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Mounessa J, Caravaglio JV, Domozych R, Chapman S, Dellavalle RP, Dunnick CA, Norris D. Commonly prescribed medications associated with alopecia. J Am Acad Dermatol 2023; 88:1326-1337.e2. [PMID: 37268392 DOI: 10.1016/j.jaad.2017.01.060] [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: 08/25/2016] [Revised: 01/27/2017] [Accepted: 01/31/2017] [Indexed: 06/04/2023]
Abstract
BACKGROUND The diagnosis and treatment of medication-associated alopecia often challenges patients and physicians. While numerous studies on the topic exist, limited information on the strength and magnitude of these studies exists. OBJECTIVES We investigated the most commonly prescribed medications with high levels of evidence to support associations with alopecia. METHODS A list of most commonly prescribed medications was compiled using the "Top 100 Prescriptions, Sales" (Intercontinental Marketing Services) and "Top 200 Names Searched" (RxList.com). PubMed, Embase, and Web of Science were searched for "generic drug name" AND "alopecia" and "generic drug name" AND "hair loss." Two reviewers independently reviewed articles for drug, study type and level of evidence, and number of alopecia cases. RESULTS A total of 192 unique drugs were investigated, with 110 yielding positive search results. Of these, 13 were associated with alopecia in studies with strong levels of evidence (adalimumab, infliximab, budesonide, interferon β-1α, tacrolimus, enoxaparin, zoster vaccine, lamotrigine, docetaxel, capecitabine, erlotinib, imatinib, and bortezomib). LIMITATIONS Only full-length articles available in the English language were included. The methodology used relied on lists of drugs based on their sales rather than number of prescriptions, which likely overrepresented expensive drugs. CONCLUSIONS Few studies with high levels of evidence have been conducted on the topic of medication-associated alopecia. The mechanisms of hair loss must be further identified to provide effective management.
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Affiliation(s)
- Jessica Mounessa
- Stony Brook University School of Medicine, Stony Brook, New York; Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | | | - Renee Domozych
- University of Central Florida College of Medicine, Orlando, Florida
| | - Stephanie Chapman
- College of Human Medicine, Michigan State University, Grand Rapids, Michigan
| | - Robert P Dellavalle
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Dermatology Service, US Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Cory A Dunnick
- Dermatology Service, US Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado; Department of Epidemiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David Norris
- Department of Dermatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; Dermatology Service, US Department of Veterans Affairs, Eastern Colorado Health Care System, Denver, Colorado.
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Low-molecular-weight heparin administered by subcutaneous catheter is a safe and effective anti-coagulation regimen in selected inpatient infants and children with complex congenital heart disease. Cardiol Young 2021; 31:1439-1444. [PMID: 33588972 DOI: 10.1017/s1047951121000317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND/HYPOTHESIS Disadvantages of intravenous therapeutic unfractionated heparin, the first-line anti-coagulant agent in children with complex congenital heart disease, include unpredictable pharmacokinetics requiring frequent phlebotomies and the need for continuous intravenous access. OBJECTIVE To compare efficacy and safety of low-molecular-weight heparin administered by a subcutaneous indwelling catheter with intravenous unfractionated heparin. MATERIALS AND METHODS Clinical data from 31 inpatients prospectively enrolled to receive subcutaneous low-molecular-weight heparin were compared with those from a historical group of 44 inpatients receiving intravenous unfractionated heparin. Investigation of parents' satisfaction by telephone survey. RESULTS The percentage of anti-factor Xa levels outside therapeutic range was lower in the subcutaneous low-molecular-weight heparin group compared with the percentage of activated partial thromboplastin times outside therapeutic range in the intravenous unfractionated heparin group (40% versus 90%, p < 0.001). Neither group had a major complication. Transient local reactions occurred in 19% of patients of the subcutaneous low-molecular-weight heparin group. The number of needle punctures and that of placement of indwelling catheters were significantly lower in the subcutaneous low-molecular-weight heparin compared with the intravenous unfractionated heparin group (p < 0.001). In total, 84.2% of parents in the subcutaneous low-molecular-weight heparin group reported a positive experience when asked about comparison with prior intravenous unfractionated heparin treatment. CONCLUSION Subcutaneous low-molecular-weight heparin offers a safe anti-coagulation regimen for children with complex congenital heart disease providing more efficient therapeutic anti-coagulation and a reduction in needle punctures, thus causing less pain and anxiety in this children.
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Noailly J, Sadozaï L, Hurtaud-Roux MF, Naudin J, Bonnefoy R, Farnoux C, Kwon T, Bourdon O, Prot-Labarthe S. [Enoxaparin and tinzaparin in pediatrics: Impact of recommendation on prescription quality and anti-Xa levels]. ANNALES PHARMACEUTIQUES FRANÇAISES 2021; 79:710-719. [PMID: 33675741 DOI: 10.1016/j.pharma.2021.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/27/2021] [Accepted: 02/24/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES A protocol has been written and distributed in May 2017 to all prescribers in a pediatric hospital to standardize and to secure the prescriptions of enoxaparin and tinzaparin considered as two high risk medications. The aim of this study is to evaluate the impact of the protocol on those prescriptions in a pediatric population. METHODS This is a monocentric retrospective study comparing prescriptions of this two low-molecular-weight heparins for patients under 18 years old in 2016 and 2018, thus before and after the protocol redaction. RESULTS In 2016, 2246 prescriptions of enoxaparin and tinzaparin were analyzed for 627 patients. Among them, 142 (22.6%) patients have had at least one anti-Xa level dosed. On the other hand, in 2018, 2061 prescriptions were written for 628 patients including 96 (15.3%) who have had at least one anti-Xa level dosed. The conformity rate of the first dose in IU/kg/administration of the first enoxaparin prescription goes from 36.3% before protocol to 52.1% after (P=0.03*). Concerning tinzaparin, the conformity rate goes from 69.2% to 83.3%. (P=0.19). The rate of first anti-Xa level in the range 0.4 to 1.2 IU/ml increase between 2016 and 2018 from 27.7% to 43.8% (P<0.001*). CONCLUSION This protocol enabled to improve the quality of prescriptions in terms of: dosage written in IU/kg/administration, frequency of administration, dilution conformity, and result of the first anti-Xa level. Some efforts must be made in writing the dose in IU not in mg or ml.
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Affiliation(s)
- J Noailly
- Service de Pharmacie, AP-HP, Hôpital Robert-Debré, Paris, France
| | - L Sadozaï
- Service de Pharmacie, AP-HP, Hôpital Robert-Debré, Paris, France
| | - M-F Hurtaud-Roux
- Service d'Hématologie Biologique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - J Naudin
- Service de Réanimation et surveillance continue Pédiatrique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - R Bonnefoy
- Service de Cardiologie Pédiatrique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - C Farnoux
- Service de Néonatologie, AP-HP, Hôpital Robert-Debré, Paris, France
| | - T Kwon
- Service de Néphrologie Pédiatrique, AP-HP, Hôpital Robert-Debré, Paris, France
| | - O Bourdon
- Service de Pharmacie, AP-HP, Hôpital Robert-Debré, Paris, France; Département de pharmacie clinique, Université Paris Descartes, Paris, France; Laboratoire Educations et Pratiques de Santé, Université Paris XIII, Bobigny, France
| | - S Prot-Labarthe
- Service de Pharmacie, AP-HP, Hôpital Robert-Debré, Paris, France; Université de Paris, ECEVE, Inserm, 75010 Paris, France.
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Klaassen IL, Sol JJ, Suijker MH, Fijnvandraat K, van de Wetering MD, Heleen van Ommen C. Are low-molecular-weight heparins safe and effective in children? A systematic review. Blood Rev 2019; 33:33-42. [DOI: 10.1016/j.blre.2018.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 10/28/2022]
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Safe Use of Low-Molecular-weight Heparin in Pediatric Acute Lymphoblastic Leukemia and Lymphoma Around Lumbar Punctures. J Pediatr Hematol Oncol 2017; 39:596-601. [PMID: 28991127 DOI: 10.1097/mph.0000000000000988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children with acute lymphoblastic leukemia or lymphoma (ALL) undergo multiple lumbar punctures (LPs) and frequently require low-molecular-weight heparin (LMWH) for thromboembolic complications. We evaluated if withholding LMWH 24 hours before and after LPs prevented bleeding complications. Children (n=133) with ALL from who were: (1) treated at St. Jude Children's Research Hospital, (2) received LMWH (2×/day of ~1 mg/kg) between January 2004 until December 2012, and (3) underwent a LP were analyzed. Spinal hematoma was defined as a clinical suspicion leading to diagnostic imaging. Traumatic LP was defined as ≥10 red blood cells per microliter of cerebrospinal fluid. In 1708 LPs, no hematomas occurred. For each child treated with LMWH, the probability of experiencing a spinal hematoma during the entire ALL treatment course was 0% (95% confidence interval [CI], 0.0%-2.7%), and in each LP, assuming no intrapatient correlation, the probability of spinal hematoma was 0% (95% CI, 0.0%-0.2%). Traumatic LPs were more common when performed when children were not receiving LMWH therapy (odds ratio [OR], 1.5; 95% CI, 1.1-2.2) which may be explained by clinician optimization of known risk factors for traumatic cerebrospinal fluid before the procedures. Withholding LMWH for 24 hours before and after LPs in children being treated for ALL is safe.
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Abstract
Although venous thromboembolism (VTE) occurs in less than 1% of hospitalized pediatric trauma patients, care providers must make decisions about VTE prophylaxis on a daily basis. The consequences of VTE are significant; the risks of developing VTE are variable; and the effectiveness of prophylaxis against VTE is not conclusive in children. While the value of VTE prophylaxis is well defined in adult trauma care, it is unclear how this translates to the care of injured children. This review evaluates the incidence and risks of VTE in pediatric trauma and assesses the merits of prophylaxis in children. Pharmacologic prophylaxis against VTE is a reasonable strategy in critically injured adolescent trauma patients. Further study is needed to establish the risks and benefits of VTE prophylaxis across the spectrum of injured children.
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Affiliation(s)
- John K Petty
- Section of Pediatric Surgery, Department of General Surgery, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157.
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Moffett BS, Dinh K, Placencia J, Pelkey G, Hui SKR, Teruya J. Stability and Sterility of Enoxaparin 8 mg/mL Subcutaneous Injectable Solution. J Pediatr Pharmacol Ther 2016; 21:322-326. [PMID: 27713671 DOI: 10.5863/1551-6776-21.4.322] [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: 11/11/2022]
Abstract
BACKGROUND: Enoxaparin is often diluted to accurately deliver doses to neonatal and infant patients. Current recommendations for dilutions may not be adequate for the smallest patients. METHODS: Review of dosing at our institution occurred, and an 8 mg/mL concentration of enoxaparin was chosen. A concentration of 8 mg/mL was compounded by diluting 0.4 mL of enoxaparin (100 mg/mL) into 4.6 mL of sterile water for injection into an empty sterile vial. Four syringes of the 8 mg/mL concentration were prepared by 5 technicians (20 total syringes). Stability and sterility testing occurred a 0, 7, 14, and 30 days. One-way repeated-measures analysis of variance was used to detect significant differences in Anti-Factor Xa concentrations at the testing time points. RESULTS: The dilution of enoxaparin was sterile at 30 days but exhibited significant degradation at the 30-day point (p < 0.05). CONCLUSION: A dilution of enoxaparin 8 mg/mL is stable and sterile for 14 days refrigerated but is not stable at 30 days.
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Affiliation(s)
- Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas
| | - Kimberly Dinh
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas
| | | | - Gregory Pelkey
- Department of Laboratory, Texas Children's Hospital, Houston, Texas
| | - Shiu-Ki Rocky Hui
- Department of Pathology & Immunology, Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Jun Teruya
- Department of Pathology & Immunology, Pediatrics, Baylor College of Medicine, Houston, Texas
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Warad D, Rao AN, Mullikin T, Graner K, Shaughnessy WJ, Pruthi RK, Rodriguez V. A retrospective analysis of outcomes of dalteparin use in pediatric patients: a single institution experience. Thromb Res 2015; 136:229-33. [PMID: 26026634 DOI: 10.1016/j.thromres.2015.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/11/2015] [Accepted: 05/20/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Dalteparin is a commonly used low molecular weight heparin (LMWH) with extensive safety data in adults. With distinct advantages of once daily dosing and relative safety in renal impairment, it has been used off-label in pediatric practice; however, age-based dosing guidelines, safety and efficacy data in children are evolving. OBJECTIVES To report our institutional experience with the use of dalteparin in the treatment and prophylaxis of venous thromboembolism (VTE) in pediatric patients. PATIENTS/METHODS Retrospective chart review of all children (0-18years) that received dalteparin from December 1, 2000 through December 31, 2011. Doses per unit body weight per day (units/kg/day) were calculated for age-based group comparisons. RESULTS Of 166 patients identified, 116 (70%) received prophylactic doses while 50 (30%) received therapeutic doses of dalteparin. Infants (<1year) required significantly higher weight-based dosing to achieve therapeutic anti-Xa levels compared to children (1-10years) or adolescents (>10-18years) (mean dose units/kg/day; 396.6 versus 236.7 and 178.8 respectively, p<0.0001). Overall response rate, including complete and partial thrombus resolution, was 83%. Bleeding complications were minor and the rates were similar in therapeutic and prophylaxis patients. No significant differences in dosing or bleeding events were noted based on obesity or malignancy. CONCLUSIONS In our experience, dalteparin is effective for prophylaxis and therapy of VTE in pediatric patients. Dosing should be customized in an age-based manner with close monitoring of anti-Xa activity in order to achieve optimal levels, prevent bleeding complications, and to allow full benefit of prevention or therapy of thrombotic complications.
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Affiliation(s)
- Deepti Warad
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States; Special Coagulation Laboratory, Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States.
| | - Amulya Nageswara Rao
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Trey Mullikin
- Mayo Medical School, Mayo Clinic, Rochester, Minnesota, United States
| | - Kevin Graner
- Mayo Pharmacy Services, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Rajiv K Pruthi
- Special Coagulation Laboratory, Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, United States
| | - Vilmarie Rodriguez
- Division of Pediatric Hematology-Oncology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, United States
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Abstract
Thromboembolic episodes are disorders encountered in both children and adults, but relatively more common in adults. However, the occurrence of venous thromboembolism and use of anticoagulants in pediatrics are increasing. Unfractionated Heparin (UH) is used as a treatment and prevention of thrombosis in adults and critically ill children. Heparin utilization in pediatric is limited by many factors and the most important ones are Heparin Induced Thrombocytopenia (HIT) and anaphylaxis. However, Low Molecular Weight Heparin (LMWH) appears to be an effective and safe alternative treatment. Hence, it is preferred over than UH due to favorable pharmacokinetic and side effect profile. Direct Thrombin Inhibitors (DTI) is a promising class over the other anticoagulants since it offers potential advantages. The aim of this review is to discuss the differences between adult and pediatric thromboembolism and to review the current anticoagulants in terms of pharmacological action, doses, drug reactions, pharmacokinetics, interactions, and parameters. This review also highlights the differences between old and new anticoagulant therapy in pediatrics.
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Affiliation(s)
- Mariam K Dabbous
- Department of Pharmacy Practice, School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Fouad R Sakr
- Department of Biomedical Sciences, School of Pharmacy, Lebanese International University, Beirut, Lebanon
| | - Diana N Malaeb
- Department of PharmD, School of Pharmacy, Lebanese International University, Beirut, Lebanon
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Thompson AJ, McSwain SD, Webb SA, Stroud MA, Streck CJ. Venous thromboembolism prophylaxis in the pediatric trauma population. J Pediatr Surg 2013; 48:1413-21. [PMID: 23845640 DOI: 10.1016/j.jpedsurg.2013.02.059] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 02/13/2013] [Accepted: 02/15/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND/PURPOSE The aim of this study was to review evidence-based literature addressing pertinent questions about venous thromboembolism (VTE) after traumatic injury in children. METHODS Data were obtained from English-language articles identified through Pubmed published from 1995 until November 2012, and from bibliographies of relevant articles. Studies were included if they contributed evidence to one of the following questions. In the pediatric traumatic injury population: (1) What is the overall incidence of VTE? (2) Is age (adolescence versus pre-adolescence) associated with higher VTE incidence? (3) Which risk factors are associated with higher VTE incidence? (4) Does mechanical and/or pharmacological prophylaxis impact outcomes? RESULTS Eighteen articles were included in this systematic review. The evidence regarding each question was evaluated, graded by author consensus, and summarized. CONCLUSIONS The overall incidence of VTE is low. Older (>13years) and more severely injured patients are at higher VTE risk. Additional factors including injury type or presence of a central venous catheter also place a patient at higher VTE risk. Implementation of a risk-based clinical practice guideline for VTE prophylaxis has been associated with reduced symptomatic VTE at one institution. Randomized, prospective trials analyzing outcomes of VTE prophylaxis in pediatric trauma victims are needed.
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Affiliation(s)
- A Jill Thompson
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA.
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Hicks JK, Shelton CM, Sahni JK, Christensen ML. Retrospective evaluation of enoxaparin dosing in patients 48 weeks' postmenstrual age or younger in a neonatal intensive care unit. Ann Pharmacother 2012; 46:943-51. [PMID: 22828970 DOI: 10.1345/aph.1r116] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Enoxaparin is the anticoagulant of choice in neonates because of the ease of administration, predictable pharmacokinetics, and reduced adverse effects when compared to heparin. The Chest guidelines recommend that therapy in patients younger than 2 months should be initiated with enoxaparin 1.5 mg/kg administered subcutaneously twice daily. This starting dosage may be inadequate, leading to a delay in achieving therapeutic anti-factor Xa plasma concentrations. OBJECTIVE To determine an enoxaparin dose for neonatal patients that achieves a therapeutic anti-factor Xa plasma concentration and compare that dose to the recommended enoxaparin dose per published guidelines for this patient population. METHODS The study was designed as a single-center chart review. Eligible patients were identified by pharmacy anticoagulation records or a search of the electronic medical record for enoxaparin orders. Patients must have received enoxaparin subcutaneously twice daily and have had a postmenstrual age of 48 weeks or younger. Patients diagnosed with renal failure and those receiving prophylactic doses of enoxaparin were excluded. RESULTS The mean (SD) initial dose of enoxaparin was 1.4 (0.3) mg/kg subcutaneously twice daily, resulting in 27 of 33 patients (81.8%) having a subtherapeutic anti-factor Xa concentration. A mean enoxaparin dose of 2.0 (0.5) mg/kg was required to achieve a therapeutic anti-factor Xa plasma concentration (p < 0.001). Patients born prematurely required a higher enoxaparin dose (2.2 [0.5] mg/kg) than did those born at full-term gestation (1.8 [0.4] mg/kg; p < 0.05). CONCLUSIONS For patients 48 weeks' postmenstrual age or younger who are treated in a neonatal intensive care unit, a higher initial dose of enoxaparin than that suggested by the Chest guidelines is required to attain a therapeutic antifactor Xa plasma concentration. Premature neonates require a larger starting dose of enoxaparin than do infants born at full-term gestation.
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Affiliation(s)
- J Kevin Hicks
- Department of Pharmacy, Le Bonheur Children's Hospital, Memphis, TN, USA.
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Monagle P, Chan AKC, Goldenberg NA, Ichord RN, Journeycake JM, Nowak-Göttl U, Vesely SK. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S-e801S. [PMID: 22315277 DOI: 10.1378/chest.11-2308] [Citation(s) in RCA: 950] [Impact Index Per Article: 79.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Neonates and children differ from adults in physiology, pharmacologic responses to drugs, epidemiology, and long-term consequences of thrombosis. This guideline addresses optimal strategies for the management of thrombosis in neonates and children. METHODS The methods of this guideline follow those described in the Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that where possible, pediatric hematologists with experience in thromboembolism manage pediatric patients with thromboembolism (Grade 2C). When this is not possible, we suggest a combination of a neonatologist/pediatrician and adult hematologist supported by consultation with an experienced pediatric hematologist (Grade 2C). We suggest that therapeutic unfractionated heparin in children is titrated to achieve a target anti-Xa range of 0.35 to 0.7 units/mL or an activated partial thromboplastin time range that correlates to this anti-Xa range or to a protamine titration range of 0.2 to 0.4 units/mL (Grade 2C). For neonates and children receiving either daily or bid therapeutic low-molecular-weight heparin, we suggest that the drug be monitored to a target range of 0.5 to 1.0 units/mL in a sample taken 4 to 6 h after subcutaneous injection or, alternatively, 0.5 to 0.8 units/mL in a sample taken 2 to 6 h after subcutaneous injection (Grade 2C). CONCLUSIONS The evidence supporting most recommendations for antithrombotic therapy in neonates and children remains weak. Studies addressing appropriate drug target ranges and monitoring requirements are urgently required in addition to site- and clinical situation-specific thrombosis management strategies.
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Affiliation(s)
- Paul Monagle
- Haematology Department, The Royal Children's Hospital, Department of Paediatrics, The University of Melbourne, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Anthony K C Chan
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Neil A Goldenberg
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplantation and Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado, Aurora, CO
| | - Rebecca N Ichord
- Department of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Janna M Journeycake
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX
| | - Ulrike Nowak-Göttl
- Thrombosis and Hemostasis Unit, Institute of Clinical Chemistry, University Hospital Kiel, Kiel, Germany
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK.
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Monagle P, Newall F, Campbell J. Anticoagulation in neonates and children: Pitfalls and dilemmas. Blood Rev 2010; 24:151-62. [PMID: 20663595 DOI: 10.1016/j.blre.2010.06.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Anticoagulation in children is problematic for many reasons, related to the patient population as well as the anticoagulant drugs themselves. This paper describes the multitude of reasons why providing anticoagulation therapy in children is different from anticoagulation therapy in adults, and hence why dedicated paediatric anticoagulant services are the ideal structure to provide this service. The paper then describes the three most common anticoagulants used in children, and details specifically what is and is not known about them in the paediatric population. Finally the paper addresses the issue of how best to introduce newer anticoagulant drugs into the paediatric population. There remains much research to be done in this field, in the meantime clinicians need to carefully consider the evidence available to them and manage each individual patient accordingly.
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Affiliation(s)
- Paul Monagle
- Department of Clinical Haematology, Royal Children's Hospital, Parkville, Victoria 3052, Australia.
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Trame MN, Mitchell L, Krümpel A, Male C, Hempel G, Nowak-Göttl U. Population pharmacokinetics of enoxaparin in infants, children and adolescents during secondary thromboembolic prophylaxis: a cohort study. J Thromb Haemost 2010; 8:1950-8. [PMID: 20586920 DOI: 10.1111/j.1538-7836.2010.03964.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Enoxaparin has been extensively studied in adults on its safety and efficacy during prevention of symptomatic thromboembolism when acute anticoagulation or secondary prevention is required as a result of venous thrombosis or stroke. In children, it is still used off-label and little is known about the pharmacokinetics in children. OBJECTIVES The aim of the present study was to evaluate whether a once- or twice-daily dosing regimen would be feasible in children to achieve appropriate plasma levels of enoxaparin. PATIENTS/METHODS A population pharmacokinetic model was developed using anti-factor (F)Xa activity data from 126 children (median age: 5.9 years) receiving enoxaparin either as a once- or twice-daily dosing regimen. RESULTS A two-compartment model was adequate for describing the enoxaparin kinetics. Body weight proved to be the most predictive covariate for clearance and central volume of distribution: clearance 15 mL h⁻¹ kg⁻¹, central volume of distribution 169 mL kg⁻¹, intercompartmental clearance 58 mL h⁻¹, peripheral volume of distribution 10 L and absorption rate 0.414 h⁻¹. Interindividual variability was found to be 54% for clearance and 42% for volume of distribution. CONCLUSION The model is capable of describing all age groups and dosing levels of our population and predicts 12 h and 24 h enoxaparin activities sufficiently. According to our results, a once-daily enoxaparin dosing regimen with frequent monitoring is feasible. In 53.2% of the patients the median 24 h trough level was above the desired range of 0.1 IU mL⁻¹ anti-FXa activity for prophylaxis therapy.
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Affiliation(s)
- M N Trame
- Department of Pharmaceutical and Medical Chemistry - Clinical Pharmacy, University of Münster, Münster, Germany.
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16
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Abstract
The number of children receiving anticoagulation is increasing. Thromboembolic events are associated with significant risk of morbidity and mortality although the optimal management of asymptomatic events remains unclear. Specific challenges in paediatrics include the diagnosis of thrombosis, delivery and monitoring of anticoagulation in a wide range of ages from neonates through to adolescents. The development of the haemostatic system as children age results in changing pathophysiology of thrombosis and response to anticoagulation agents. Although registry and observational studies have provided vital information, specific paediatric, prospective anticoagulation studies have been few and limited in design. The result is that much of current practice is extrapolated from adult studies. Traditional anticoagulants have significant limitations. Both heparin and warfarin are in widespread use but many fundamental questions regarding dose, therapeutic range, efficacy and optimum duration have not been fully answered. Alternative agents, such as direct thrombin inhibitors and the selective anti-factor Xa inhibitor fondaparinux, may have advantages for children. Clinical trials in adults and preliminary data in children are promising but caution should be applied until specific paediatric studies have demonstrated safety and efficacy.
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Affiliation(s)
- Jeanette H Payne
- Department of Paediatric Haematology, Sheffield Children's Hospital, Sheffield, UK.
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17
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Cerebral venous thrombosis treated with enoxaparin in an IUGR neonate with DIC. Childs Nerv Syst 2009; 25:899-902. [PMID: 19373478 DOI: 10.1007/s00381-009-0860-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 02/17/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The case of a term IUGR newborn who presented a cerebral vein thrombosis diagnosed by routine ultrasound brain scan, and confirmed by magnetic resonance imaging and magnetic resonance venography, is reported. A thrombosis of cortical cerebral veins and intracerebral haemorrhage in the right frontal paramedian region was observed. METHODS Treatment with enoxaparin was started at the initial dose of 0.5 mg/kg subcutaneously every 12 h and then at 1.25 mg/kg per 12 h in order to obtain anti-factor Xa levels between 0.5 and 1.0 U/ml. After hospital discharge, enoxaparin was continued for 2 months with a lower dose (1.8 mg/kg/die). CONCLUSION Treatment with enoxaparin was effective as demonstrated by a complete "restitutio ad integrum".
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18
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Effects of nadroparin, enoxaparin, and unfractionated heparin on endogenous factor Xa and IIa formation and on thrombelastometry profiles. Blood Coagul Fibrinolysis 2009; 20:71-7. [DOI: 10.1097/mbc.0b013e32831d0f80] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Monagle P, Chalmers E, Chan A, deVeber G, Kirkham F, Massicotte P, Michelson AD. Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; 133:887S-968S. [PMID: 18574281 DOI: 10.1378/chest.08-0762] [Citation(s) in RCA: 415] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This chapter about antithrombotic therapy in neonates and children is part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patient values may lead to different choices (for a full understanding of the grading, see Guyatt et al in this supplement, pages 123S-131S). In this chapter, many recommendations are based on extrapolation of adult data, and the reader is referred to the appropriate chapters relating to guidelines for adult populations. Within this chapter, the majority of recommendations are separate for neonates and children, reflecting the significant differences in epidemiology of thrombosis and safety and efficacy of therapy in these two populations. Among the key recommendations in this chapter are the following: In children with first episode of venous thromboembolism (VTE), we recommend anticoagulant therapy with either unfractionated heparin (UFH) or low-molecular-weight heparin (LMWH) [Grade 1B]. Dosing of IV UFH should prolong the activated partial thromboplastin time (aPTT) to a range that corresponds to an anti-factor Xa assay (anti-FXa) level of 0.35 to 0.7 U/mL, whereas LMWH should achieve an anti-FXa level of 0.5 to 1.0 U/mL 4 h after an injection for twice-daily dosing. In neonates with first VTE, we suggest either anticoagulation or supportive care with radiologic monitoring and subsequent anticoagulation if extension of the thrombosis occurs during supportive care (Grade 2C). We recommend against the use of routine systemic thromboprophylaxis for children with central venous lines (Grade 1B). For children with cerebral sinovenous thrombosis (CSVT) without significant intracranial hemorrhage (ICH), we recommend anticoagulation initially with UFH, or LMWH and subsequently with LMWH or vitamin K antagonists (VKAs) for a minimum of 3 months (Grade 1B). For children with non-sickle-cell disease-related acute arterial ischemic stroke (AIS), we recommend UFH or LMWH or aspirin (1 to 5 mg/kg/d) as initial therapy until dissection and embolic causes have been excluded (Grade 1B). For neonates with a first AIS, in the absence of a documented ongoing cardioembolic source, we recommend against anticoagulation or aspirin therapy (Grade 1B).
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Affiliation(s)
- Paul Monagle
- From the Haematology Department, The Royal Children's Hospital and Department of Pathology, The University of Melbourne, Melbourne, VIC, Australia.
| | - Elizabeth Chalmers
- Consultant Pediatric Hematologist, Royal Hospital for Sick Children, Glasgow, UK
| | | | - Gabrielle deVeber
- Division of Neurology, Hospital for Sick Children, Toronto, ON, Canada
| | | | - Patricia Massicotte
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Alan D Michelson
- Center for Platelet Function Studies, University of Massachusetts Medical School, Worcester, MA
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20
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Abstract
Low-molecular-weight heparins are increasingly used for treatment of pediatric venous thromboembolic disease (VTE). Pediatric data about therapeutic doses of nadroparin are not available. To evaluate pharmacodynamics and safety of therapeutic doses of nadroparin, consecutive patients (age 0 to 18 y) with objectively diagnosed VTE and treated with nadroparin were included in this single center study over a 12-year period. All patients started with 85.5 IU/kg of nadroparin twice daily. The target therapeutic range (TTR) was set at 0.5 to 1.0 anti-Xa IU/mL 4 hours postdose. Safety end points were major bleeding and therapy-related death. A total of 84 patients were enrolled, of whom 8 patients did not undergo measurement of anti-Xa levels. Fifty-four (71%) of 76 patients achieved TTR. The maintenance dose (mean+/-SE) was 448+/-42 IU/kg/d in neonates (<2 mo, n=6), 253+/-22 IU/kg/d in infants (2 mo to 1 y, n=10), 214+/-8 IU/kg/d in children (2 to 11 y, n=13), and 183+/-5 IU/kg/d in adolescents (12 to 18 y, n=25). Neonates required significantly more dose adjustments and time to achieve TTR than adolescents. No major bleeding or therapy-related death occurred. In summary, an age-dependent response to nadroparin exists in pediatric patients. Nadroparin therapy seems to be safe for treatment of pediatric VTE.
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21
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Nowak-Göttl U, Bidlingmaier C, Krümpel A, Göttl L, Kenet G. Pharmacokinetics, efficacy, and safety of LMWHs in venous thrombosis and stroke in neonates, infants and children. Br J Pharmacol 2007; 153:1120-7. [PMID: 17906688 PMCID: PMC2275453 DOI: 10.1038/sj.bjp.0707447] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Since the early nineties it has been shown that low molecular weight heparin (LMWH) has significant advantages over unfractionated heparin and oral anticoagulants for both the treatment and the prevention of thrombosis, not only in adults, but also in children. The present review was based on an 'EMBASE', 'Medline' and 'PubMed' search including literature published in any language since 1980 on LMWH in neonates, infants and children. It included paediatric pharmacokinetic studies, the use of LMWH in children with venous thrombosis, LMWH administration in paediatric patients with ischaemic stroke, and its use in order to prevent symptomatic thromboembolism in children at risk. An increasing rate of off-label use of LMWH in children has been reported, showing that LMWHs offer important benefits to children with symptomatic thromboembolic events and poor venous access. Two well-conducted pharmacokinetic studies in this age group showed that neonates and younger infants require higher LMWH doses than older children to achieve the targeted anti-Xa levels, due to an increased extra vascular clearance. Recurrent symptomatic thromboses under LMWH occur in approximately 4% of children treated for venous thrombosis, and in 7% of children treated for stroke; major bleed was documented in 3% of children with therapeutic target LMWH anti-Xa levels, whereas minor bleeding was reported in approximately 23% of children receiving either therapeutic or prophylactic doses, respectively. Further randomized controlled trials are recommended to evaluate the optimum duration and application for different LMWH indications in children.
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Affiliation(s)
- U Nowak-Göttl
- Department of Paediatric Haematology and Oncology, University of Münster, Münster, Germany.
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22
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Nouri S, Mahdhaoui N, Beizig S, Salem N, Methlouthi J, Ben Dhafer S, Seboui H. Thrombose aortique néonatale majeure: à propos d'une observation. Arch Pediatr 2007; 14:1097-100. [PMID: 17572076 DOI: 10.1016/j.arcped.2007.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Accepted: 05/11/2007] [Indexed: 11/15/2022]
Abstract
Aortic thrombosis is a rare and severe condition in neonates which often is revealed by ischemia of lower limbs. We report a case of major aortic thrombosis revealed by renal failure, hematuria and dehydration in a 10-day-old girl. Clinical features consisted in hypertension at upper limbs without ischemic signs of the lower limbs. Diagnosis was made using renal Doppler ultrasound. Thrombosis resolved after thrombolytic treatment and anticoagulation using heparin. The case report is followed by a review of the literature dealing with clinical, etiological and therapeutic aspects of neonatal arterial thrombosis.
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Affiliation(s)
- S Nouri
- Service de néonatologie, CHU Farhat-Hached, avenue Ibn-El-Jazzar, 4000 Sousse, Tunisie.
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23
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Merkel N, Gunther G, Schobess R. Long-term treatment of thrombosis with enoxaparin in pediatric and adolescent patients. Acta Haematol 2006; 115:230-6. [PMID: 16549901 DOI: 10.1159/000090940] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Thrombosis is a rare event in childhood and adolescence. Nevertheless, increasing numbers of invasive diagnostic and therapeutic procedures also result in increasing numbers of thromboses in pediatric cases, necessitating effective antithrombotic treatment regimens. In recent years, low-molecular-weight heparins (LMWH) in particular have been proved to be a safe and effective alternative to unfractioned heparins. However, the application of LMWH in pediatric patients has not been supported by a single controlled study so far. Furthermore, there is no official approval of these drugs for children. In this pilot study 27 children with deep venous thromboses (DVT) were treated with the LMWH enoxaparin at a dosage of 1.5 mg/kg body weight b.i.d. in neonates and infants and 1 mg/kg body weight b.i.d. in children. This dosage was lowered for prophylaxis if therapeutic success was achieved. The aim of the study was to investigate both, efficacy with respect to patency rates and safety during acute and long-term follow-up. Sufficient therapeutic success required a rapid production of anti-Xa target activity and was reached in 85% of the treated patients, who showed patency of the affected vessel at last follow-up. The mean duration of treatment with full dosage was 16.5 days, followed by prophylaxis over a mean duration of 9.8 months. Rethrombosis or adverse events including heparin-induced thrombocytopenia were not observed in any patient. In conclusion, enoxaparin provides an effective and safe alternative to unfractioned heparins in the treatment of thrombosis in infancy, childhood and adolescence.
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Affiliation(s)
- Nick Merkel
- Universitatsklinik und Poliklinik fur Kinder- und Jugendmedizin, Martin-Luther-Universitat Halle-Wittenberg, Halle/Saale, Deutschland
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24
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Van Ommen CH, Peters M. Acute pulmonary embolism in childhood. Thromb Res 2006; 118:13-25. [PMID: 15992866 DOI: 10.1016/j.thromres.2005.05.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2005] [Revised: 03/11/2005] [Accepted: 05/19/2005] [Indexed: 10/25/2022]
Abstract
Pulmonary embolism is an uncommon, but potentially fatal disease in children. Most children with pulmonary embolism have underlying clinical conditions, of which the presence of a central venous catheter is the most frequent. The clinical presentation is often subtle, or masked by the underlying clinical condition. Diagnostic as well as therapeutic strategies for pulmonary embolism in children are mostly extrapolated from studies in adults. Pulmonary angiography is still the gold standard in diagnosing pulmonary embolism, but several other radiographic tests can be used to diagnose pulmonary embolism, including ventilation-perfusion lung scanning, helical computed tomography, magnetic resonance imaging and echocardiography. The choice of treatment depends on the clinical presentation of the patient. Anticoagulation is the mainstay of therapy for children with pulmonary embolism. However, thrombolytic therapy can be considered for patients with hemodynamic instability. The outcome of pediatric pulmonary embolism is uncertain and needs to be studied.
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Affiliation(s)
- C Heleen Van Ommen
- Department of Pediatric Hematology, Emma Children's Hospital AMC, PO Box 22700, 1100 DE Amsterdam, The Netherlands.
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25
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Wiernikowski JT, Athale UH. Thromboembolic complications in children with cancer. Thromb Res 2006; 118:137-52. [PMID: 16039698 DOI: 10.1016/j.thromres.2005.06.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2005] [Revised: 06/06/2005] [Accepted: 06/07/2005] [Indexed: 10/25/2022]
Abstract
Thrombosis is a significant problem in patients with cancer. The impact of thromboembolism in association with childhood cancer is not clearly defined. Similarly the information of prevention and management of thromboembolic events in children receiving cancer-therapy is limited. This review aims to examine current knowledge regarding the epidemiology, pathophysiology and management of thrombosis in association with cancer in children.
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Affiliation(s)
- John T Wiernikowski
- Division of Hematology/Oncology, McMaster Children's Hospital Hamilton, Ontario, Canada
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26
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Shaw PH, Ranganathan S, Gaines B. A spontaneous intramural hematoma of the bowel presenting as obstruction in a child receiving low-molecular-weight heparin. J Pediatr Hematol Oncol 2005; 27:558-60. [PMID: 16217261 DOI: 10.1097/01.mph.0000183865.56533.9b] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Low-molecular-weight heparin (LMWH) is a safe and effective alternative to unfractionated heparin and coumadin in the treatment and prophylaxis of thrombosis in children. When compared with these more established anticoagulants, it is easier to achieve therapeutic levels and the incidence of hemorrhagic complications is equivalent or lower. In children there is less published experience than in adults, but the low frequency of significant bleeding appears to be similar. The authors describe a child on therapeutic doses of LMWH for a deep vein thrombosis who spontaneously developed an intramural hemorrhage in his small bowel, leading to infarction and a partial bowel resection.
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Affiliation(s)
- Peter H Shaw
- Department of Pediatrics, University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh, Pittsburgh, PA 15213-2583, USA. shawph@chpedu
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27
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Ho SH, Wu JK, Hamilton DP, Dix DB, Wadsworth LD. An assessment of published pediatric dosage guidelines for enoxaparin: a retrospective review. J Pediatr Hematol Oncol 2004; 26:561-6. [PMID: 15342982 DOI: 10.1097/01.mph.0000139453.22338.d9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the ability of published dosage guidelines for enoxaparin to achieve therapeutic anticoagulation and to determine whether the routine monitoring of anti-Xa levels is still necessary at a tertiary care pediatric institution. METHODS Consecutive charts and laboratory records were reviewed for all patients receiving treatment doses of enoxaparin for thrombosis in the authors institution over a 4-year period (1998-2002). RESULTS Sixty-six percent (25/38) of the anti-Xa levels were within the recommended therapeutic range (0.5-1.0 [+/- 10%] U/mL) after two doses. The success rates of achieving therapeutic levels were 1/6, 2/3, 6/9, 10/11, and 6/9, for patients 2 months or younger, more than 2 months to 1 year, more than 1 year to 6 years, more than 6 years to 12 years, and more than 12 years of age, respectively. Patients with cardiac or renal disease were more likely to achieve high anti-Xa levels. Thirty-seven percent of patients reported adverse effects. The most common effects were injection site-related bruising and minor bleeding. One patient experienced a major bleed that was not life-threatening. CONCLUSIONS Most patients achieved therapeutic anticoagulation when dosed according to the published guidelines. Children with cardiac conditions or renal insufficiency or those younger than 2 months were more likely to require dosage adjustments to achieve the therapeutic range. Routine monitoring of anti-Xa levels is still necessary in these patient populations, particularly when the early establishment of therapeutic anticoagulation may be critical. Enoxaparin appears to be well tolerated in the authors' patient population.
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Affiliation(s)
- Sharon H Ho
- Department of Pharmacy, British Columbia's Children's Hospital, Vancouver, British Columbia, Canada.
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28
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Affiliation(s)
- Deepa Bhojwani
- Department of Pediatrics, The New York University Medical Center, New York, New York, USA
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29
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Gosselin RC, King JH, Janatpour KA, Dager WE, Larkin EC, Owings JT. Variability of Plasma Anti-Xa Activities with Different Lots of Enoxaparin. Ann Pharmacother 2004; 38:563-8. [PMID: 14982983 DOI: 10.1345/aph.1d245] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Previous studies have indicated the variability of anti-Xa activity in different sources of heparin and the variability of different methods used for measuring anti-Xa activity. Manufacturers of low-molecular-weight heparins (LMWHs) determine each lot's anti-Xa activity against the World Health Organization standard, but little information is known about anti-Xa activity variation between lots of LMWH and the impact on reported anti-Xa activity in patient samples. OBJECTIVE To determine the variation of plasma anti-Xa activity in patients receiving enoxaparin when different lots of enoxaparin are used for test calibration. METHODS We obtained 7 lots of enoxaparin containing approximately 10 000 IU/mL and one lot containing approximately 15 000 IU/mL of anti-Xa activity. For each lot, a 2.0 anti-Xa IU/mL dilution was prepared and a calibration curve performed using a chromogenic method. To test the variation in reported results between the different calibration lots, 20 patient samples were tested. Nineteen patients receiving enoxaparin and one patient not receiving enoxaparin (negative control) were tested in a blinded fashion, and the changes in light absorbance recorded. Anti-Xa activity results from tested plasmas were then extrapolated from each enoxaparin lot calibration curve. RESULTS Using Student's paired t-test, there were statistically significant differences between the plasma anti-Xa activities generated from the various enoxaparin lots. In the range of 0.5–1.0 IU/mL of anti-Xa activity, 3 (4.2%) samples had a >0.2 IU/mL difference (maximum difference 0.33 IU/mL) in anti-Xa activity between 2 lots of enoxaparin. For samples that had supratherapeutic anti-Xa activities (1.0–1.5 IU/mL anti-Xa activity), there was a wider variation (>0.2 IU/mL) in anti-Xa activity, which may have resulted in a dosing change. CONCLUSIONS The statistical differences in plasma anti-Xa activities noted between enoxaparin lots are not clinically significant. However, anti-Xa activities in the upper therapeutic and supratherapeutic ranges (>1.0 IU/mL of anti-Xa activity) resulted in a deviation of >0.3 IU/mL in reported anti-Xa activity, which may result in dosing changes.
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Affiliation(s)
- Robert C Gosselin
- Department of Pathology, University of California Davis Medical Center, Sacramento, CA 95817-2201, USA
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Revel-Vilk S, Sharathkumar A, Massicotte P, Marzinotto V, Daneman A, Dix D, Chan A. Natural history of arterial and venous thrombosis in children treated with low molecular weight heparin: a longitudinal study by ultrasound. J Thromb Haemost 2004; 2:42-6. [PMID: 14717964 DOI: 10.1111/j.1538-7836.2004.00532.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Low molecular weight heparin (LMWH) is efficacious in preventing recurrent thromboembolic events (TEs) in children. The efficacy of LMWH in resolving thrombus in children is, however, unknown and may differ from what has been observed in adults due to known differences in the hemostatic system. We reviewed the ultrasound (US) scanning reports of children treated with LMWH in order to determine the rate and predictors of thrombus resolution. Of 245 children consecutively treated for a non-cerebral TE with enoxaparin (Lovenox, Aventis Pharma Inc., QC, Canada) for at least 5 consecutive days, 190 (78%) had serial ultrasound available for analysis. The mean follow-up time was 7 months (median 3 months, range 3 days to 6.6 years). The rate of complete thrombus resolution was 101/190 (53%, 95% confidence interval 46.2-60.2%). On univariate analysis, arterial and non-occlusive thrombus had an increased rate of resolution when compared with venous and occlusive thrombus. Age at time of TE (neonates vs. non-neonates), location of TE, initial treatment (unfractionated heparin vs. LMWH) and dose of enoxaparin were not related to outcome. On multivariate analysis, type of vessel (vein vs. artery) and occlusion (occlusive vs. non-occlusive thrombus) independently predicted outcome. In children, the rate of complete thrombus resolution is similar to the rate in adults. The clinical significance of residual abnormal vessels, specifically to the occurrence of post-thrombotic syndrome and for the diagnosis of recurrence, needs to be explored in prospective studies.
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Affiliation(s)
- S Revel-Vilk
- Pediatric Hematology/Oncology unit, Hadassah Hebrew University Hospital, Jerusalem, Israel
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Nowak-Göttl U, Sträeter R, Sébire G, Kirkham F. Antithrombotic drug treatment of pediatric patients with ischemic stroke. Paediatr Drugs 2003; 5:167-75. [PMID: 12608881 DOI: 10.2165/00128072-200305030-00003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Causes of stroke in children include congenital heart malformations, sickle cell disease, infections, and metabolic disorders. Up to 80% of children with ischemic stroke have cerebrovascular disease, and case control studies demonstrate an association of ischemic stroke in children with hereditary prothrombotic risk factors. There have been no randomized, clinical trials for primary prevention, short-term treatment, or secondary prevention of pediatric ischemic stroke. Treatment recommendations are based on small case series or case reports, and have mainly been adapted from adult stroke studies. Antiplatelet agents (e.g. aspirin [acetylsalicylic acid]) and heparins (e.g. low molecular weight heparin), have been used on an individual patient basis. Warfarin is administered in children with cardioembolic stroke, arterial dissection, or persistent hypercoagulable states. Alteplase has been used in a few patients within 3 hours of the onset of symptoms. In each patient treated the benefit of anticoagulation has to be weighed up against the individual bleeding risk.
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Affiliation(s)
- Ulrike Nowak-Göttl
- Department of Paediatric Haematology and Oncology, University Paediatric Hospital, University of Münster, Albert-Schweitzer-Strasse 3, 48149 Münster, Germany.
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32
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Roschitz B, Beitzke A, Gamillscheg A, Sudi K, Koestenberger M, Leschnik B, Muntean W. Signs of thrombin generation in pediatric cardiac catheterization with unfractionated heparin bolus or subcutaneous low molecular weight heparin for antithrombotic cover. Thromb Res 2003; 111:335-41. [PMID: 14698650 DOI: 10.1016/j.thromres.2003.09.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Thrombosis is one of the most frequent adverse events after cardiac catheterization, which can be reduced by anticoagulation with unfractionated heparin (UFH) in both children and adults. Low molecular weight heparin (LMWH) might possibly offer advantages. Laboratory signs of thrombin generation during pediatric cardiac catheterization, with unfractionated heparin (UFH) bolus or subcutaneous LMWH for thrombosis prophylaxis, were determined in a first step to investigate the potential of LMWH for antithrombotic cover. MATERIALS AND METHODS Signs of thrombin generation (D-dimer and F1+2), anti-Xa activity and activated clotting time (ACT) were measured in 65 patients with congenital heart disease. A total of 40 patients were treated with a UFH bolus of 100 IU/kg bodyweight and, in 25 children, enoxaparin was subcutaneously administered at a dosage of 1/1.6 mg/kg bodyweight. RESULTS The dose to plasma activity of enoxaparin was more consistent than in the UFH group. Only a slight elevation of F1+2 was found in some patients, which was a little higher in the enoxaparin group, but no difference of incidence of increased F1+2 generation was detected between the two groups. D-dimer was elevated in three children after UFH bolus application, but no such effect was observed in any child after LMWH administration. CONCLUSIONS Application of LMWH was equally efficacious during pediatric cardiac catheterization than UFH bolus administration, as determined by plasma levels and markers of clotting activation. In contrast to UFH bolus, no further monitoring was necessary after the application of LMWH during cardiac catheterization due to a consistent dose to plasma activity.
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Affiliation(s)
- Birgit Roschitz
- Ludwig Boltzmann Research Institute for Pediatric Thrombosis and Hemostasis, Division of Pediatric Cardiology, Graz, Austria
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