapse
Affiliation(s)
- Susan Halimeh
- Gerinnungszentrum Rhein Ruhr, Duisburg, North Rhine-Westphalia, Germany
| | - Christoph Male
- Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Wien, Austria
| | | |
Collapse
|
6
|
Male C. Anticoagulation in Pediatric Patients. Hamostaseologie 2022; 42:46-53. [PMID: 35042258 DOI: 10.1055/a-1703-0821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Special aspects of anticoagulation in children include the different epidemiology of thrombosis, developmental changes in the coagulation system, age-dependent pharmacokinetics of anticoagulants, risk of bleeding, and practical hurdles to anticoagulation. The classical anticoagulants so far used in children have several limitations, resulting in the need for regular monitoring. The pharmacological properties of direct oral anticoagulants (DOACs) and the special challenges of anticoagulation in children make the DOACs particularly attractive for children. All DOACs have pediatric development programs, targeting various indications for prevention and treatment of thrombosis. Child-appropriate formulations have been developed, age-specific dosing information generated, and safety and efficacy evaluated in ongoing phase 3 trials. Rivaroxaban and dabigatran have already been authorized for children for treatment of acute venous thrombosis and for extended secondary prevention. Their safety and efficacy have been demonstrated comparable to that of standard-of-care anticoagulants, without need for monitoring. Further studies are ongoing, which are expected to lead to pediatric authorizations of DOACs for primary venous thromboembolic event prevention in some high-risk settings. More real-life data will be necessary from postmarketing studies and registries to complement the evidence base for DOAC use in children, particularly in the youngest age groups and special disease populations.
Collapse
Affiliation(s)
- Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
7
|
Prospective Exploratory Experience With Bivalirudin Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:975-985. [PMID: 32976347 DOI: 10.1097/pcc.0000000000002527] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Objective of this study was to determine if bivalirudin resulted in less circuit interventions than unfractionated heparin. A secondary objective was to examine associations between bivalirudin dose and partial thromboplastin time, international normalized ratio, and activated clotting time. DESIGN Prospective observational. SETTING Medical-surgical and cardiac PICUs. PATIENTS Neonatal and pediatric extracorporeal membrane oxygenation patients who received bivalirudin anticoagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty extracorporeal membrane oxygenation runs in 18 patients used bivalirudin; 90% were venoarterial. Median (interquartile range) age was 4.5 months (1.6-35 mo). Thirteen patients (72%) had an underlying cardiac diagnosis. Of the 20 runs using bivalirudin, 16 (80%) were initially started on unfractionated heparin and transitioned to bivalirudin due to ongoing circuit thrombosis despite therapeutic anti-Xa levels (n = 13), ongoing circuit thrombosis with unfractionated heparin greater than or equal to 40 U/kg/hr (n = 2), or absence of increase in ACT after bolus of 100 U/kg of unfractionated heparin and escalation of unfractionated heparin infusion (n = 1). Initial bivalirudin dose ranged from 0.2 to 0.5 mg/kg/hr; no bolus doses were used. Median (range) bivalirudin dose was 0.9 mg/kg/hr (0.15-1.6 mg/kg/hr). Median (interquartile range) time on extracorporeal membrane oxygenation was 226.5 hours (150.5-393.0 hr) including 84 hours (47-335 hr) on bivalirudin. Nonparametric results are as follows: the rate of circuit intervention was significantly lower in patients on bivalirudin than on unfractionated heparin (median [interquartile range]: 0 [0-1] and 1 [1-2], respectively; Wilcoxon p = 0.0126). Bivalirudin dose was correlated to PTT (rs = 0.4760; p < 0.0001), INR (rs = 0.6833; p < 0.0001), and ACT (rs = 0.6161; p < 0.0001). Four patients had a significant bleeding complication on bivalirudin. Survival to hospital discharge was 56%. CONCLUSIONS Bivalirudin appears to be a viable option for systemic anticoagulation in pediatric extracorporeal membrane oxygenation patients who have failed unfractionated heparin, but questions remain namely its optimal monitoring strategy. This pilot study supports the need for larger prospective studies of bivalirudin in pediatric extracorporeal membrane oxygenation, particularly focusing on meaningful monitoring variables.
Collapse
|
8
|
Snyder CW, Goldenberg NA, Nguyen ATH, Smithers CJ, Kays DW. A perioperative bivalirudin anticoagulation protocol for neonates with congenital diaphragmatic hernia on extracorporeal membrane oxygenation. Thromb Res 2020; 193:198-203. [DOI: 10.1016/j.thromres.2020.07.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 11/17/2022]
|
9
|
Abstract
Warfarin is the most commonly prescribed anticoagulant for children in the outpatient setting in Australia. Pediatric patients likely have different challenges to warfarin adherence compared with their adult counterparts; however, little is known about warfarin adherence among this population. This study aimed to understand warfarin adherence among community-based pediatric patients by using an online survey design. The survey instrument incorporated parent or patient self-reported warfarin doses missed in the preceding month, a validated warfarin adherence assessment tool, the 13-item Self-Efficacy for Appropriate Medication use Scale (SEAMS-13), and an open-ended question asking about the challenges of warfarin adherence. The indication of warfarin administration and patient's time in therapeutic range were obtained from medical records. The study recruited outpatients managed by a tertiary pediatric hospital who had previously consented to participate in warfarin research. In total, 53 families were contacted with 43 responses (81% response rate) and 41 completed surveys. The median age of the children from participating families was 10.6 years (range, 4.1 to 18.9 y). The majority of these children (n=42) used warfarin prophylactically and only 1 child used it to treat deep venous thrombosis. The time in therapeutic range achievement of this cohort was 64.4% (95% confidence interval, 58.7-70.2). The mean SEAMS-13 score was 33.5 (95% confidence interval, 31.75-35.37) and the total missed doses was 2.5%. Participants also identified barriers and enablers of warfarin adherence. This study was the first of its kind and thus it provides baseline data for future research. The warfarin adherence of this cohort was likely optimized because of frequent clinical contact and access to self-testing. Future studies are required to examine the different approaches aiming to improve the anticoagulant adherence after the emergence of direct oral anticoagulants with a wider therapeutic index and minimal monitoring that could contribute to less clinical contact.
Collapse
|
10
|
Jaffray J, Goldenberg N. Current approaches in the treatment of catheter-related deep venous thrombosis in children. Expert Rev Hematol 2020; 13:607-617. [DOI: 10.1080/17474086.2020.1756260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Julie Jaffray
- Department of Pediatrics, Division of Hematology/Oncology, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Neil Goldenberg
- Departments of Pediatrics and Medicine, Divisions of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins All Children’s Cancer and Blood Disorders Institute, St. Petersburg, FL, USA
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, St. Petersburg, FL, USA
| |
Collapse
|
11
|
Goswami D, DiGiusto M, Wadia R, Barnes S, Schwartz J, Steppan D, Nelson-McMillan K, Ringel R, Steppan J. The Use of Bivalirudin in Pediatric Cardiac Surgery and in the Interventional Cardiology Suite. J Cardiothorac Vasc Anesth 2020; 34:2215-2223. [PMID: 32127273 DOI: 10.1053/j.jvca.2020.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 01/07/2020] [Accepted: 01/10/2020] [Indexed: 01/19/2023]
Abstract
Anticoagulation is an essential component for patients undergoing cardiopulmonary bypass or extracorporeal membrane oxygenation and for those with ventricular assist devices. However, thrombosis and bleeding are common complications. Heparin continues to be the agent of choice for most patients, likely owing to practitioners' comfort and experience and the ease with which the drug's effects can be reversed. However, especially in pediatric cardiac surgery, there is increasing interest in using bivalirudin as the primary anticoagulant. This drug circumvents certain problems with heparin administration, such as heparin resistance and heparin-induced thrombocytopenia, but it comes with additional challenges. In this manuscript, the authors review the literature on the emerging role of bivalirudin in pediatric cardiac surgery, including its use with cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, ventricular assist devices, and interventional cardiology. Moreover, they provide an overview of bivalirudin's pharmacodynamics and monitoring methods.
Collapse
Affiliation(s)
- Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Matthew DiGiusto
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD; Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Rajeev Wadia
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Sean Barnes
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Jamie Schwartz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Diana Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Kristen Nelson-McMillan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD; Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Richard Ringel
- Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD.
| |
Collapse
|
12
|
Derebail VK, Rheault MN, Kerlin BA. Role of direct oral anticoagulants in patients with kidney disease. Kidney Int 2019; 97:664-675. [PMID: 32107019 DOI: 10.1016/j.kint.2019.11.027] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/01/2019] [Accepted: 11/15/2019] [Indexed: 12/13/2022]
Abstract
The anticoagulation field is experiencing a renaissance that began with regulatory approval of the direct thrombin inhibitor dabigatran, a direct oral anticoagulant (DOAC), in 2010. The DOAC medication class has rapidly evolved to include the additional approval of 4 direct factor Xa inhibitors. Commensurately, DOAC use has increased and collectively account for the majority of new anticoagulant prescriptions. Despite exclusion of patients with moderate-to-severe kidney disease from most pivotal DOAC trials, DOACs are increasingly used in this setting. An advantage of DOACs is similar or improved antithrombotic efficacy with less bleeding risk when compared with traditional agents. Several post hoc analyses, retrospective studies, claims data studies, and meta-analyses suggest that these benefits extend to patients with kidney disease. However, the lack of randomized controlled trial data in specific kidney disease settings, with their unique pathophysiology, should be a call to action for the kidney community to systematically study these agents, especially because early data suggest that DOACs may pose less risk of anticoagulant-related nephropathy than do vitamin K antagonists. Most DOACs are renally cleared and are significantly protein bound in circulation; thus, the pharmacokinetics of these drugs are influenced by reduced renal function and proteinuria. DOACs are susceptible to altered metabolism by P-glycoprotein inhibitors and inducers, including drugs commonly used for the management of kidney disease comorbidities. We summarize the currently available literature on DOAC use in kidney disease and illustrate knowledge gaps that represent important opportunities for prospective investigation.
Collapse
Affiliation(s)
- Vimal K Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA.
| | - Bryce A Kerlin
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's, Columbus, Ohio, USA; Division of Hematology/Oncology/Blood & Marrow Transplantation, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| |
Collapse
|
13
|
Monagle P, Lensing AWA, Thelen K, Martinelli I, Male C, Santamaría A, Samochatova E, Kumar R, Holzhauer S, Saracco P, Simioni P, Robertson J, Grangl G, Halton J, Connor P, Young G, Molinari AC, Nowak-Göttl U, Kenet G, Kapsa S, Willmann S, Pap AF, Becka M, Twomey T, Beyer-Westendorf J, Prins MH, Kubitza D. Bodyweight-adjusted rivaroxaban for children with venous thromboembolism (EINSTEIN-Jr): results from three multicentre, single-arm, phase 2 studies. LANCET HAEMATOLOGY 2019; 6:e500-e509. [PMID: 31420317 DOI: 10.1016/s2352-3026(19)30161-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/10/2019] [Accepted: 06/13/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Rivaroxaban has been shown to be efficacious for treatment of venous thromboembolism in adults, and has a reduced risk of bleeding compared with standard anticoagulants. We aimed to develop paediatric rivaroxaban regimens for the treatment of venous thromboembolism in children and adolescents. METHODS In this phase 2 programme, we did three studies to evaluate rivaroxaban treatment in children younger than 6 months, aged 6 months to 5 years, and aged 6-17 years. Our studies used a multicentre, single-arm design at 54 sites in Australia, Europe, Israel, Japan, and north America. We included children with objectively confirmed venous thromboembolism previously treated with low-molecular weight heparin, fondaparinux, or a vitamin K antagonist for at least 2 months or, in children who had catheter-related venous thromboembolism for at least 6 weeks. We administered rivaroxaban orally in a bodyweight-adjusted 20 mg-equivalent dose, based on physiologically-based pharmacokinetic modelling predictions and EINSTEIN-Jr phase 1 data in young adults, in either a once-daily (tablets; for those aged 6-17 years), twice-daily (in suspension; for those aged 6 months to 11 years), or three times-daily (in suspension; for those younger than 6 months) dosing regimen for 30 days (or 7 days for those younger than 6 months). The primary aim was to define rivaroxaban treatment regimens that match the target adult exposure range. The principal safety outcome was major bleeding and clinically relevant non-major bleeding. Analyses were per-protocol. The predefined efficacy outcomes were symptomatic recurrent venous thromboembolism, asymptomatic deterioration on repeat imaging at the end of the study treatment period. These trials are registered at ClinicalTrials.gov, numbers NCT02564718, NCT02309411, and NCT02234843. FINDINGS Between Feb 11, 2013, and Dec 20, 2017, we enrolled 93 children (ten children younger than 6 months; 15 children aged 6 months to 1 year; 25 children aged 2-5 years; 32 children aged 6-11 years; and 11 children aged 12-17 years) into our study. 89 (96%) children completed study treatment (30 days of treatment, or 7 days in those younger than 6 months), and 93 (100%) children received at least one dose of study treatment and were evaluable for the primary endpoints. None of the children had a major bleed, and four (4%, 95% CI 1·2-10·6) of these children had a clinically relevant non-major bleed (three children aged 12-17 years with menorrhagia and one child aged 6-11 years with gingival bleeding). We found no symptomatic recurrent venous thromboembolism in any patients (0%, 0·0-3·9). 24 (32%) of 75 patients with repeat imaging had their thrombotic burden resolved, 43 (57%) patients improved, and eight (11%) patients were unchanged. No patient deteriorated. We confirmed therapeutic rivaroxaban exposures with once-daily dosing in children with bodyweights of at least 30 kg and with twice-daily dosing in children with bodyweights of at least 20 kg and less than 30 kg. Children with low bodyweights (<20 kg, particularly <12 kg) showed low exposures so, for future studies, rivaroxaban dosages were revised for these weight categories, to match the target adult exposure range. 61 (66%) of 93 children had adverse events during the study. Pyrexia was the most common adverse event (ten [11%] events), and anaemia and neutropenia or febrile neutropenia were the most frequent grade 3 or worse events (four [4%] events each). No children died or were discontinued from rivaroxaban because of adverse events. INTERPRETATION Treatment with bodyweight-adjusted rivaroxaban appears to be safe in children. The treatment regimens that we confirmed in children with bodyweights of at least 20 kg and the revised treatment regimens that we predicted in those with bodyweights less than 20 kg will be evaluated in the EINSTEIN-Jr phase 3 trial in children with acute venous thromboembolism. FUNDING Bayer AG, Janssen Research and Development.
Collapse
Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children's Hospital, Haematology Research Murdoch Children's Research Institute, and Department of Paediatrics, University of Melbourne, VIC, Australia
| | | | | | - Ida Martinelli
- Angelo Bianchi Bonomi Haemophilia and Thrombosis Centre, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Amparo Santamaría
- Department of Thrombosis and Haemostasis, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Elena Samochatova
- Federal Research and Clinical Centre of Paediatric Haematology, Oncology and Immunology, Moscow, Russia
| | - Riten Kumar
- Division of Pediatric Hematology and Oncology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Susanne Holzhauer
- Department of Paediatric Haematology and Oncology, Charité-Universitätsmedizin, Berlin, Germany
| | - Paola Saracco
- Department of Paediatrics, Haematology Unit, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza Torino, Turin, Italy
| | - Paolo Simioni
- Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, Padova, Italy
| | - Jeremy Robertson
- Haematology Service, Division of Medicine, Queensland Children's Hospital, South Brisbane, QLD, Australia
| | - Gernot Grangl
- Department of Paediatrics and Adolescence Medicine, Division of Paediatric Cardiology, Medical University of Graz, Graz, Austria
| | - Jacqueline Halton
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Phillip Connor
- The Noah's Ark Children's Hospital for Wales, Cardiff, UK
| | - Guy Young
- Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Angelo C Molinari
- Thrombosis and Haemostasis Unit, Giannina Gaslini Children's Hospital, Genoa, Italy
| | - Ulrike Nowak-Göttl
- Thrombosis and Haemostasis Treatment Centre, Institute of Clinical Chemistry, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Israeli National Haemophilia Centre and Thrombosis Unit and The Amalia Biron Thrombosis Research Institute, Sheba Medical Centre, Tel Hashomer, Israel
| | | | | | | | | | | | - Jan Beyer-Westendorf
- Department of Medicine I, Division of Haematology and Haemostaseology, University Hospital Carl Gustav Carus, Dresden, Germany; King's Thrombosis Service, Department of Haematology, King's College London, London, UK
| | - Martin H Prins
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | | |
Collapse
|
14
|
Nair S, Oommen J, Chandrabose VT, Muhammed H, Kalathingal K, Sivadasan A, Joseph S, Pydi R, Shet S, Samantaray S. An unusual combination of complications in a pediatric burn patient with successful outcome. INDIAN JOURNAL OF BURNS 2019. [DOI: 10.4103/ijb.ijb_25_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
15
|
Male C, Thom K, O'Brien SH. Direct oral anticoagulants: What will be their role in children? Thromb Res 2019; 173:178-185. [DOI: 10.1016/j.thromres.2018.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 01/01/2023]
|
16
|
S. Aleidan F. Oral anticoagulants: Optimizing venous thromboembolism management. JOURNAL OF APPLIED HEMATOLOGY 2019. [DOI: 10.4103/joah.joah_47_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
17
|
Kubitza D, Willmann S, Becka M, Thelen K, Young G, Brandão LR, Monagle P, Male C, Chan A, Kennet G, Martinelli I, Saracco P, Lensing AWA. Exploratory evaluation of pharmacodynamics, pharmacokinetics and safety of rivaroxaban in children and adolescents: an EINSTEIN-Jr phase I study. Thromb J 2018; 16:31. [PMID: 30534007 PMCID: PMC6278122 DOI: 10.1186/s12959-018-0186-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 10/29/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The EINSTEIN-Jr program will evaluate rivaroxaban for the treatment of venous thromboembolism (VTE) in children, targeting exposures similar to the 20 mg once-daily dose for adults. METHODS This was a multinational, single-dose, open-label, phase I study to describe the pharmacodynamics (PD), pharmacokinetics (PK) and safety of a single bodyweight-adjusted rivaroxaban dose in children aged 0.5-18 years. Children who had completed treatment for a venous thromboembolic event were enrolled into four age groups (0.5-2 years, 2-6 years, 6-12 years and 12-18 years) receiving rivaroxaban doses equivalent to 10 mg or 20 mg (either as a tablet or oral suspension). Blood samples for PK and PD analyses were collected within specified time windows. RESULTS Fifty-nine children were evaluated. In all age groups, PD parameters (prothrombin time, activated partial thromboplastin time and anti-Factor Xa activity) showed a linear relationship versus rivaroxaban plasma concentrations and were in line with previously acquired adult data, as well as in vitro spiking experiments. The rivaroxaban pediatric physiologically based pharmacokinetic model, used to predict the doses for the individual body weight groups, was confirmed. No episodes of bleeding were reported, and treatment-emergent adverse events occurred in four children and all resolved during the study. CONCLUSIONS Bodyweight-adjusted, single-dose rivaroxaban had predictable PK/PD profiles in children across all age groups from 0.5 to 18 years. The PD assessments based on prothrombin time and activated partial thromboplastin time demonstrated that the anticoagulant effect of rivaroxaban was not affected by developmental hemostasis in children. TRIAL REGISTRATION ClinicalTrials.gov number, NCT01145859.
Collapse
Affiliation(s)
- Dagmar Kubitza
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Stefan Willmann
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Michael Becka
- Research and Clinical Sciences, Bayer AG, Wuppertal, Germany
| | - Kirstin Thelen
- Bayer AG, Global Drug Discovery – Clinical Sciences, Clinical Pharmacology Cardiovascular, Aprather Weg 18a, Gebäude 429, 42113 Wuppertal, Germany
| | - Guy Young
- Children’s Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA USA
| | - Leonardo R. Brandão
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Paul Monagle
- Department of Haematology Royal Children’s Hospital, Department of Paediatrics, University of Melbourne, Murdoch Children’s Research Institute, Melbourne, Australia
| | - Christoph Male
- Thrombosis & Haemostasis Unit, Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - Anthony Chan
- McMaster Children’s Hospital/Hamilton Health Sciences Foundation Pediatric Thrombosis and Hemostasis, Hamilton, Canada
| | - Gili Kennet
- National Hemophilia Center & Thrombosis Institute, Sheba Medical Center, Ramat Gan, Israel
| | - Ida Martinelli
- A.Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca’ Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Paola Saracco
- Pediatric Hematology, University Hospital Città della Salute e della Scienza, Torino, Italy
| | | |
Collapse
|
18
|
Lê BV, Jandrot-Perrus M, Couture C, Checkmahomed L, Venable MC, Hamelin MÈ, Boivin G. Evaluation of anticoagulant agents for the treatment of human metapneumovirus infection in mice. J Gen Virol 2018; 99:1367-1380. [PMID: 30102144 DOI: 10.1099/jgv.0.001135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Thrombin has been demonstrated to be involved in several viral diseases including human metapneumovirus (hMPV) infections. We previously showed that immediate administration of thrombin inhibitor argatroban post-infection protected mice against hMPV disease. This current work aims at determining whether warfarin and heparin, two other anticoagulants inhibiting thrombin formation and activities, may also be used for treatment against hMPV in vivo. We found that immediate injections of argatroban, warfarin or heparin after virus challenge protected mice against hMPV infection, as evidenced by decreased or no mortality, less weight loss, reduced viral load and attenuated inflammation. However, delayed treatments starting 1 day post-infection with argatroban or warfarin almost did not impact the survival whereas delayed treatment with heparin induced an increased mortality during infection. Moreover, these treatments also did not reduce weight loss, viral replication and inflammation. In agreement with these results, thrombin generation was decreased upon immediate anticoagulant treatments but was unaltered upon delayed treatments. Thus, thrombin generation occurs at the onset of hMPV infection and thrombin inhibition may be only useful for the treatment of this disease when initiated in the early stage. In this case, heparin is not recommended because of its reduced efficacy on mortality in infected mice whereas argatroban and warfarin appear as safe and effective drugs for the treatment of hMPV disease. The antiviral and anti-inflammatory effects of argatroban occur via thrombin-dependent pathways whereas the mechanisms by which warfarin exerts its beneficial effects against hMPV infection were not elucidated and need to be further studied.
Collapse
Affiliation(s)
- Ba Vuong Lê
- 1Infectious Disease Research Centre, Laval University, Quebec City, Quebec, Canada
| | | | - Christian Couture
- 3Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Liva Checkmahomed
- 1Infectious Disease Research Centre, Laval University, Quebec City, Quebec, Canada
| | | | - Marie-Ève Hamelin
- 1Infectious Disease Research Centre, Laval University, Quebec City, Quebec, Canada
| | - Guy Boivin
- 1Infectious Disease Research Centre, Laval University, Quebec City, Quebec, Canada
| |
Collapse
|
19
|
Jooste EH, Scholl R, Wu YH, Jaquiss RDB, Lodge AJ, Ames WA, Homi HM, Machovec KA, Greene NH, Donahue BS, Shah N, Benkwitz C. Double-Blind, Randomized, Placebo-Controlled Trial Comparing the Effects of Antithrombin Versus Placebo on the Coagulation System in Infants with Low Antithrombin Undergoing Congenital Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 33:396-402. [PMID: 30072263 DOI: 10.1053/j.jvca.2018.05.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To determine whether precardiopulmonary bypass (CPB) normalization of antithrombin levels in infants to 100% improves heparin sensitivity and anticoagulation during CPB and has beneficial effects into the postoperative period. DESIGN Randomized, double-blinded, placebo-controlled prospective study. SETTING Multicenter study performed in 2 academic hospitals. PARTICIPANTS The study comprised 40 infants younger than 7 months with preoperative antithrombin levels <70% undergoing CPB surgery. INTERVENTIONS Antithrombin levels were increased with exogenous antithrombin to 100% functional level intraoperatively before surgical incision. MEASUREMENTS AND MAIN RESULTS Demographics, clinical variables, and blood samples were collected up to postoperative day 4. Higher first post-heparin activated clotting times (sec) were observed in the antithrombin group despite similar initial heparin dosing. There was an increase in heparin sensitivity in the antithrombin group. There was significantly lower 24-hour chest tube output (mL/kg) in the antithrombin group and lower overall blood product unit exposures in the antithrombin group as a whole. Functional antithrombin levels (%) were significantly higher in the treatment group versus placebo group until postoperative day 2. D-dimer was significantly lower in the antithrombin group than in the placebo group on postoperative day 4. CONCLUSION Supplementation of antithrombin in infants with low antithrombin levels improves heparin sensitivity and anticoagulation during CPB without increased rates of bleeding or adverse events. Beneficial effects may be seen into the postoperative period, reflected by significantly less postoperative bleeding and exposure to blood products and reduced generation of D-dimers.
Collapse
Affiliation(s)
- Edmund H Jooste
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Rebecca Scholl
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Yi-Hung Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Robert D B Jaquiss
- Department of Cardiovascular and Thoracic Surgery, UT Southwestern Medical Center and Children's Medical Center, Dallas, TX
| | - Andrew J Lodge
- Division of Congenital Cardiac Surgery, Department of Cardiothoracic Surgery, Duke University Medical Center, Durham
| | - Warwick A Ames
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - H Mayumi Homi
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Kelly A Machovec
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Nathaniel H Greene
- Pediatric Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brian S Donahue
- Division of Pediatric Cardiac Anesthesiology, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
| | - Nirmish Shah
- Division of Pediatric Hematology/Oncology, Duke University Medical Center, Durham, NC
| | - Claudia Benkwitz
- Department of Anesthesia and Perioperative Care, UCSF Benioff Children's Hospital, San Francisco, CA
| |
Collapse
|
20
|
Nakamura S, Honjo O, Crawford-Lean L, Foreman C, Sano M, O’Leary JD. Predicting Heparin Responsiveness in Children Before Cardiopulmonary Bypass. Anesth Analg 2018; 126:1617-1623. [DOI: 10.1213/ane.0000000000002785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
21
|
Abstract
Venous thromboembolism is occurring with increasing frequency in children resulting in the more widespread use of anticoagulation in pediatrics. Antithrombotic drugs in children can be divided into the standard and alternative agents. This review discusses standard and alternative anticoagulants. Because standard anticoagulants have significant limitations, including variable pharmacokinetics, issues with therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects, it is expected that the use of alternative anticoagulants will increase over time. With their improved properties and recent prospective clinical trial data, the current and future use of these agents will likely slowly replace of the standard anticoagulants.
Collapse
Affiliation(s)
- Guy Young
- Hemostasis and Thrombosis Center, Children's Hospital Los Angeles, Department of Pediatrics, Division of Pediatric Hematology/Oncology, University of Southern California Keck School of Medicine, 4650 Sunset Blvd, Los Angeles, CA 90027, USA.
| |
Collapse
|
22
|
Musgrave KM, Webber K, Murphy P, Avery P, Biss TT. Evaluation of the age-dependent dosing recommendations for the administration of daily tinzaparin in children with thrombosis. J Thromb Haemost 2017; 15:2361-2366. [PMID: 28976613 DOI: 10.1111/jth.13856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Indexed: 11/26/2022]
Abstract
Essentials The once-daily dosing of tinzaparin provides an advantage over other low molecular weight heparins. The recommended age-dependent doses of tinzaparin in children have not previously been validated. Once-daily administration of tinzaparin is a safe and effective treatment of childhood thrombosis. Recommended doses are appropriate but monitoring may be required due to inter-individual variation. SUMMARY Background The recommended starting doses of tinzaparin for the treatment of thrombosis in children have not previously been validated. There are few data to support the efficacy and safety of once-daily tinzaparin dosing in children with thrombosis. Objectives To investigate the use of tinzaparin for the treatment of childhood thrombosis, and to evaluate the age-dependent dosing recommendations and define outcomes in terms of efficacy and safety. Methods This was a retrospective cohort study of children aged 0 to < 16 years treated for thrombosis at a large teaching hospital in the UK between 2008 and 2015. Medical records were reviewed to evaluate tinzaparin dosing, anti-activated factor X (FXa) levels, and patient outcomes. Results Seventy-nine children were identified as having received tinzaparin. Dosing information was available for 57. Younger children required higher doses to reach a therapeutic level. The therapeutic dose requirement varied within age groups, supporting the use of anti-FXa monitoring. Over a median follow-up of 35 months, there were 13 (16%) bleeding episodes (two major; seven clinically relevant but non-major; and four minor). There were two (3%) recurrent episodes of thrombosis. Children were treated for a median duration of 3 months, and the majority (86%) remained on tinzaparin for the duration of their anticoagulant therapy. Conclusion Once-daily tinzaparin is a safe and effective treatment for childhood thrombosis, with rates of recurrence and bleeding similar to those for other anticoagulants used in children. The recommended starting doses are appropriate, but anti-FXa monitoring may be required, owing to interindividual variability in the therapeutic dose requirement.
Collapse
Affiliation(s)
- K M Musgrave
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - K Webber
- Newcastle University Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - P Murphy
- Blood Sciences Laboratory, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - P Avery
- School of Mathematics and Statistics, Newcastle University, Newcastle upon Tyne, UK
| | - T T Biss
- Department of Haematology, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| |
Collapse
|
23
|
Hinsley K, Evans-Langhorst M, Porter C, Chandler S, VanderPluym C, Triedman J, Bezzerides VJ. Low molecular weight heparin as an anticoagulation strategy for left-sided ablation procedures. CONGENIT HEART DIS 2017; 13:222-225. [DOI: 10.1111/chd.12551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/16/2017] [Accepted: 10/28/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Karen Hinsley
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts, USA
| | | | - Courtney Porter
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts, USA
| | - Stephanie Chandler
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts, USA
| | | | - John Triedman
- Department of Cardiology; Boston Children's Hospital; Boston Massachusetts, USA
| | | |
Collapse
|
24
|
Balci KG, Maden O, Balci MM, Çetin EH, Kafes H, Tola M, Selcuk H, Selcuk MT. Relation Between TRCA Complication Rates and Peak ACT Levels Stratified According to the BMI Tertiles. Angiology 2017; 69:400-405. [PMID: 28893082 DOI: 10.1177/0003319717729289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the efficacy and safety of the fixed dose of 5000 IU unfractionated heparin (UFH) represented as peak activated clotting time (ACT) according to the body mass index (BMI) tertiles in patients undergoing diagnostic transradial coronary angiography (TRCA). A total of 422 patients were included in the present study, 84 in the normal weight group, 218 in the overweight group, and the 120 in the grades 1 and 2 obesity groups. Radial artery occlusion (RAO) was observed in 29 (6.8%) patients and the hematoma was observed in 43 (10.1%) patients. The rate of RAO and hematoma did not differ across the BMI tertiles ( P = .749 and P = .066). Also, peak ACT and procedure duration did not differ between the study groups ( P = .703 and P = .999). The only independent predictor of hematoma was sheath/radial artery diameter ( P = .011) and the independent predictors for RAO were peak ACT, sheath/radial artery diameter, and procedure duration ( P = .001, P = .028, and P < .001, respectively). In conclusion, a fixed dose of 5000 IU UFH is safe and effective regardless of the BMI in diagnostic TRCA procedure.
Collapse
Affiliation(s)
| | - Orhan Maden
- 1 Turkiye Yuksek Ihtisas Research and Education Hospital, Altındağ, Ankara, Turkey
| | | | - Elif Hande Çetin
- 1 Turkiye Yuksek Ihtisas Research and Education Hospital, Altındağ, Ankara, Turkey
| | - Habibe Kafes
- 1 Turkiye Yuksek Ihtisas Research and Education Hospital, Altındağ, Ankara, Turkey
| | - Muharrem Tola
- 1 Turkiye Yuksek Ihtisas Research and Education Hospital, Altındağ, Ankara, Turkey
| | - Hatice Selcuk
- 1 Turkiye Yuksek Ihtisas Research and Education Hospital, Altındağ, Ankara, Turkey
| | - Mehmet Timur Selcuk
- 1 Turkiye Yuksek Ihtisas Research and Education Hospital, Altındağ, Ankara, Turkey
| |
Collapse
|
25
|
Young G, Male C, van Ommen CH. Anticoagulation in children: Making the most of little patients and little evidence. Blood Cells Mol Dis 2017; 67:48-53. [PMID: 28552476 DOI: 10.1016/j.bcmd.2017.05.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 04/25/2017] [Accepted: 05/03/2017] [Indexed: 01/19/2023]
Abstract
Thrombotic complications are increasing at a steady and significant rate in children resulting in the more widespread use of anticoagulation in this population. Anticoagulant drugs in children can be divided into the standard agents (heparin, low molecular weight heparin, and vitamin K antagonists) and alternative agents (argatroban, bivalirudin, and fondaparinux). This review will compare and contrast the standard and alternative anticoagulants and suggest situations in which it may be appropriate to use argatroban, bivalirudin, and fondaparinux. Clearly, the standard anticoagulants all have significant shortcomings including variable pharmacokinetics, issues with therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects. The alternative anticoagulants have properties which overcome these shortcomings and prospective clinical trial data are presented supporting the current and future use of these agents in place of the standard anticoagulants.
Collapse
Affiliation(s)
- Guy Young
- Children's Hospital Los Angeles, University of Southern California Keck School of Medicine.
| | - Christoph Male
- Department of Paediatrics, Medical University of Vienna, Vienna, Austria
| | - C Heleen van Ommen
- Department of Pediatric Hematology/Oncology, Erasmus MC Sophia's Children's Hospital, Rotterdam, Netherlands
| |
Collapse
|
26
|
Betensky M, Bittles MA, Colombani P, Goldenberg NA. How We Manage Pediatric Deep Venous Thrombosis. Semin Intervent Radiol 2017; 34:35-49. [PMID: 28265128 PMCID: PMC5334487 DOI: 10.1055/s-0036-1597762] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Over the past two decades, the incidence and recognition of venous thromboembolism (VTE) in children has significantly increased, likely as a result of improvements in the medical care of critically ill patients and increased awareness of thrombotic complications among medical providers. Current recommendations for the management of VTE in children are largely based on data from pediatric registries and observational studies, or extrapolated from adult data. The scarcity of high-quality evidence-based recommendations has resulted in marked variations in the management of pediatric VTE among providers. The purpose of this article is to summarize our institutional approach for the management of VTE in children based on available evidence, guidelines, and clinical practice considerations. Therapeutic strategies reviewed in this article include the use of conventional anticoagulants, parenteral targeted anticoagulants, new direct oral anticoagulants, thrombolysis, and mechanical approaches for the management of pediatric VTE.
Collapse
Affiliation(s)
- Marisol Betensky
- Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Mark A. Bittles
- Department of Radiology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Paul Colombani
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A. Goldenberg
- Pediatric Thrombosis Program, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
27
|
Maden O, Kafes H, Balci KG, Tola M, Selçuk MT, Burak C, Çetin EH, Selçuk H, Balci MM, Kısacık HL. Relation Between End-Procedural Activated Clotting Time Values and Radial Artery Occlusion Rate With Standard Fixed-Dose Heparin After Transradial Cardiac Catheterization. Am J Cardiol 2016; 118:1455-1459. [PMID: 27645762 DOI: 10.1016/j.amjcard.2016.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 08/02/2016] [Accepted: 08/02/2016] [Indexed: 11/24/2022]
Abstract
Although heparin administration has reduced the incidence of radial artery occlusion (RAO) during the transradial coronary angiography (TRCA), the effective activated clotting time (ACT) value for guiding unfractionated heparin dosing in patients undergoing TRCA is unknown. Four hundred thirty-two patients who were scheduled for elective TRCA were enrolled in our prospective study. All the patients received a standard dose of 5,000 IU unfractionated heparin. Anticoagulation level was assessed by ACT measurements that were taken at the end of the procedure just before the sheath removal. The day after TRCA, all patients were evaluated by color Doppler ultrasound to detect RAO. RAO was found in 29 patients (6.7%). A median ACT of 205 seconds in the RAO group and 265 seconds in the radial artery patent group were detected (p <0.001). Mean procedure duration was significantly longer in the RAO group than in the radial artery patent group (18.55 ± 9.80 vs 11.24 ± 7.07 minutes, p <0.001). There was a negative correlation between end-procedural ACT and procedure duration (r = -0.117, p = 0.015). In multivariate analysis, end-procedural ACT (odds ratio 0.981, 95% confidence interval [CI] 0.972 to 0.989, p <0.001), procedure duration (odds ratio 1.076, 95% CI, 1.037 to 1.116, p <0.001), and radial artery diameter (odds ratio 0.240, 95% CI 0.063 to 0.907, p = 0.035) were found as independent predictors of RAO. In conclusion, shorter end-procedural ACT levels, longer procedural duration, and smaller radial arterial diameter were independently associated with RAOs after TRCA with standard-dose heparin. In prolonged procedures, ACT-based heparin dosing may be useful to overcome RAO.
Collapse
|
28
|
|
29
|
Abstract
OBJECTIVES The objective of this article is to review the particular tendencies as well as specific concerns of bleeding and clotting in children with critical cardiac disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION Children with critical heart disease are at particular risk for bleeding and clotting secondary to intrinsic as well as extrinsic factors. We hope that this review will aid the clinician in managing the unique challenges of bleeding and clotting in this patient population, and serve as a springboard for much needed research in this area.
Collapse
|
30
|
Al-Sallami H, Newall F, Monagle P, Ignjatovic V, Cranswick N, Duffull S. Development of a population pharmacokinetic-pharmacodynamic model of a single bolus dose of unfractionated heparin in paediatric patients. Br J Clin Pharmacol 2016; 82:178-84. [PMID: 26972703 DOI: 10.1111/bcp.12930] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/24/2016] [Accepted: 03/07/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Unfractionated heparin (UFH) is the anticoagulant of choice in paediatric patients undergoing a variety of cardiac procedures. There are currently no population pharmacokinetic-pharmacodynamic (PKPD) models for UFH in paediatrics. OBJECTIVE The aim of the present study was to develop and evaluate a PKPD model of UFH in paediatrics. METHODS Data from 64 children who received 75-100 IU kg(-1) of UFH during cardiac angiography were analysed. Five blood samples were collected at baseline and at 15, 30, 45 and 120 min postdose. The UFH concentration was quantified using a protamine titration assay. The UFH effect was quantified using activated partial thromboplastin time (aPTT). A PKPD model was fitted using nonlinear mixed-effects modelling. Patient covariates such as gender, weight (WT) and fat-free mass (FFM) were tested. The final model was evaluated using the likelihood ratio test and visual predictive checks (VPCs). RESULTS A one-compartment model with linear elimination provided the best fit for the dose-concentration data. FFM was a significant covariate on clearance. A linear model provided the best fit for the concentration-effect data using aPTT as a biomarker for effect. The models performed well using VPCs. However, when used to simulate UFH infusion (at a much lower dose), the model overpredicted target aPTT responses. CONCLUSIONS A PKPD model to describe the time course of the UFH effect was developed in a paediatric population. FFM was shown to describe drug disposition well. However, when applied to smaller UFH infusion doses, the model overpredicted target aPTT responses. This unsuccessful extrapolation may be attributed to a possible nonlinear relationship for heparin PKPD.
Collapse
Affiliation(s)
| | - Fiona Newall
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Clinical Haematology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Clinical Haematology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Noel Cranswick
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of Pharmacology, University of Melbourne, Melbourne, Vic, Australia
| | - Stephen Duffull
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| |
Collapse
|
31
|
Vitamin K antagonists in children with central venous catheter on chronic haemodialysis: a pilot study. Pediatr Nephrol 2016; 31:827-32. [PMID: 26667238 DOI: 10.1007/s00467-015-3293-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/02/2015] [Accepted: 12/03/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND To date, no study has investigated the use of vitamin K antagonists (VKA) in children undergoing chronic haemodialysis (HD) with a central venous catheter (CVC). METHODS Consecutive patients aged <18 years with a newly placed tunnelled CVC for chronic HD were enrolled over a 3-year period. Children with active nephrotic syndrome or a history of venous thrombosis received warfarin (VKA group) with therapeutic target international normalised ratios of between 2.0 and 3.0. Patients at standard risk of CVC malfunction were not treated with VKA (standard group). The primary end-point was overall CVC survival. RESULTS The VKA group consisted of nine patients (median age 10.6 years; range 1.2-15.3 years) with 11 CVC, and the standard group comprised eight patients (11.8 years; 6.1-17.3 years) with ten CVC. The 6- and 12-month CVC survival was significantly longer in the VKA group than in the standard group (100 vs. 60 % and 83.3 vs. 16.7 %, respectively; p < 0.05), with a median survival of 369 and 195 days, respectively (p < 0.05). None of the CVC in the VKA group required removal due to malfunction, as compared to four in the standard group. No major bleeding episodes occurred in either group. CONCLUSIONS Therapy with VKA would appear to be safe in children on chronic HD and may improve CVC survival in patients at increased risk of CVC thrombosis.
Collapse
|
32
|
Kurnik K, Bidlingmaier C, Hütker S, Olivieri M. [Haemostatic disorders in children]. Hamostaseologie 2016; 36:109-25. [PMID: 26988657 DOI: 10.5482/hamo-15-04-0016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 03/04/2016] [Indexed: 12/28/2022] Open
Abstract
Haemorrhagic and thrombotic events occur in both children and adults. The underlying causes are congenital or acquired disorders. In contrast to haemorrhagic disorders, inherited thrombotic disorders nearly exclusively in association with additional external risk factors lead to thrombotic events predominantly during the newborn period and adolescence. It is necessary to be aware of age-specific properties of coagulation in order to correctly interpret clinical and laboratory findings and to provide optimal care for children with haemorrhagic and thrombotic complications.
Collapse
Affiliation(s)
- Karin Kurnik
- Priv.-Doz. Dr. med. Karin Kurnik, Kinderklinik im Dr. von Haunerschen Kinderspital Klinikum der Universität München, Lindwurmstr. 4, 80337 München,
| | | | | | | |
Collapse
|
33
|
Manlhiot C, Gruenwald CE, Holtby HM, Brandão LR, Chan AK, Van Arsdell GS, McCrindle BW. Challenges with heparin-based anticoagulation during cardiopulmonary bypass in children: Impact of low antithrombin activity. J Thorac Cardiovasc Surg 2016; 151:444-50. [DOI: 10.1016/j.jtcvs.2015.10.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/24/2015] [Accepted: 10/01/2015] [Indexed: 01/19/2023]
|
34
|
Buck ML. Bivalirudin as an Alternative to Heparin for Anticoagulation in Infants and Children. J Pediatr Pharmacol Ther 2016; 20:408-17. [PMID: 26766931 DOI: 10.5863/1551-6776-20.6.408] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Bivalirudin, a direct thrombin inhibitor, is a useful alternative to heparin for anticoagulation in infants and children. It has been found to be effective in patients requiring treatment of thrombosis, as well as those needing anticoagulation during cardiopulmonary bypass, extracorporeal life support, or with a ventricular assist device. While it has traditionally been used in patients who were unresponsive to heparin or who developed heparin-induced thrombocytopenia, it has recently been studied as a first-line agent. Bivalirudin, unlike heparin, does not require antithrombin to be effective, and as a result, has the potential to provide a more consistent anticoagulation. The case reports and clinical studies currently available suggest that bivalirudin is as effective as heparin at reaching target activated clotting times or activated partial thromboplastin times, with equivalent or the lower rates of bleeding or thromboembolic complications. It is more expensive than heparin, but the cost may be offset by reductions in the costs associated with heparin use, including anti-factor Xa testing and the need for administration of antithrombin. The most significant disadvantage of bivalirudin remains the lack of larger prospective studies demonstrating its efficacy and safety in the pediatric population.
Collapse
Affiliation(s)
- Marcia L Buck
- Departments of Pharmacy Services and Pediatrics, University of Virginia Children's Hospital, Charlottesville, Virginia
| |
Collapse
|
35
|
Venous Thromboembolic Disease in Children and Adolescents. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:149-165. [DOI: 10.1007/5584_2016_113] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
36
|
Abstract
Thrombotic complications are increasing at a steady and significant rate in children, resulting in the more widespread use of anticoagulation in this population. Anticoagulant drugs in children can be divided into the older multitargeted agents (heparin, low-molecular-weight heparin, and warfarin) and the newer targeted agents (argatroban, bivalirudin, and fondaparinux). This review will compare and contrast the multitargeted and targeted anticoagulants and suggest situations in which it may be appropriate to use argatroban, bivalirudin, and fondaparinux. The various agents differ in their pharmacokinetics, requirements for therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects. The targeted anticoagulants have properties that may make them more attractive for use in specific clinical situations. Prospective clinical trial data are presented supporting the current and future use of these agents in children.
Collapse
|
37
|
Abstract
Abstract
Thrombotic complications are increasing at a steady and significant rate in children, resulting in the more widespread use of anticoagulation in this population. Anticoagulant drugs in children can be divided into the older multitargeted agents (heparin, low-molecular-weight heparin, and warfarin) and the newer targeted agents (argatroban, bivalirudin, and fondaparinux). This review will compare and contrast the multitargeted and targeted anticoagulants and suggest situations in which it may be appropriate to use argatroban, bivalirudin, and fondaparinux. The various agents differ in their pharmacokinetics, requirements for therapeutic drug monitoring, frequency of administration, efficacy, and adverse effects. The targeted anticoagulants have properties that may make them more attractive for use in specific clinical situations. Prospective clinical trial data are presented supporting the current and future use of these agents in children.
Collapse
|
38
|
Antithrombin activity and heparin response in neonates and infants undergoing congenital cardiac surgery: a retrospective cohort study. Can J Anaesth 2015; 63:38-45. [DOI: 10.1007/s12630-015-0500-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Revised: 08/03/2015] [Accepted: 09/17/2015] [Indexed: 10/23/2022] Open
|
39
|
Abstract
Increasing thrombotic complications in children with complex medication conditions have led to more widespread use of anticoagulants [Raffini et al. in Pediatrics 124(4):1001-8, 2009]. While current guidelines for the management of antithrombotic therapy in neonates and children exist, they are based on low- and very low-quality evidence [Monagle et al. in Chest 141(2 Suppl):e737-801S, 2012]. Despite numerous differences, current anticoagulation practice is largely extrapolated from adult studies. This is sub-optimal, particularly in neonates who have a rapidly evolving hemostatic system. The majority of pediatric patients have underlying medical conditions that may significantly influence drug choice and bleeding risk. This article reviews the use of anticoagulants in children with thrombosis, focusing on practical aspects such as dosing, monitoring, and complications. Low molecular weight heparin has become the preferred anticoagulant in children, although unfractionated heparin and warfarin remain frequently used. Other anticoagulants, including fondaparinux, direct thrombin inhibitors, and the newer target-specific oral anticoagulants are also discussed. Given the many unique challenges surrounding the use of anticoagulants in children, pediatric hospitals should have written practice guidelines as well as experienced providers to care for children with thrombosis. This is an evolving field, and further studies of the use of anticoagulants in neonates and children are greatly needed to help optimize care.
Collapse
|
40
|
Abstract
Historically, oral anticoagulation involved the administration of vitamin K antagonists, such as warfarin. However, because of the need for frequent monitoring and the desire for safer anticoagulants, several novel oral anticoagulants have been developed. These newer agents include the factor Xa inhibitors (eg, rivaroxaban, apixaban, edoxaban), along with the direct thrombin inhibitors (eg, dabigatran). This manuscript provides a brief overview of their uses and mechanisms of action, along with a review of currently available evidence for reversal strategies when life-threatening bleeding occurs.
Collapse
Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, Section of Medical Toxicology, University of Southern California, 1200 North State Street, Room 1011, Los Angeles, CA, 90033, USA,
| | | |
Collapse
|
41
|
Harter K, Levine M, Henderson SO. Anticoagulation drug therapy: a review. West J Emerg Med 2015; 16:11-7. [PMID: 25671002 PMCID: PMC4307693 DOI: 10.5811/westjem.2014.12.22933] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 12/23/2014] [Accepted: 12/23/2014] [Indexed: 01/12/2023] Open
Abstract
Historically, most patients who required parenteral anticoagulation received heparin, whereas those patients requiring oral anticoagulation received warfarin. Due to the narrow therapeutic index and need for frequent laboratory monitoring associated with warfarin, there has been a desire to develop newer, more effective anticoagulants. Consequently, in recent years many novel anticoagulants have been developed. The emergency physician may institute anticoagulation therapy in the short term (e.g. heparin) for a patient being admitted, or may start a novel anticoagulation for a patient being discharged. Similarly, a patient on a novel anticoagulant may present to the emergency department due to a hemorrhagic complication. Consequently, the emergency physician should be familiar with the newer and older anticoagulants. This review emphasizes the indication, mechanism of action, adverse effects, and potential reversal strategies for various anticoagulants that the emergency physician will likely encounter.
Collapse
Affiliation(s)
- Katherine Harter
- University of Southern California, LA+USC Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Michael Levine
- University of Southern California, LA+USC Medical Center, Department of Emergency Medicine, Los Angeles, California
| | - Sean O Henderson
- University of Southern California, LA+USC Medical Center, Department of Emergency Medicine, Los Angeles, California
| |
Collapse
|
42
|
Hong X, Shan PR, Huang WJ, Zhu QL, Xiao FY, Li S, Zhou H. Influence of Body Mass Index on the Activated Clotting Time Under Weight-Based Heparin Dose. J Clin Lab Anal 2014; 30:108-13. [PMID: 25425223 DOI: 10.1002/jcla.21823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 10/22/2014] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Activated clotting time (ACT) has been successfully applied during percutaneous coronary intervention (PCI) to monitor the extent of thrombin inhibition and anti-coagulation from unfractionated heparin (UFH) aiming to reduce the incidence of thrombotic adverse events and hemorrhagic complications. And this investigation was to explore the influence of body mass index (BMI) on ACT in patients received weight-based dose of UFH during PCI treatment. METHODS 78 male patients undergoing coronary angiography or PCI treatment with a mean age of 63.86 ± 6.89 years were enrolled in this study. The patients were statistically divided into four quartiles according to their BMI. The ACT values were recorded as ACT0 , ACT5 , ACT10 , ACT30 and ACT60 , respectively. Taking the preoperative ACT0 as reference, and the differences of the other ACT values with ACT0 was indicated as ΔACTs. ACT values peaked at 5 min in 33.33% of the patients, 10 min in 51.33% of the patients and 30 min in 15.34% of the patients, respectively. RESULTS In addition, significant differences were found in overall maximum post-UFH ACT values among all BMI quartiles. UFH doses per blood volume were significantly different among the BMI quartiles, showing a positive association with BMI quartiles; further evidence revealed that the areas under the ΔACT-time curves increased gradually from quartile I to quartile IV. The proportions of ACT60 > 250 s and ACT60 > 300 s were found to be positively correlated with the increased BMI at 60 min after heparin loading. CONCLUSIONS The results of our study have shown that a standardized dosing nomogram that uses the actual body weight to calculate the heparin doses may result in UFH overdose for patients with higher BMI compared to patients with lower BMI.
Collapse
Affiliation(s)
- Xia Hong
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Pei-Ren Shan
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Wei-Jian Huang
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Qian-Li Zhu
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Fang-Yi Xiao
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Sheng Li
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| | - Hao Zhou
- Department of Cardiology, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, P.R. China
| |
Collapse
|
43
|
Saini A, Spinella PC. Management of Anticoagulation and Hemostasis for Pediatric Extracorporeal Membrane Oxygenation. Clin Lab Med 2014; 34:655-73. [DOI: 10.1016/j.cll.2014.06.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
44
|
Abstract
PURPOSE OF REVIEW To review the current literature on venous thromboembolism (VTE) in critically ill children. RECENT FINDINGS There is an increasing concern for VTE and its complications in critically ill children. Critically ill children are at increased risk of thromboembolism because of the treatment that they are receiving and their underlying condition. A complex relationship exists between thrombosis and infection. A thrombus is a nidus for infection, while infection increases the risk of thrombosis. Pediatric-specific guidelines for the prevention and treatment of thromboembolism are lacking. Current guidelines are based on the data from adults. Novel anticoagulants are now available for use in adults. Studies are ongoing to determine their safety in children. Risk assessment tools have recently been developed to determine the risk of thromboembolism in critically ill children. Certain molecules are associated with thromboembolism in adults. SUMMARY Pediatric critical care practitioners should be cognizant of the importance of VTE in critically ill children to allow early identification and treatment. Adequately powered clinical trials are critically needed to generate evidence that will guide the treatment and prevention of thromboembolism in critically ill children. Risk assessment tools that incorporate biomarkers may improve our ability to predict the occurrence of thromboembolism in critically ill children.
Collapse
|
45
|
Bavare AC, Naik SX, Lin PH, Poi MJ, Yee DL, Bronicki RA, Philip JX, Desai MS. Catheter-directed thrombolysis for severe pulmonary embolism in pediatric patients. Ann Vasc Surg 2014; 28:1794.e1-7. [PMID: 24698774 DOI: 10.1016/j.avsg.2014.03.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 03/21/2014] [Accepted: 03/25/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Catheter-directed thrombolytic (CDT) therapies for severe pulmonary embolism (PE) have been shown to be effective and safe when compared with systemic thrombolysis in adults. Pediatric studies assessing efficacy and safety of CDT for PE are lacking. Hence, our aim was to review CDT as a therapy for pediatric PE. METHODS We retrospectively reviewed charts of patients aged <18 years, who underwent CDT for main or major branch pulmonary artery occlusion associated with hypotension or right ventricular dysfunction secondary to PE during a 3-year period, in our tertiary care academic Pediatric Intensive Care Unit. RESULTS Six CDT interventions were performed on 5 patients with PE (median age: 16.5 years). All patients presented with chest pain and dyspnea. The predisposing factors for thrombogenesis differed in all patients, and all had multiple risk factors. Five of six procedures (83%) were accompanied by ultrasound agitation with EKOS endowave infusion system (ultrasound-accelerated CDT [UCDT]), whereas 1 had CDT without ultrasound agitation. Complete resolution of PE occurred in 4 instances (67%) at 24 hr, whereas in 2 cases (33%), there was partial resolution. One patient with complete resolution underwent another successful UCDT after 4 months for recurrence. Clinical parameters (heart rate, respiratory rate, blood pressure, and oxygen saturations) and echocardiographic findings improved after treatment in all the patients. Median duration of hospital stay was 9 days with no mortality and treatment-related complications. All patients were discharged with long-term anticoagulation. CONCLUSIONS Our case series is the first that describes CDT/UCDT as an effective and safe therapy for pediatric patients with severe PE. CDT is known to accelerate fibrinolysis via focused delivery of thrombolytic agent to the thrombus site. For carefully selected patients, CDT/UCDT provides a useful treatment option for severe PE irrespective of the etiology, predisposing conditions, and associated comorbidities.
Collapse
Affiliation(s)
- Aarti C Bavare
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX.
| | - Swati X Naik
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Peter H Lin
- Division of Vascular Surgery and Endovascular Therapy, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Mun Jye Poi
- Division of Vascular Surgery and Endovascular Therapy, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Donald L Yee
- Section of Hematology and Oncology, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Ronald A Bronicki
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Joseph X Philip
- Congenital Heart Center, Shands Hospital, University of Florida, Gainsville, Florida
| | - Moreshwar S Desai
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| |
Collapse
|