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Bhat RV, Young G, Sharathkumar AA. How I treat pediatric venous thromboembolism in the DOAC era. Blood 2024; 143:389-403. [PMID: 37390311 PMCID: PMC10862368 DOI: 10.1182/blood.2022018966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/02/2023] Open
Abstract
ABSTRACT The direct oral anticoagulants (DOACs) rivaroxaban and dabigatran are newly licensed for the treatment and prevention of venous thromboembolism (VTE) in children and mark a renaissance in pediatric anticoagulation management. They provide a convenient option over standard-of-care anticoagulants (heparins, fondaparinux, and vitamin K antagonists) because of their oral route of administration, child-friendly formulations, and significant reduction in monitoring. However, limitations related to therapeutic monitoring when needed and the lack of approved reversal agents for DOACs in children raise some safety concerns. There is accumulating experience of safety and efficacy of DOACs in adults for a broad scope of indications; however, the cumulative experience of using DOACs in pediatrics, specifically for those with coexisting chronic illnesses, is sparse. Consequently, clinicians must often rely on their experience for treating VTE and extrapolate from data in adults while using DOACs in children. In this article, the authors share their experience of managing 4 scenarios that hematologists are likely to encounter in their day-to-day practice. Topics addressed include (1) appropriateness of indication; (2) use for special populations of children; (3) considerations for laboratory monitoring; (4) transition between anticoagulants; (5) major drug interactions; (6) perioperative management; and (7) anticoagulation reversal.
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Affiliation(s)
- Rukhmi V. Bhat
- Center for Cancer and Blood Disorders, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
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Fasanya C, Arrillaga A, Caronia C, Rothburd L, Japhe T, Hahn Y, Joseph P, Reci D, Eckardt P. Use of Andexanet Alfa for Factor Xa Inhibitor Reversal in US Verified Trauma Centers: A National Survey. Clin Appl Thromb Hemost 2024; 30:10760296241238013. [PMID: 38494906 PMCID: PMC10946067 DOI: 10.1177/10760296241238013] [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: 11/16/2023] [Revised: 02/14/2024] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
Direct oral factor Xa inhibitors are replacing vitamin K-dependent antagonists as anticoagulation treatment in many clinical scenarios. Trauma centers are noting an increase in patients presenting on these medications. The 2018 Food and Drug Administration approval of andexanet alfa provides an alternative anticoagulation reversal. Barriers may limit utilization of new medications including a lack of grade 1A evidence supporting the use of prothrombin complex concentrate (PCC) versus andexanet alfa and cost. To evaluate barriers of andexanet alfa utilization by trauma surgeons, a 15-question survey was conducted. There was a 9% completion rate (n = 89). The results revealed 23.5% would choose andexanet alfa as first-line treatment in children, and 25.8% as first-line treatment in adults. The majority of respondents, 64.7% and 67.4%, would use PCC preferentially in children and adults, respectively. Respondents indicated that cost burden was an overriding factor (76.3%); 42.4% cited lack of high-level efficacy data of andexanet alfa for reversal of factor Xa inhibitors. Additional double-blinded multi-institutional randomized controlled trials comparing 4F-PCC and andexanet alfa for factor Xa inhibitor reversal are needed to support efficacy especially with the increased cost associated.
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Affiliation(s)
- Charles Fasanya
- Department of Trauma Surgery/Critical Care, Good Samaritan University Hospital, West Islip, New York, USA
| | - Abenámar Arrillaga
- Department of Trauma Surgery/Critical Care, Good Samaritan University Hospital, West Islip, New York, USA
| | - Catherine Caronia
- Department of Pediatrics, Graduate Medical Education, Good Samaritan University Hospital, West Islip, New York, USA
| | - Lauren Rothburd
- Trauma Services, Good Samaritan University Hospital, West Islip, New York, USA
| | - Tenzing Japhe
- Department of Surgery, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Younghee Hahn
- Department of Surgery, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Paul Joseph
- Department of Surgery, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Dajana Reci
- Department of Surgery, New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York, USA
| | - Patricia Eckardt
- Trauma Services, Nursing Administration, Good Samaritan University Hospital, West Islip, New York, USA
- Barbara H. Hagan School of Nursing and Health Sciences, Molloy University, Rockville Centre, New York, USA
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Al-Ghafry M, Sharathkumar A. Direct oral anticoagulants in pediatric venous thromboembolism: Review of approved products rivaroxaban and dabigatran. Front Pediatr 2022; 10:1005098. [PMID: 36313874 PMCID: PMC9606656 DOI: 10.3389/fped.2022.1005098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/12/2022] [Indexed: 11/29/2022] Open
Abstract
Venous thromboembolism is a major hospital acquired complication in the pediatric population over the last two-decades, with a 130% increase in the past decade. Direct oral anticoagulants (DOACs) are a newer class of anticoagulant medication for the treatment and prophylaxis of VTEs that provide the primary advantages of an oral route of administration without a requirement to adjust dosing to achieve a therapeutic level. It is anticipated that these medications will quickly replace parenteral anticoagulants and clinicians should familiarize themselves with DOACs. In this article, we provide an overview of the pharmacological properties of DOACs, with a specific focus on rivaroxaban and dabigatran, which have been approved for use in pediatric patients. Each drug's characteristics are discussed along with data from their respective clinical trials.
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Affiliation(s)
- Maha Al-Ghafry
- Division of Pediatric Hematology and Oncology, Royal Hospital, Muscat, Oman
| | - Anjali Sharathkumar
- Division of Pediatric Hematology and Oncology Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, United States
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