Anticoagulant therapy in pediatrics

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.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

“…For UFH, a bolus of 75 IU/kg followed by perfusion at 28 IU/kg/hour for infants < 1 year of age and 20 IU/kg/ hour for older children is generally used, adjusted to an APTT of 55 e 85 seconds. 291 Succesful treatment by systemic thrombolysis is also reported, although there is a risk of intracranial bleeding, especially in preterm infants. 292e 294 Long term outcomes of conservative management have also been evaluated, suggesting that 15% of affected children will have either intermittent claudication or limb discrepancy as a result of impaired growth later in life.…”

Effect of Plasmapheresis on the Anti-Factor Xa Activity of Enoxaparin in an Obese Adolescent Patient

“…In adult patients, LMWHs have been shown to be more efficacious than unfractionated heparin in the treatment of acute venous thromboembolism (VTE) . In adolescent patients, LMWHs are often the anticoagulant of choice because of their lower risk of heparin‐induced thrombocytopenia, lack of drug or diet interactions, and extensive clinical experience . In instances where monitoring is recommended due to variable pharmacokinetics and pharmacodynamics (e.g., obese patients, pediatric and adolescent patients), an anti–factor Xa assay can determine the level of anticoagulation of a particular LMWH.…”

“…2 In adolescent patients, LMWHs are often the anticoagulant of choice because of their lower risk of heparin-induced thrombocytopenia, lack of drug or diet interactions, and extensive clinical experience. 3,4 In instances where monitoring is recommended due to variable pharmacokinetics and pharmacodynamics (e.g., obese patients, pediatric and adolescent patients), an anti-factor Xa assay can determine *Address for correspondence: Jeremy S. Stultz Plasmapheresis is a procedure for removing blood components, including plasma, antibodies, or cells, and is an immunotherapy used for the management of autoimmune-mediated encephalopathy in children. 5 Separation of blood components is accomplished through the use of semipermeable membranes or centrifugation.…”

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“…Different coagulation disorders are benefiting from the use of LMWH to initiate anticoagulation like atrial fibrillation, unstable angina, and non-Q-wave myocardial infarction (MI), deep-vein thrombosis, and pulmonary emboli 2 . Enoxaparin has multiple clinical advantages as a more predictable dose response, a longer half-life for outpatient use, no obvious drug or food interactions, and lower risk of osteoporosis 3 .…”