Strategies to Prevent and Manage Thrombotic Complications of Acute Lymphoblastic Leukemia in Children and Young People Vary Between Centers in the United Kingdom

Abstract

There is a lack of evidence-based guidance for the prevention and management of thrombosis in children and young people treated for acute lymphoblastic leukemia. To determine current UK practice, a survey was sent to 28 centers participating in the Medical Research Council UKALL 2011 trial. Marked variation in practice was noted. In total, 43% of centers defer central venous access device insertion until end of induction for treatment of low-risk disease. Central venous access devices are removed at the end of intensive blocks in 38% and end of treatment in 42%. Duration of anticoagulation for line-associated thrombosis is 6 weeks in 43% and 3 months in 33% and for cerebral sinovenous thrombosis is 3 months in 71% and 6 months in 24%. Platelet transfusion to maintain platelet count >50×10/L, in preference to interrupting therapeutic anticoagulation, is used by 50% for line-associated thrombosis and 73% for cerebral sinovenous thrombosis. Conformity of practice was seen in some areas. In total, 70% treat thrombosis with twice-daily low-molecular weight heparin and 86% monitor antifactor Xa activity levels. In total, 91% reexpose individuals to asparaginase following a thrombotic event. Given this variation in practice, in the absence of high-quality evidence, consensus guidelines may be helpful.

BSH Guideline: management of thrombotic and haemostatic issues in paediatric malignancy

“…There are no data available to define a safe platelet count for continuation of therapeutic anticoagulant therapy in those being treated for VTE. Consensus opinion suggests that a count >50 × 10 9 /l is adequate for continuation of full therapeutic anticoagulation (Manco‐Johnson et al , 2006; Payne, ; Farge et al , ) although a lower threshold of 30 × 10 9 /l is used by some centres in stable patients with no other risk factors for bleeding (Biss et al , ). In life‐threatening VTE, or if recurrent thrombosis is more likely, e.g.…”

“…Venous thromboembolism (VTE) and bleeding are serious complications of cancer and its treatment. A recent survey of UK paediatric haematologists and oncologists identified a broad variety of practice in the management of issues relating to these complications in children with leukaemia, reflecting significant areas of uncertainty (Biss et al , , ). The purpose of this guideline is to provide information and guidance on the management of these issues in children being treated for leukaemia and other forms of cancer.…”

Supportive methods for childhood acute lymphoblastic leukemia then and now: A compilation for clinical practice

“…Thromboembolic complications are well known and frequently observed in childhood ALL ( 70 ) and can lead to acute events with increased morbidity and mortality as well as to long-term sequelae. However, there is no consensus on the safety and effectiveness of thromboembolic prophylaxis in children to date and the most varied approaches from different centers were observed ( 71 ). So far, many studies have dealt with this topic, with the result that only low molecular weight heparin can effectively and safely reduce thromboembolic complications in pediatric oncology (especially in ALL) ( 22 , 72 ).…”

Prophylaxis with enoxaparin and antithrombin III in drug-induced coagulation alterations in childhood leukemia: a retrospective experience of 20 years

“…Thus, several authors agree that prophylaxis with anticoagulants should be considered in this sensitive phase of therapy [ 4 ]. However, to date there is no generally valid consensus on the effectiveness of thromboembolic prophylaxis in children with cancer and different centers take different approaches [ 5 ]. As early as 2008, we were able to show that the use of prophylactic low-molecular-weight heparin (LMWH) in combination with AT III substitution led to a significant reduction in severe thrombosis without increasing the risk of major bleeding [ 6 ].…”