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Albisetti M, Tartakovsky I, Halton J, Bomgaars L, Chalmers E, Mitchell LG, Luciani M, Nurmeev I, Gorbatikov K, Miede C, Brueckmann M, Brandão LR. Dabigatran for Treatment and Secondary Prevention of Venous Thromboembolism in Pediatric Congenital Heart Disease. J Am Heart Assoc 2024; 13:e028957. [PMID: 38348778 PMCID: PMC11010117 DOI: 10.1161/jaha.122.028957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/02/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND Congenital heart disease (CHD) is common in children and associated with greater risk of thrombotic complications. Management of these complications with standard-of-care treatment is suboptimal for these children. METHODS AND RESULTS The effectiveness and safety of dabigatran were demonstrated in pivotal pediatric studies for the treatment of acute venous thromboembolism (VTE; NCT01895777) and secondary VTE prevention (NCT02197416). We report safety and efficacy outcomes from subgroup analyses of these studies for children with CHD (diagnosed according to local practice) and those without. In NCT01895777, 17/21 (81.0%) and 16/27 (59.3%) patients with CHD (including cyanotic) treated with dabigatran and standard of care, respectively, met the primary end point (complete thrombus resolution, freedom from recurrent VTE, and freedom from VTE-related death; odds ratio [OR], 0.34 [95% CI, 0.08-1.23]). In patients without CHD, 41.0% (n=64) versus 34.9% (n=22) achieved this end point with the respective treatments (OR, 0.77 [95% CI, 0.42-1.41]). Although numerical differences were observed, no heterogeneity in treatment effect of dabigatran on the composite primary end point was detected in patients with and without CHD (interaction P =0.2674). In NCT02197416, recurrent VTE at 12 months occurred in 0/17 patients with CHD versus 3/194 (1.5%) without. No patient with CHD experienced major or clinically relevant nonmajor bleeding events. CONCLUSIONS Data on favorable anticoagulant alternatives for the unmet needs of children with CHD are emerging, and our exploratory results suggest that dabigatran could be an appropriate treatment choice, although challenging sample size limitations in pediatric studies require cautious interpretation of findings. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifiers: NCT01895777, NCT02197416.
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Affiliation(s)
- Manuela Albisetti
- Hematology Department University Children's Hospital Zürich Switzerland
| | | | - Jacqueline Halton
- Children's Hospital of Eastern Ontario University of Ottawa Ottawa Ontario Canada
| | - Lisa Bomgaars
- Department of Pediatrics Texas Children's Hospital, Baylor College of Medicine Houston TX USA
| | | | | | - Matteo Luciani
- Pediatric Hematology/Oncology Department Pediatric Hospital Bambino Gesù Rome Italy
| | - Ildar Nurmeev
- Pediatric Hospital, Republic of Tatarstan Kazan Medical University Kazan Russian Federation
| | - Kirill Gorbatikov
- Pediatric Cardiovascular Surgery Regional Hospital #1 Tyumen Region Russian Federation
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH Ingelheim Germany
- First Department of Medicine Faculty of Medicine Mannheim of the University of Heidelberg Mannheim Germany
| | - Leonardo R Brandão
- The Hospital for Sick Children University of Toronto Toronto Ontario Canada
- Dalla Lana School of Public Health University of Toronto Toronto Ontario Canada
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Halton J, Brandão LR, Luciani M, Bomgaars L, Chalmers E, Mitchell LG, Nurmeev I, Sharathkumar A, Svirin P, Gorbatikov K, Tartakovsky I, Simetzberger M, Huang F, Sun Z, Kreuzer J, Gropper S, Reilly P, Brueckmann M, Albisetti M. Dabigatran etexilate for the treatment of acute venous thromboembolism in children (DIVERSITY): a randomised, controlled, open-label, phase 2b/3, non-inferiority trial. Lancet Haematol 2020; 8:e22-e33. [PMID: 33290737 DOI: 10.1016/s2352-3026(20)30368-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/29/2020] [Accepted: 11/04/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dabigatran etexilate is a direct oral anticoagulant with potential to overcome the limitations of standard of care in children with venous thromboembolism. The aims of this clinical trial were to study the appropriateness of a paediatric dabigatran dosing algorithm, and the efficacy and safety of dabigatran dosed according to that algorithm versus standard of care in treating children with venous thromboembolism. METHODS DIVERSITY is a randomised, controlled, open-label, parallel-group, phase 2b/3 non-inferiority trial done in 65 centres in 26 countries. Standard of care (low-molecular-weight heparins, unfractionated heparin, vitamin K antagonists or fondaparinux) was compared with a paediatric oral dabigatran dosing regimen (an age-adjusted and weight-adjusted nomogram) in children younger than 18 years with acute venous thromboembolism initially treated (5-21 days) with parenteral anticoagulation, requiring anticoagulation therapy for at least 3 months. Patients were randomised 1:2 (standard of care:dabigatran) and stratified by age (12 to <18 years, 2 to <12 years, and birth to <2 years) via interactive response technology. The primary composite efficacy endpoint (intention-to-treat analysis) was the proportion of children with complete thrombus resolution, and freedom from recurrent venous thromboembolism and venous thromboembolism-related death. A non-inferiority margin of absolute differences of 20% was used. Secondary endpoints included safety (determined by major bleeding events [time-to-event analysis on the treated set]), and pharmacokinetic-pharmacodynamic relationships (descriptive analyses). This trial is registered with ClinicalTrials.gov, NCT01895777 and is completed. FINDINGS 328 children were enrolled between Feb 18, 2014, and Nov 14, 2019. 267 were randomly assigned (90 [34%] to standard of care and 177 [66%] to dabigatran) and included in the analyses. Median exposure to standard of care was 85·0 days (IQR 80·0-90·0) and to dabigatran was 84·5 days (78·0-89·0). Similar proportions of children treated with standard of care and dabigatran met the composite efficacy endpoint (38 [42%] of 90 vs 81 [46%] of 177; Mantel-Haenszel weighted difference, -0·04; 90% CI -0·14 to 0·07; p<0·0001 for non-inferiority). On-treatment bleeding events were reported in 22 (24%) of 90 children receiving standard of care and 38 (22%) of 176 children receiving dabigatran (hazard ratio [HR] 1·15, 95% CI 0·68 to 1·94; p=0·61); major bleeding events were similar between the groups (two [2%] of 90 and four [2%] of 176; HR 0·94, 95% CI 0·17 to 5·16; p=0·95). Pharmacokinetic-pharmacodynamic curves showed a linear relationship between total dabigatran plasma concentration and diluted thrombin time and ecarin clotting time, and a non-linear relationship with activated partial thromboplastin time; curves were similar to those for adults. Serious adverse events were reported for 18 (20%) of 90 children receiving standard of care and 22 (13%) of 176 children receiving dabigatran. The most common severe adverse events were vascular disorders (standard of care three [3%] of 90, dabigatran two [1%] of 176), and gastrointestinal disorders (standard of care two [2%] of 90 and dabigatran five [3%] of 176). One on-treatment death occurred in the standard of care group (retroperitoneal bleeding, not considered treatment related by the study investigators). INTERPRETATION An age-adjusted and weight-adjusted dabigatran dosing algorithm was appropriate in children aged birth to less than 18 years with venous thromboembolism. Dabigatran was non-inferior to standard of care in terms of efficacy, with similar pharmacokinetic-pharmacodynamic relationships as those seen in adults, and might be a suitable alternative to standard of care. FUNDING Boehringer Ingelheim.
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Affiliation(s)
- Jacqueline Halton
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | | | - Matteo Luciani
- Pediatric Hematology/Oncology Department, Pediatric Hospital Bambino Gesù, Rome, Italy
| | - Lisa Bomgaars
- Department of Pediatrics, Texas Children's Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX, USA
| | | | - Lesley G Mitchell
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Ildar Nurmeev
- Pediatric Hospital, Republic of Tatarstan, Kazan Medical University, Kazan, Russian Federation
| | - Anjali Sharathkumar
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Pavel Svirin
- Pediatric Hematology Department, Municipal Children's Hospital "Morozovskaya", Moscow, Russian Federation
| | - Kirill Gorbatikov
- Pediatric Cardiovascular Surgery, Regional hospital #1, Tyumen region, Russia
| | - Igor Tartakovsky
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International, Ingelheim am Rhein, Germany
| | | | - Fenglei Huang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Zhichao Sun
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | | | - Savion Gropper
- Therapeutic Area Inflammation Medicine, Boehringer Ingelheim International, Ingelheim, Germany
| | - Paul Reilly
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA
| | - Martina Brueckmann
- Therapeutic Area Cardiovascular Medicine, Boehringer Ingelheim International Pharma, Ingelheim, Germany; Faculty of Medicine Mannheim of the University of Heidelberg, Mannheim, Germany
| | - Manuela Albisetti
- Hematology Department, University Children's Hospital, Zurich, Switzerland.
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