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van Ommen CH, Luijnenburg SE. Anticoagulation of pediatric patients with venous thromboembolism in 2023. Thromb Res 2024; 235:186-193. [PMID: 38378308 DOI: 10.1016/j.thromres.2023.12.019] [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: 09/30/2023] [Revised: 12/24/2023] [Accepted: 12/24/2023] [Indexed: 02/22/2024]
Abstract
Venous thromboembolism (VTE) is a rare and heterozygous disease in children. Management of VTE in children is complicated by age-related differences in epidemiology, recurrent VTE and bleeding risk, hemostatic proteins and pharmacokinetics of anticoagulants. Recently, the choice of anticoagulation has expanded to oral factor IIa and Xa inhibitors, which have been authorized for children for treatment of acute VTE and extended secondary prevention. These drugs have several properties that make them extremely suitable for use in children, including oral administration, antithrombin independence, less interactions with food and drugs and no need for monitoring. Unfortunately, the phase 3 studies had many exclusion criteria, and only a few term neonates and infants were included in these studies. Additional real-world data is needed to make evidence-based recommendations in these age and patient groups, as well.
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Affiliation(s)
- C Heleen van Ommen
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus MC, Rotterdam, the Netherlands.
| | - Saskia E Luijnenburg
- Department of Pediatric Hematology, Sophia Children's Hospital, Erasmus MC, Rotterdam, the Netherlands
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2
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Salem AM, Smith T, Wilkes J, Bailly DK, Heyrend C, Profsky M, Yellepeddi VK, Gopalakrishnan M. Pharmacokinetic Modeling Using Real-World Data to Optimize Unfractionated Heparin Dosing in Pediatric Patients on Extracorporeal Membrane Oxygenation and Evaluate Target Achievement-Clinical Outcomes Relationship. J Clin Pharmacol 2024; 64:30-44. [PMID: 37565528 DOI: 10.1002/jcph.2333] [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: 04/19/2023] [Accepted: 08/07/2023] [Indexed: 08/12/2023]
Abstract
Unfractionated heparin (UFH) is a commonly used anticoagulant for pediatric patients undergoing extracorporeal membrane oxygenation (ECMO), but evidence is lacking on the ideal dosing. We aimed to (1) develop a population pharmacokinetic (PK) model for UFH, measured through anti-factor Xa assay; (2) optimize UFH starting infusions and dose titrations through simulations; and (3) explore UFH exposure-clinical outcomes relationship. Data from 218 patients admitted to Utah's Primary Children's Hospital were retrospectively collected. A 1-compartment PK model with time-varying clearance (CL) adequately described UFH PK. Weight on CL and volume of distribution and ECMO circuit change on CL were significant covariates. The typical estimates for initial CL and first-order rate constant to reach steady-state CL were 0.57 L/(h·10 kg) and 0.02/h. Comparable to non-ECMO patients, the typical steady-state CL was 0.81 L/(h·10 kg). Simulations showed that a 75 IU/kg UFH bolus dose followed by starting infusions of 25 and 20 IU/h/kg for patients aged younger than 6 years and 6 years or older, respectively, achieved the therapeutic target in 56.6% of all patients, whereas only 3.1% exceeded the target. The proposed UFH titration schemes achieved the target in more than 90% of patients while less than 0.63% were above the target after 24 and 48 hours of treatment. The median intensive care unit survival time in patients within and below the target at 24 hours was 136 and 66 hours, respectively. In conclusion, PK model of UFH was developed for pediatric patients on ECMO. The proposed UFH dosing scheme attained the anti-factor Xa target rapidly and safely.
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Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Trey Smith
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Jacob Wilkes
- Pediatric Analytics, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - David K Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Caroline Heyrend
- Department of Pharmacy, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Michael Profsky
- Mechanical Circulatory Support, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, UT, USA
| | - Venkata K Yellepeddi
- Division of Clinical Pharmacology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Molecular Pharmaceutics, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, MD, USA
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Kiskaddon AL, Do NL, Williams P, Betensky M, Goldenberg NA. Anticoagulation with Intravenous Direct Thrombin Inhibitors in Pediatric Extracorporeal Membrane Oxygenation: A Systematic Review of the Literature. Semin Thromb Hemost 2023; 49:756-763. [PMID: 37643746 DOI: 10.1055/s-0043-1772838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Although intravenous (IV) direct thrombin inhibitors (DTI) have gained interest in pediatric extracorporeal membrane oxygenation (ECMO), dosing and safety information is limited. The objective of this systematic review was to characterize DTI types, dosing, monitoring, and outcomes (bleeding and thromboembolic) in pediatric ECMO patients managed with IV DTIs. We conducted searches of MEDLINE (Ovid) and Embase (Elsevier) from inception through December 2022. Case reports, retrospective studies, and prospective studies providing per-patients or summary data for patient(s) <18 years of age receiving IV DTI for ECMO anticoagulation were included. Study selection and data extraction were conducted independently by two reviewers. A total of 28 studies: 14 case reports, 13 retrospective studies, and 1 prospective study were included, totaling 329 patients. Bivalirudin was utilized in 318 (96.7%), argatroban in 9 (2.7%), and lepirudin in 2 (0.6%) patients. Infusion dosing included: bivalirudin 0.14 ± 0.37 mg/kg/h, argatroban 0.69 ± 0.73 µg/kg/min, lepirudin 0.14 ± 0.02 mg/kg/h. Laboratory monitoring tests utilized were the activated clotting time, activated partial thromboplastin time (aPTT), diluted thrombin time, and thromboelastography measures. The aPTT was utilized in most patients (95%). Thromboembolism, bleeding, or death were observed in 17%, 17%, and 23% of bivalirudin, argatroban, and lepirudin patients, respectively. Bivalirudin appears to be the most frequently used DTI in pediatric ECMO. Dosing and laboratory monitoring varied, and bleeding and thromboembolic events were reported in 17% of patients. Prospective studies are warranted to establish dosing, monitoring, safety, and efficacy of bivalirudin and other IV DTI in pediatric ECMO.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Department of Pediatrics, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nhue L Do
- Division of Pediatric Cardiac Surgery, Section of Surgical Sciences, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Pamela Williams
- Medical Library, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Marisol Betensky
- Department of Pediatrics, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida
| | - Neil A Goldenberg
- Department of Pediatrics, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins All Children's Institute for Clinical and Translational Research, St. Petersburg, Florida
- Departments of Pediatrics and Medicine, Division of Hematology, Johns Hopkins School of Medicine, Baltimore, Maryland
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Valdes CA, Sharaf OM, Bleiweis MS, Jacobs JP, Mumtaz M, Sharaf RM, Jeng EI, Peek GJ. Heparin-based versus bivalirudin-based anticoagulation in pediatric extracorporeal membrane oxygenation: A systematic review. Front Med (Lausanne) 2023; 10:1137134. [PMID: 36999064 PMCID: PMC10043325 DOI: 10.3389/fmed.2023.1137134] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
IntroductionOptimal anticoagulation therapy is essential for the prevention of thrombotic and hemorrhagic complications in pediatric patients supported with extracorporeal membrane oxygenation (ECMO). Recent data have demonstrated bivalirudin has the potential to surpass and replace heparin as the anticoagulant of choice.MethodsWe conducted a systematic review comparing the outcomes of heparin-based versus bivalirudin-based anticoagulation in pediatric patients supported on ECMO to identify the preferred anticoagulant to minimize bleeding events, thrombotic complications, and associated mortality. We referenced the PubMed, Cochrane Library, and Embase databases. These databases were searched from inception through October 2022. Our initial search identified 422 studies. All records were screened by two independent reviewers using the Covidence software for adherence to our inclusion criteria, and seven retrospective cohort studies were identified as appropriate for inclusion.ResultsIn total, 196 pediatric patients were anticoagulated with heparin and 117 were anticoagulated with bivalirudin while on ECMO. Across the included studies, it was found that for patients treated with bivalirudin, trends were noted toward lower rates of bleeding, transfusion requirements, and thrombosis with no difference in mortality. Overall costs associated with bivalirudin therapy were lower. Time to therapeutic anticoagulation varied between studies though institutions had different anticoagulation targets.ConclusionBivalirudin may be a safe, cost-effective alternative to heparin in achieving anticoagulation in pediatric ECMO patients. Prospective multicenter studies and randomized control trials with standard anticoagulation targets are needed to accurately compare outcomes associated with heparin versus bivalirudin in pediatric ECMO patients.
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Salem AM, Niu T, Li C, Moffett BS, Ivaturi V, Gopalakrishnan M. Reassessing the Pediatric Dosing Recommendations for Unfractionated Heparin Using Real-World Data: a Pharmacokinetic-Pharmacodynamic Modeling Approach. J Clin Pharmacol 2021; 62:733-746. [PMID: 34816442 DOI: 10.1002/jcph.2007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/19/2021] [Indexed: 11/07/2022]
Abstract
Optimal pediatric dosing of unfractionated heparin (UFH) is challenging due to paucity of clinical outcome and pharmacokinetic-pharmacodynamic (PK/PD) studies in pediatrics. This study aimed to: (i) develop a PK/PD model for UFH, quantified by anti-factor Xa assay and the UFH effect measured by activated partial thromboplastin time (aPTT) (ii) evaluate pediatric UFH infusions in achieving anti-factor Xa (0.3 - 0.7 IU/mL) therapeutic target by simulations. Electronic health record data were retrospectively collected from 633 patients < 19 years old admitted to Texas Children's Hospital. The PK/PD model was developed using a 70% (training)-30% (test) data split approach. A one-compartment PK model with linear elimination adequately described the UFH PK. An allometrically scaled body weight on clearance (CL) and volume of distribution (Vd) with an age-dependent maturation function of extracellular water on Vd were the covariates identified. Comparable with literature, the typical values for CL and Vd were 3.28 L/(hr·50 kg) and 8.83 L/50 kg, respectively. A linear model adequately described the UFH-aPTT relationship with an estimated slope of 150. Simulations of the currently recommended starting infusions (28 IU/hr/kg for pediatrics < 1 year old or 20 IU/hr/kg for pediatrics > 1 year old) showed that anti-factor Xa therapeutic target was achieved only in 15.3%, 14.6%, 36.9% and 45.11% of subjects in the age groups of < 1 year, 1-6 years, 6-12 years, and 12-19 years, respectively. In conclusion, the UFH anti-factor Xa target is not achieved initially especially in young pediatrics, suggesting the need to optimize UFH dosing to achieve higher therapeutic success. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ahmed M Salem
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Tao Niu
- Modeling & Simulations, Vertex Pharmaceuticals, Boston, MA, USA
| | - Chao Li
- Fosun Pharma, Princeton, NJ, USA
| | - Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, Texas, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Vijay Ivaturi
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mathangi Gopalakrishnan
- Center for Translational Medicine, Department of Pharmacy Practice, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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Röshammar D, Huang F, Albisetti M, Bomgaars L, Chalmers E, Luciani M, Halton J, Mitchell LG, Bergstrand M, Ibrahim MMA, Joseph D, Tartakovsky I, Gropper S, Brueckmann M, Brandão LR. Pharmacokinetic modeling and simulation support for age- and weight-adjusted dosing of dabigatran etexilate in children with venous thromboembolism. J Thromb Haemost 2021; 19:1259-1270. [PMID: 33636042 PMCID: PMC8251571 DOI: 10.1111/jth.15277] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/19/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Dabigatran etexilate (DE), a direct oral thrombin inhibitor, has been evaluated in children with venous thromboembolism (VTE) using oral solution, pellets, or capsules. OBJECTIVES This study evaluated DE pharmacokinetics (PK) in children with VTE and the appropriateness of a DE pediatric age- and weight-based dosing algorithm. PATIENTS/METHODS A population PK model was fitted to data from four single-arm and one randomized, comparative pediatric VTE studies (358 children aged birth to <18 years; 2748 PK observations) and one healthy-adult study (32 males aged <40 years; 1523 PK observations) using nonlinear mixed-effects modeling. A stepwise, covariate, model-building procedure evaluated the influence of covariates (e.g., age, body weight, body surface area [BSA]-normalized renal function, and sex). The final model was used to evaluate the pediatric dosing algorithm, with simulations comparing pediatric trough exposure with reference exposure defined for the pediatric studies. RESULTS The population PK of dabigatran was adequately described by a two-compartment model with first-order elimination and absorption. Age, weight, BSA-normalized renal function, and sex were statistically significant covariates (all P < .05). Apparent clearance increased with age (independently of body weight), diminished with decreasing BSA-normalized renal function, and was lower in females than males. All disposition parameters increased with body weight escalation (allometric scaling). Simulations confirmed that for all DE formulations, the final pediatric dosing algorithms achieved reference exposure without dose adjustment. CONCLUSIONS Using a population PK model of DE for children with VTE, simulations showed that the final dosing algorithms were appropriate for all DE formulations; no dose titration was needed.
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Affiliation(s)
| | - Fenglei Huang
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldConnecticutUSA
| | - Manuela Albisetti
- Hematology DepartmentUniversity Children’s HospitalZürichSwitzerland
| | - Lisa Bomgaars
- Department of PediatricsTexas Children’s Cancer CenterBaylor College of MedicineHoustonTexasUSA
| | - Elizabeth Chalmers
- Department of HaematologyRoyal Hospital for Children, GlasgowScotlandUnited Kingdom
| | - Matteo Luciani
- Pediatric Hematology/Oncology DepartmentPediatric Hospital Bambino GesùRomeItaly
| | - Jacqueline Halton
- Department of Pediatrics, Children’s Hospital of Eastern OntarioUniversity of OttawaOttawaOntarioCanada
| | - Lesley G. Mitchell
- Katz Group Centre for ResearchUniversity of AlbertaEdmontonAlbertaCanada
| | | | | | - David Joseph
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldConnecticutUSA
| | - Igor Tartakovsky
- Therapeutic Area Cardiovascular MedicineBoehringer Ingelheim International GmbHIngelheimGermany
| | - Savion Gropper
- Therapeutic Area Inflammation MedicineBoehringer Ingelheim International GmbHIngelheimGermany
| | - Martina Brueckmann
- Therapeutic Area Cardiovascular MedicineBoehringer Ingelheim International GmbHIngelheimGermany
- Faculty of Medicine Mannheim of the University of HeidelbergMannheimGermany
| | - Leonardo R. Brandão
- Department of PaediatricsThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
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Effectiveness and Safety of Nadroparin Therapy in Preterm and Term Neonates with Venous Thromboembolism. J Clin Med 2021; 10:jcm10071483. [PMID: 33918440 PMCID: PMC8038284 DOI: 10.3390/jcm10071483] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/19/2021] [Accepted: 03/26/2021] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Optimal neonatal nadroparin dosages to treat venous thromboembolism (VTE) are unknown. OBJECTIVE To evaluate therapeutic nadroparin dosages to reach therapeutic target ranges (TTR: 0.5-1.0 International Unit (IU)/mL) and the effectiveness and safety of nadroparin in neonatal VTE. METHODS Retrospective study including neonates with VTE on nadroparin in a tertiary center between 2007 and 2018. Two groups were distinguished: neonates before (group 1) and after (group 2) switch to higher starting dosages in 2014. RESULTS Sixty-one neonates (44 preterm, 17 term) with 64 VTEs were included. TTR was reached in 32/64 (50%) VTEs (group 1: 35.7%; group 2: 61.1%). Median nadroparin dosage to reach TTR was 197 (97.9-330.3) IU/kg/12 h. No therapy-related deaths occurred. Recurrent VTE developed in 6 (9.8%) neonates. Complete clot resolution was observed in 31/41 (75.6%) VTEs. TTR was reached in 58.1% VTEs with complete clot resolution. No major bleeding occurred. Non-major clinically relevant bleedings occurred in 3/64 (4.7%) VTEs, consisting of large hematomas due to the use of subcutaneous catheters. CONCLUSIONS High nadroparin dosages are needed to reach TTR in neonates, which seem to be safe. Clot resolution may occur without reaching TTR. Subcutaneous catheters may cause important bleeding complications.
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Prospective Exploratory Experience With Bivalirudin Anticoagulation in Pediatric Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:975-985. [PMID: 32976347 DOI: 10.1097/pcc.0000000000002527] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Objective of this study was to determine if bivalirudin resulted in less circuit interventions than unfractionated heparin. A secondary objective was to examine associations between bivalirudin dose and partial thromboplastin time, international normalized ratio, and activated clotting time. DESIGN Prospective observational. SETTING Medical-surgical and cardiac PICUs. PATIENTS Neonatal and pediatric extracorporeal membrane oxygenation patients who received bivalirudin anticoagulation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty extracorporeal membrane oxygenation runs in 18 patients used bivalirudin; 90% were venoarterial. Median (interquartile range) age was 4.5 months (1.6-35 mo). Thirteen patients (72%) had an underlying cardiac diagnosis. Of the 20 runs using bivalirudin, 16 (80%) were initially started on unfractionated heparin and transitioned to bivalirudin due to ongoing circuit thrombosis despite therapeutic anti-Xa levels (n = 13), ongoing circuit thrombosis with unfractionated heparin greater than or equal to 40 U/kg/hr (n = 2), or absence of increase in ACT after bolus of 100 U/kg of unfractionated heparin and escalation of unfractionated heparin infusion (n = 1). Initial bivalirudin dose ranged from 0.2 to 0.5 mg/kg/hr; no bolus doses were used. Median (range) bivalirudin dose was 0.9 mg/kg/hr (0.15-1.6 mg/kg/hr). Median (interquartile range) time on extracorporeal membrane oxygenation was 226.5 hours (150.5-393.0 hr) including 84 hours (47-335 hr) on bivalirudin. Nonparametric results are as follows: the rate of circuit intervention was significantly lower in patients on bivalirudin than on unfractionated heparin (median [interquartile range]: 0 [0-1] and 1 [1-2], respectively; Wilcoxon p = 0.0126). Bivalirudin dose was correlated to PTT (rs = 0.4760; p < 0.0001), INR (rs = 0.6833; p < 0.0001), and ACT (rs = 0.6161; p < 0.0001). Four patients had a significant bleeding complication on bivalirudin. Survival to hospital discharge was 56%. CONCLUSIONS Bivalirudin appears to be a viable option for systemic anticoagulation in pediatric extracorporeal membrane oxygenation patients who have failed unfractionated heparin, but questions remain namely its optimal monitoring strategy. This pilot study supports the need for larger prospective studies of bivalirudin in pediatric extracorporeal membrane oxygenation, particularly focusing on meaningful monitoring variables.
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Challenges and Opportunities in the Pharmacological Treatment of Acute Venous Thromboembolism in Children. Paediatr Drugs 2020; 22:385-397. [PMID: 32519267 DOI: 10.1007/s40272-020-00403-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Venous thromboembolism (VTE) is an important but historically under-recognized problem in pediatrics, with an incidence concentrated in hospitalized children. A number of specific VTE diseases with discrete triggers have been described, but the most common pediatric trigger is the presence of central venous access devices. VTE diseases, though heterogenous in etiology, are linked by the common therapeutic strategies shared by their management. Historically, the most commonly used drug therapies have been unfractionated heparin, low-molecular-weight heparins, and vitamin K antagonists, based on extrapolation from adult data rather than any specific pediatric trials. Although these widely used drugs appear safe and effective in expert hands, the historical lack of pediatric data is problematic in view of the recognized significant differences between children and adults with regards to hemostatic physiology, VTE etiology, and drug pharmacokinetics. The increasing adult usage of novel VTE pharmacotherapies such as direct oral anticoagulants (DOACs) has led to considerable interest in exploring the pediatric applications of these newer drugs. This review summarizes the advantages and disadvantages of existing VTE pharmacotherapies and outlines emerging novel pediatric VTE therapies, particularly DOACs, within the context of the current pediatric trial landscape.
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Sniderman J, Monagle P, Annich GM, MacLaren G. Hematologic concerns in extracorporeal membrane oxygenation. Res Pract Thromb Haemost 2020; 4:455-468. [PMID: 32548547 PMCID: PMC7292669 DOI: 10.1002/rth2.12346] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022] Open
Abstract
This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.
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Affiliation(s)
| | - Paul Monagle
- Department of PaediatricsDepartment of HaematologyUniversity of MelbourneThe Royal Children's HospitalHaematology Research Murdoch Children’s Research InstituteMelbourneVic.Australia
| | - Gail M. Annich
- Department of Critical Care MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Graeme MacLaren
- Paediatric ICURoyal Children’s HospitalMelbourneVic.Australia
- Department of PaediatricsUniversity of MelbourneParkvilleVic.Australia
- Cardiothoracic ICUNational University Health SystemSingapore CitySingapore
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Avila ML, Shah PS, Brandão LR. Different unfractionated heparin doses for preventing arterial thrombosis in children undergoing cardiac catheterization. Cochrane Database Syst Rev 2020; 2:CD010196. [PMID: 32065663 PMCID: PMC7025780 DOI: 10.1002/14651858.cd010196.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The role of cardiac catheterization in pediatrics has progressed significantly over the last two decades, evolving from a primary diagnostic tool to a primary treatment modality in children with congenital heart disease. Vascular complications, particularly arterial thrombosis, are among the most common unwanted post-cardiac catheterization events. In 1974, unfractionated heparin proved to be superior to placebo in decreasing the incidence of arterial thrombosis in pediatric patients. However, the optimal dose of unfractionated heparin to be utilized in this setting remains a matter of controversy. This is an update of the review first published in 2014. OBJECTIVES To evaluate the use of low-dose (< 100 units/kg) versus high-dose (≥ 100 units/kg) unfractionated heparin administered as an intravenous bolus at the time of initiation of cardiac catheterization (that is, immediately after arterial puncture), with or without subsequent heparin maintenance doses, for the prevention of post-procedural arterial thrombosis in children. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 15 October 2019. We planned to undertake reference checking of identified trials to identify additional studies. No language restrictions were applied. SELECTION CRITERIA We included randomized or quasi-randomized trials that compared low dose to high dose unfractionated heparin administered prior to cardiac catheterization. We selected studies conducted in children aged 0 to 18 years. DATA COLLECTION AND ANALYSIS The first screening of potentially eligible studies was conducted by one of the authors (MLA). The second screening, risk of bias assessment and data extraction were independently conducted by two authors (MLA, LRB). Outcomes (thrombotic events, bleeding complications, other complications) were treated as dichotomous variables. The effect measures used were risk ratio (RR), risk difference (RD) and number needed to treat (NNT), with 95% confidence intervals (CI). We assessed the certainty of evidence for each outcome using the GRADE approach. MAIN RESULTS We identified no new studies for inclusion in this review. In total, two studies with a total of 492 participants were included. We had concerns about risk of bias for one of the two studies. The certainty of the evidence for our key outcomes was downgraded to moderate due to risk of bias concerns and imprecision. The confidence interval for the risk of arterial thrombotic events was compatible with benefits of either high or low unfractionated heparin dose regimens (RR low-dose versus high-dose 1.06, 95% CI 0.58 to 1.92). Only one of the studies reported the frequency of bleeding events and found no clear difference in the incidence of major or minor bleeding events between arms (RR low-dose versus high-dose 2.96, 95% CI 0.12 to 71.34 for major bleeding events; RR low-dose versus high-dose 1.38, 95% CI 0.46 to 4.13 for minor bleeding). This study also reported on the incidence of deep vein thrombosis when comparing the high versus low dose of heparin and reported a non-significant difference (RR low-dose versus high-dose 0.34, 95% CI 0.01 to 8.28). The other study lacked information about bleeding. Additional side effects of heparin other than bleeding events were not reported in either of the studies. AUTHORS' CONCLUSIONS Due to the limitations of the current evidence, small number of included studies, and lack of details reported in one study, we are unable to determine the effects of different dosing regimens of unfractionated heparin for the prevention of vascular thrombosis during cardiac catheterization in children. Further adequately powered, randomized clinical trials are needed.
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Affiliation(s)
- Maria L Avila
- The Hospital for Sick ChildrenDivision of Haematology‐Oncology555 University AvenueTorontoONCanadaM5G 1X8
| | - Prakeshkumar S Shah
- University of Toronto Mount Sinai HospitalDepartment of Paediatrics and Institute of Health Policy, Management and Evaluation600 University AvenueTorontoONCanadaM5G 1XB
| | - Leonardo R Brandão
- The Hospital for Sick ChildrenDivision of Haematology‐Oncology555 University AvenueTorontoONCanadaM5G 1X8
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Cao H, Xia X, Fu J, Wu T, Chen W, Dai Y, Xia X, Zhang J. Gene-based anticoagulation regimens for an infant after mitral-valve replacement: A case report. Medicine (Baltimore) 2020; 99:e18651. [PMID: 31914049 PMCID: PMC6959923 DOI: 10.1097/md.0000000000018651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 11/06/2019] [Accepted: 12/04/2019] [Indexed: 12/04/2022] Open
Abstract
RATIONALE Heart-valve replacement is one of the main surgical methods for various heart-valve diseases. Warfarin is the only oral anticoagulant used for thrombosis prevention after heart-valve replacement. However, warfarin has a narrow therapeutic window, large differences in efficacy between individuals, and can be affected by drugs, food and disease status. PATIENT CONCERNS We used the Hamberg model to develop an anticoagulation regimen for a 10-month-old Chinese male after mitral-valve replacement. DIAGNOSES Echocardiography revealed mitral malformation with severe regurgitation, patent foramen ovale, thickening of the left ventricular wall, enlargement of the left atrium, and the overall systolic function of the left ventricle was lower than normal. INTERVENTIONS First, the patient was treated with Mitral valvuloplasty plus temporary implantation of a pacing wire. Since this was inadequate, he underwent mitral-valve replacement. Then, we used the Hamberg model to develop an anticoagulation regimen. OUTCOMES After discharge from hospital, the pharmacist provided anticoagulation management for this pediatric patient using an "Online Anticoagulation Clinic" (OAC). Point-of-care testing could be employed by the boy's mother at home to obtain the International Normalized Ratio. His time to response was 89.6% during the 6 months after hospital discharge, and adverse reactions such as bleeding or thrombosis did not occur. LESSONS This is the first time the Hamberg model has been employed to design anticoagulation therapy for an Asian infant. His anticoagulation therapy may be managed using the OAC.
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Affiliation(s)
- Hua Cao
- Department of Cardiac Surgery, Fujian Medical University Union Hospital Fujian Maternity and Children Health Hospital, Fuzhou, Fujian, PR China
| | - Xiaotong Xia
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of pharmacy, Fujian Medical University
| | - Jinglan Fu
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of pharmacy, Fujian Medical University
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of pharmacy, Fujian Medical University
| | - Wenjun Chen
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of pharmacy, Fujian Medical University
| | - Ying Dai
- Department of Pharmacy, Fujian Medical University Union Hospital
| | - Xuan Xia
- Department of Pharmacy, Fujian Medical University Union Hospital
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital
- College of pharmacy, Fujian Medical University
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13
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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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14
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Maas H, Gropper S, Huang F, Stangier J, Tartakovsky I, Brueckmann M, Halton JML, Mitchell LG. Anticoagulant Effects of Dabigatran in Paediatric Patients Compared with Adults: Combined Data from Three Paediatric Clinical Trials. Thromb Haemost 2018; 118:1625-1636. [PMID: 30112751 PMCID: PMC6202931 DOI: 10.1055/s-0038-1668132] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Physiological age-related changes in the haemostatic and coagulation systems result in differing anticoagulant assay responses to standard anticoagulants. Therefore, we investigated the response of anticoagulant assays to dabigatran etexilate (DE) in children compared with adults. OBJECTIVE This article assesses the relationship between plasma dabigatran concentration and coagulation assay results across age groups in children and adults. PATIENTS AND METHODS Data from three clinical trials in which children received DE following standard of care for venous thromboembolism were compared with data from adult clinical trials. The effects of dabigatran concentration on diluted thrombin time (dTT), ecarin clotting time (ECT) and activated partial thromboplastin time (aPTT) were analysed graphically and with modelling. RESULTS The concentration-dTT relationships were consistent in children across all ages and adults in the graphical analysis. For ECT and aPTT, relationships based on ratios over baseline were similar across all ages; absolute clotting times showed that the same exposure resulted in longer clotting times in some of the children aged < 1 year versus adults. Modelling showed concentration-clotting time relationships for all three assays were largely comparable between adults and children, except in those aged < 2 months, in whom there was a slight upward shift in ECT and aPTT relative to adults. CONCLUSION Results suggest that developmental haemostatic changes will have little impact on response to DE. However, further paediatric clinical trials assessing the relationship between coagulation assay responses and clinical outcomes will be needed to confirm this finding.
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Affiliation(s)
- Hugo Maas
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Savion Gropper
- Clinical Development and Medical Affairs, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Fenglei Huang
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States
| | - Joachim Stangier
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Igor Tartakovsky
- Clinical Development and Medical Affairs, Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Martina Brueckmann
- Clinical Development and Medical Affairs, Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim, Department of Medicine I, University of Heidelberg, Mannheim, Germany
| | - Jacqueline M L Halton
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Lesley G Mitchell
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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15
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Voulgarelis S, Vitola B, Lerret SM, Hong JC, Scott JP. Perioperative anticoagulation practices for pediatric liver transplantation. Pediatr Transplant 2018; 22:e13193. [PMID: 29663585 DOI: 10.1111/petr.13193] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2018] [Indexed: 12/13/2022]
Abstract
Despite continued advancements in perioperative care for pediatric liver transplant (LT), graft-threatening vascular occlusion events including hepatic artery thrombosis (HAT) and portal vein thrombosis (PVT) remain a source of significant morbidity and mortality. Perioperative anticoagulation is commonly used for the prevention of HAT and PVT, but evidence-based guidelines are lacking. The goals of this survey were to determine the frequency of use of an anticoagulation protocol and to describe variation in anticoagulation practices among pediatric LT centers. The study consisted of an online survey distributed to members of SPLIT. The survey focused on institutional anticoagulation practices employed to reduce the incidence of graft and life-threatening vascular occlusion events. Responses were received from 31 of 39 SPLIT centers. All respondents report using anticoagulation after pediatric LT, and approximately 90% have institutional anticoagulation protocols. Subgroup analysis of high volume pediatric LT centers revealed similar variability in anticoagulation patterns. All participating SPLIT centers reported the use of post-transplant anticoagulation and nearly all use a protocol. However, there is marked variability in the type and dose of anticoagulation as well as the timing of initiation and duration of therapy across centers.
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Affiliation(s)
- Stylianos Voulgarelis
- Divisions of Pediatric and Adult Cardiac Anesthesiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Bernadette Vitola
- Division of Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Stacee M Lerret
- Division of Gastroenterology and Transplant Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - John P Scott
- Divisions of Pediatric Anesthesiology and Pediatric Critical Care, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Pediatric Liver Transplant Anesthesia, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA.,Pediatric Intensive Care Unit, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI, USA
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16
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Nakamura S, Honjo O, Crawford-Lean L, Foreman C, Sano M, O’Leary JD. Predicting Heparin Responsiveness in Children Before Cardiopulmonary Bypass. Anesth Analg 2018; 126:1617-1623. [DOI: 10.1213/ane.0000000000002785] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Newall F, Branchford B, Male C. Anticoagulant prophylaxis and therapy in children: current challenges and emerging issues. J Thromb Haemost 2018; 16:196-208. [PMID: 29316202 DOI: 10.1111/jth.13913] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This review is aimed at describing the unique challenges of anticoagulant prophylaxis and treatment in children, and highlighting areas for research for improving clinical outcomes of children with thromboembolic disease. The evidence presented demonstrates the challenges of advancing the evidence base informing optimal management of thromboembolic disease in children. Recent observational studies have identified risk factors for venous thromboembolism in children, but there are few interventional studies assessing the benefit-risk balance of using thromboprophylaxis in risk-stratified clinical subgroups. A risk level-based framework is proposed for administering mechanical and pharmacological thromboprophylaxis. More research is required to refine the assignment of risk levels. The anticoagulants currently used predominantly in children are unfractionated heparin, low molecular weight heparin, and vitamin K antagonists. There is a paucity of robust evidence on the age-specific pharmacology of these agents, and their efficacy and safety for prevention and treatment of thrombosis in children. The available literature is heterogeneous, reflecting age-specific differences, and the various clinical settings for anticoagulation in children. Monitoring assays and target ranges are not well established. Nevertheless, weight-based dosing appears to achieve acceptable outcomes in most indications. Given the limitations of the classical anticoagulants for children, there is great interest in the direct oral anticoagulants (DOACs), whose properties appear to be particularly suitable for children. All DOACs currently approved for adults have Pediatric Investigation Plans ongoing or planned. These are generating age-specific formulations and systematic dosing information. The ongoing pediatric studies still have to establish whether DOACs have a positive benefit-risk balance in the various pediatric indications and age groups.
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Affiliation(s)
- F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Haematology Research Group, Murdoch Childrens Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - B Branchford
- Department of Pediatrics, Section of Hematology/Oncology/Bone Marrow Transplant and the Hemophilia and Thrombosis Center, School of Medicine and Center for Cancer and Blood Disorders, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - C Male
- Haemostasis and Thrombosis Unit, Department of Paediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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18
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Patricia Massicotte M, Bauman ME. Developmental hemostasis and ventricular assist devices: A troubled relationship. PROGRESS IN PEDIATRIC CARDIOLOGY 2017. [DOI: 10.1016/j.ppedcard.2017.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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19
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Hepponstall M, Chan A, Monagle P. Anticoagulation therapy in neonates, children and adolescents. Blood Cells Mol Dis 2017; 67:41-47. [DOI: 10.1016/j.bcmd.2017.05.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 05/10/2017] [Accepted: 05/10/2017] [Indexed: 01/29/2023]
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20
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Hanslik A, Kitzmüller E, Tran US, Thom K, Karapetian H, Prutsch N, Voitl J, Michel-Behnke I, Newall F, Male C. Anti-activated factor II assay for monitoring unfractionated heparin in children: results of the HEARTCAT study. J Thromb Haemost 2017; 15:38-46. [PMID: 27736032 DOI: 10.1111/jth.13539] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Indexed: 11/30/2022]
Abstract
Essentials Unfractionated heparin has variable effects in children and therefore, monitoring is essential. A randomized controlled trial substudy investigating an anti-IIa assay in children was conducted. Anti-IIa values are lower in younger children, an effect more pronounced at low-dose heparin. Heparin effect on Xa and IIa is not equal, particularly in infants and after high-dose heparin. SUMMARY Background Unfractionated heparin (UFH) is used for the prophylaxis and treatment of thrombosis in children. Laboratory monitoring of UFH is needed to prevent over-anticoagulation or under-anticoagulation. Objectives To investigate the association between UFH dose and UFH effect as monitored with the anti-activated factor II (FIIa) assay, the relationship between anti-FIIa and anti-activated factor X (FXa) effects, and the influence of patient age and other factors on UFH effect. Patients and methods This was a randomized controlled trial in children during cardiac catheterization, comparing high-dose UFH (100 units kg-1 bolus) with low-dose UFH (50 units kg-1 bolus). Blood samples were drawn at baseline, and after 30 min, 60 min, and 90 min. For the purpose of this study, 49 children and 117 blood samples were evaluated. Results The anti-FIIa assay discriminated well between high-dose and low-dose UFH. Multiple regression demonstrated significant influences of UFH dose and age on anti-FIIa levels. Younger children had lower anti-FIIa levels than older children, an effect that was more pronounced with low-dose UFH. Anti-FXa/anti-FIIa ratios were equal with low-dose UFH. However, anti-FXa levels were relatively increased over anti-FIIa levels in infants and after high-dose UFH bolus administration. Conclusion The UFH effect on anti-FIIa levels is lower in infants than in older children. This influence of age appears to be dose-dependent, being more pronounced with low-dose UFH. Anti-FXa and anti-FIIa levels are not equal, particularly in infants and after high-dose UFH. Monitoring UFH solely with anti-FXa assays may not be sufficient in children, and the anti-FIIa assay may provide important complementary information.
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Affiliation(s)
- A Hanslik
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kitzmüller
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - U S Tran
- School of Psychology, University of Vienna, Vienna, Austria
| | - K Thom
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - H Karapetian
- Anesthesia and Intensive Care Medicine, Sozialmedizinisches Zentrum Ost, Vienna, Austria
| | - N Prutsch
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - J Voitl
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - I Michel-Behnke
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - F Newall
- Clinical Haematology & Nursing Research, Royal Children's Hospital, Melbourne, Australia
- Haematology Research Group, Murdoch Children's Research Institute and Departments of Paediatrics and Nursing, The University of Melbourne, Melbourne, Australia
| | - C Male
- Division of Pediatric Cardiology, Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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21
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How to use unfractionated heparin to treat neonatal thrombosis in clinical practice. Blood Coagul Fibrinolysis 2016; 27:605-14. [DOI: 10.1097/mbc.0000000000000469] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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22
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Al-Sallami H, Newall F, Monagle P, Ignjatovic V, Cranswick N, Duffull S. Development of a population pharmacokinetic-pharmacodynamic model of a single bolus dose of unfractionated heparin in paediatric patients. Br J Clin Pharmacol 2016; 82:178-84. [PMID: 26972703 DOI: 10.1111/bcp.12930] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 02/24/2016] [Accepted: 03/07/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Unfractionated heparin (UFH) is the anticoagulant of choice in paediatric patients undergoing a variety of cardiac procedures. There are currently no population pharmacokinetic-pharmacodynamic (PKPD) models for UFH in paediatrics. OBJECTIVE The aim of the present study was to develop and evaluate a PKPD model of UFH in paediatrics. METHODS Data from 64 children who received 75-100 IU kg(-1) of UFH during cardiac angiography were analysed. Five blood samples were collected at baseline and at 15, 30, 45 and 120 min postdose. The UFH concentration was quantified using a protamine titration assay. The UFH effect was quantified using activated partial thromboplastin time (aPTT). A PKPD model was fitted using nonlinear mixed-effects modelling. Patient covariates such as gender, weight (WT) and fat-free mass (FFM) were tested. The final model was evaluated using the likelihood ratio test and visual predictive checks (VPCs). RESULTS A one-compartment model with linear elimination provided the best fit for the dose-concentration data. FFM was a significant covariate on clearance. A linear model provided the best fit for the concentration-effect data using aPTT as a biomarker for effect. The models performed well using VPCs. However, when used to simulate UFH infusion (at a much lower dose), the model overpredicted target aPTT responses. CONCLUSIONS A PKPD model to describe the time course of the UFH effect was developed in a paediatric population. FFM was shown to describe drug disposition well. However, when applied to smaller UFH infusion doses, the model overpredicted target aPTT responses. This unsuccessful extrapolation may be attributed to a possible nonlinear relationship for heparin PKPD.
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Affiliation(s)
| | - Fiona Newall
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Clinical Haematology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Paul Monagle
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia.,Clinical Haematology, Royal Children's Hospital, Melbourne, Vic, Australia
| | - Vera Ignjatovic
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Melbourne, Vic, Australia
| | - Noel Cranswick
- Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Department of Pharmacology, University of Melbourne, Melbourne, Vic, Australia
| | - Stephen Duffull
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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23
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Neonatal Extracorporeal Membrane Oxygenation: Update on Management Strategies and Long-Term Outcomes. Adv Neonatal Care 2016; 16:26-36. [PMID: 26808515 DOI: 10.1097/anc.0000000000000244] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) can be deployed to support patients with severe cardiorespiratory failure unresponsive to conventional medical interventions. Neonatal trials have demonstrated that ECMO is an effective treatment of severe respiratory failure, with acceptable cognitive and functional outcomes. Technological advances in ECMO have resulted in improved safety and accessibility, contributing to decreased morbidity and improved survival of increasingly complex patients requiring ECMO support. PURPOSE This review aims to describe the innovations in ECMO technology and management in the neonatal population in the last decade. The long-term outcomes of neonatal patients requiring ECMO support will be discussed. SEARCH STRATEGY Relevant clinical trials from MEDLINE and the Cochrane Library were identified. The following key words were used: ECMO, infant, neonate, and outcomes. FINDINGS Challenges still remain in supporting the premature and/or low-birth-weight infant with severe respiratory failure, as well as infants with congenital diaphragmatic hernia. Neonatal ECMO survivors can present with neurodevelopmental and respiratory problems, which become more prominent with time. IMPLICATIONS FOR PRACTICE While newer technologies have led to fewer neonates with respiratory failure progressing to ECMO, it remains an important tool to in those who have failed conventional therapies. Given the presence of neurodevelopmental problems in neonatal ECMO survivors, multidisciplinary follow-up targeting motor performance, exercise capacity, behavior, and subtle learning deficits is warranted. IMPLICATIONS FOR RESEARCH With the overall decreasing use of neonatal ECMO, ECMO centers must find ways to maintain their expertise in the light of lower patient volumes amidst complex patient physiology.
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24
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Monitoring unfractionated heparin in children: a parallel-cohort randomized controlled trial comparing 2 dose protocols. Blood 2015; 126:2091-7. [PMID: 26239090 DOI: 10.1182/blood-2015-06-651661] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/30/2015] [Indexed: 11/20/2022] Open
Abstract
Monitoring unfractionated heparin (UFH) is crucial to prevent over- or under-anticoagulation. However, the optimal parameters for monitoring UFH in children are not well established. The study objectives were to investigate (1) the relationship between UFH dose and its anticoagulant effect as assessed by anti-Xa, activated partial thromboplastin time (aPTT) and activated clotting time (ACT); (2) other factors influencing UFH effect; (3) the agreement between the assays; and (4) the association between UFH effect and clinical outcome. HEARTCAT was a parallel-cohort randomized controlled trial comparing high-dose (100 U/kg bolus followed by age-based continuous infusion in randomized children) vs low-dose UFH (50 U/kg bolus) during cardiac catheterization in children. Blood samples were drawn before and after UFH administration at 30, 60, and 90 minutes. Four-hundred and two samples of 149 patients were evaluable. Anti-Xa, aPTT, and ACT all showed good discrimination between UFH doses. Regression models demonstrated the following determinants of UFH effect: UFH dose, age, baseline antithrombin (for anti-Xa), and baseline levels of aPTT and ACT, respectively. UFH effects were lower in infants compared with older children, which was more pronounced at low-dose than at high-dose UFH. Agreement between the 3 assays was poor. Most aPTT values were above therapeutic range or beyond measuring limit and thus of limited value for UFH monitoring. No association of UFH dose or effect with clinical outcome could be observed. In conclusion, all assays reflected a significant UFH dose-effect relationship, however, with poor agreement between the respective tests. The age-dependency of UFH effect was confirmed. Notably, the influence of age on UFH effect was dose-dependent.
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25
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Massicotte MP, Bauman ME, Murray J, Almond CS. Antithrombotic therapy for ventricular assist devices in children: do we really know what to do? J Thromb Haemost 2015; 13 Suppl 1:S343-50. [PMID: 26149046 DOI: 10.1111/jth.12928] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
The use of ventricular assist devices (VADs) in children is increasing. Stroke and device-related thromboembolism remain the most feared complications associated with VAD therapy in children. The presence of a VAD causes dysregulation of hemostasis due to the presence of foreign materials and sheer forces intrinsic to the device resulting in hypercoagulability and potentially life-threatening thrombosis. The use of antithrombotic therapy in adults with VADs modulates this disruption in hemostasis, decreasing the risk of thrombosis. Yet, differences in hemostasis in children (developmental hemostasis) may result in variances in dysregulation by these devices and preclude the use of adult guidelines. Consequently, pediatric device studies must include safety and efficacy estimates of device-specific antithrombotic therapy guidelines. This review will discuss mechanisms of hemostatic dysregulation as it pertains to VADs, goals of VAD antithrombotic therapy for children and adults, and emerging antithrombotic strategies for VAD use in children.
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Affiliation(s)
- M P Massicotte
- KIDCLOT Pediatric Thrombosis, Stollery Children's Hospital, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - M E Bauman
- KIDCLOT Pediatric Thrombosis, Stollery Children's Hospital, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - J Murray
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
- Stanford University, Stanford, CA, USA
| | - C S Almond
- Division of Cardiology, Lucile Packard Children's Hospital Stanford, Stanford, CA, USA
- Stanford University, Stanford, CA, USA
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26
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Newall F, Jones S, Bauman M, Bruce A, Massicotte MP, Monagle P. Recommendations for the development of a dedicated pediatric anticoagulation service: communication from the SSC of the ISTH. J Thromb Haemost 2015; 13:155-9. [PMID: 25331069 DOI: 10.1111/jth.12763] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Accepted: 10/09/2014] [Indexed: 11/28/2022]
Affiliation(s)
- F Newall
- Clinical Haematology Department, Royal Children's Hospital, Parkville, Victoria, Australia; Nursing Research Department, Royal Children's Hospital, Parkville, Victoria, Australia; Department of Nursing, The University of Melbourne, Melbourne, Victoria, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia; Haematology Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
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27
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Saini A, Spinella PC. Management of Anticoagulation and Hemostasis for Pediatric Extracorporeal Membrane Oxygenation. Clin Lab Med 2014; 34:655-73. [DOI: 10.1016/j.cll.2014.06.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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28
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Abstract
Given the rising incidence of thrombotic complications in paediatric patients, understanding of the pharmacologic behaviour of anticoagulant drugs in children has gained importance. Significant developmental differences between children and adults in the haemostatic system and pharmacologic parameters for individual drugs highlight potentially unique aspects of anticoagulant pharmacology in this special and vulnerable population. This review focuses on pharmacologic information relevant to the dosing of unfractionated heparin, low molecular weight heparin, warfarin, bivalirudin, argatroban and fondaparinux in paediatric patients. The bulk of clinical experience with paediatric anticoagulation rests with the first three of these agents, each of which requires higher bodyweight-based dosing for the youngest patients, compared with adults, in order to achieve comparable pharmacodynamic effects, likely related to an inverse correlation between age and bodyweight-normalized clearance of these drugs. Whether extrapolation of therapeutic ranges targeted for adult patients prescribed these agents is valid for children, however, is unknown and a high priority for future research. Novel oral anticoagulants, such as dabigatran, rivaroxaban and apixaban, hold promise for future use in paediatrics but require further pharmacologic study in infants, children and adolescents.
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29
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Avila ML, Shah PS, Brandão LR. Different unfractionated heparin doses for preventing arterial thrombosis in children undergoing cardiac catheterization. Cochrane Database Syst Rev 2014:CD010196. [PMID: 24590623 DOI: 10.1002/14651858.cd010196.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The role of cardiac catheterization in pediatrics has progressed significantly over the last two decades, evolving from a primary diagnostic tool to a primary treatment modality in children with congenital heart disease. Vascular complications, particularly arterial thrombosis, are among the most common unwanted post-cardiac catheterization events. In 1974, unfractionated heparin proved to be superior to placebo in decreasing the incidence of arterial thrombosis in pediatric patients. However, the optimal dose of unfractionated heparin to be utilized in this setting remains a matter of controversy. OBJECTIVES To evaluate the use of low-dose (< 100 units/kg) versus high-dose (≥ 100 units/kg) unfractionated heparin administered as an intravenous bolus at the time of initiation of cardiac catheterization (that is, immediately after arterial puncture), with or without subsequent heparin maintenance doses, for the prevention of post-procedural arterial thrombosis in children. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched November 2013) and CENTRAL (2013, Issue 10). The authors searched MEDLINE, EMBASE, and the Virtual Health Library. Clinical trials databases and sources of grey literature were searched. No language restrictions were applied. SELECTION CRITERIA Randomized or quasi-randomized trials that compared low dose to high dose unfractionated heparin administered prior to cardiac catheterization were included. We selected studies conducted in children aged 0 to 18 years. DATA COLLECTION AND ANALYSIS The first screening of potentially eligible studies was conducted by one of the authors (MLA). The second screening, quality assessment and data extraction were independently conducted by two authors (MLA, LRB). Outcomes (thrombotic events, bleeding complications, other complications) were treated as dichotomous variables. The effect measures used were risk ratio (RR), risk difference (RD) and number needed to treat (NNT), with 95% confidence intervals (CI). MAIN RESULTS Two studies with a total of 492 participants were eligible for inclusion. Risk of bias was low for all domains in one of the studies and unclear for the other. One of the trials was stopped early. The quality of evidence for our key outcomes was moderate. The CI for the risk of arterial thrombotic events was compatible with benefits of either high or low unfractionated heparin dose regimens (RR low-dose versus high-dose 1.06, 95% CI 0.58 to 1.92). Only one of the studies reported the frequency of bleeding events for the cohort of patients and found no statistically significant difference in the incidence of major and minor bleeding events between arms (RR low-dose versus high-dose 1.38, 95% CI 0.46 to 4.13 for minor bleeding; RR low-dose versus high-dose 2.96, 95% CI 0.12 to 71.34 for major bleeding events). This study also reported on the incidence of deep vein thrombosis when comparing the high versus low dose of heparin and reported a non-significant difference (RR low-dose versus high-dose 0.34, 95% CI 0.01 to 8.28). The other study lacked information about bleeding. Side effects of heparin other than bleeding complications were not reported in either of the studies. AUTHORS' CONCLUSIONS Due to the limitations of the current evidence, small number of included studies, and lack of details reported in one study, we are unable to determine the effects of different dosing regimens of unfractionated heparin for the prevention of vascular thrombosis during cardiac catheterization in children. A further adequately powered, randomized clinical trial is needed.
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Affiliation(s)
- Maria L Avila
- Division of Haematology-Oncology, The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada, M5G-1X8
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Giglia TM, Massicotte MP, Tweddell JS, Barst RJ, Bauman M, Erickson CC, Feltes TF, Foster E, Hinoki K, Ichord RN, Kreutzer J, McCrindle BW, Newburger JW, Tabbutt S, Todd JL, Webb CL. Prevention and Treatment of Thrombosis in Pediatric and Congenital Heart Disease. Circulation 2013; 128:2622-703. [DOI: 10.1161/01.cir.0000436140.77832.7a] [Citation(s) in RCA: 202] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Taylor BN, Bork SJD, Kim S, Moffett BS, Yee DL. Evaluation of weight-based dosing of unfractionated heparin in obese children. J Pediatr 2013; 163:150-3. [PMID: 23414664 DOI: 10.1016/j.jpeds.2012.12.095] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 12/10/2012] [Accepted: 12/28/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine whether pediatric patients with obesity receiving weight-based dosages of unfractionated heparin (UFH) exhibit an enhanced response when dosed by actual body weight compared with nonobese patients as assessed primarily by the frequency of supratherapeutic anticoagulation. Secondary measures included UFH doses associated with therapeutic anticoagulation. STUDY DESIGN This single-institution retrospective case-matched study included children with and without obesity, matched on a 1:1 basis, who received a weight-based continuous infusion of UFH. Therapeutic monitoring values were defined for activated partial thromboplastin time (aPTT) level (70-101 seconds) and anti-activated factor X (Xa) level (0.35-0.7 U/mL). RESULTS The study included 50 children. The percentage of patients with supratherapeutic anticoagulation at any point in the study, as measured by either aPTT or anti-Xa level, was similar in the obese and nonobese groups (76% vs 72%; P = 1.0). However, compared with patients without obesity, those with obesity received a lower mean starting dose (17.4 vs 20.2 U/kg/hour; P = .013) and a lower mean maintenance dose (19.1 vs 24.3 U/kg/hour; P = .033) to achieve stable therapeutic monitoring test values. There was no difference in mean initial post-UFH aPTT between the 2 groups, but the mean initial anti-Xa level was higher in the obese group (0.45 vs 0.29 U/mL; P = .045). CONCLUSION Compared with children without obesity, those with obesity who received actual body weight-based continuous UFH infusions did not exhibit a higher frequency of supratherapeutic anticoagulation, but did require lower dosages to achieve comparable anticoagulation. Our results highlight recognized discrepancies between aPTT and anti-Xa monitoring assays.
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Affiliation(s)
- Breann N Taylor
- Department of Pharmacy, Texas Children's Hospital, Houston, TX, USA.
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Abstract
The anti-factor Xa (anti-Xa) assay is a functional assay that facilitates the measurement of antithrombin (AT)-catalyzed inhibition of factor Xa by unfractionated heparin (UFH) and direct inhibition of factor Xa by low-molecular-weight heparin (LMWH) (Kitchen, Br J Haematol 111:397-406, 2000; Walenga et al., Semin Thromb Hemost 11:17-25, 1985; Levine et al., Arch Intern Med 154:49-56, 1994; Barrowcliffe et al., J Pharm Biomed Anal 7:217-226, 1989; Triplett, Ther Drug Monit 1:173-197, 1979; Nelson, Clin Lab Sci 12:359-364, 1999; Laffan and Manning, Dacie and Lewis: practical haematology, Churchill Livingstone, London, pp 465-479, 2001; Olson et al., Arch Pathol Lab Med 122:782-798, 1998). Whilst automated methods for the determination of the abilities of UFH and LMWH to inhibit factor Xa have been available since the 1970s, their cost was viewed to prohibit their broad use in the clinical management of UFH and LMWH until relatively recently. The anti-Xa assay can also be used to guide the determination of therapeutic APTT ranges in the clinical management of UFH (Hirsh and Raschke, Chest 126:188S-203S, 2004). As a result, the anti-Xa assay is commonly viewed as a heparin assay, despite the fact that it actually provides a measure of UFH effect as opposed to a measure of UFH concentration.
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Affiliation(s)
- Fiona Newall
- Department of Clinical Haematology, The Royal Children's Hospital, Melbourne, Australia
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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: 970] [Impact Index Per Article: 80.8] [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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Davidson SJ, Tillyer ML, Keogh J, Hall J, Kelleher AA. Heparin concentrations in neonates during cardiopulmonary bypass. J Thromb Haemost 2012; 10:730-2. [PMID: 22329742 DOI: 10.1111/j.1538-7836.2012.04659.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Effect of rivaroxaban, in contrast to heparin, is similar in neonatal and adult plasma. Blood Coagul Fibrinolysis 2012; 22:588-92. [PMID: 21799400 DOI: 10.1097/mbc.0b013e328349f190] [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]
Abstract
Neonates have lower levels of clotting factors as well as inhibitors. Effects of heparin in neonatal plasma differ from those in adult plasma, and dosage recommendations cannot be extrapolated from adult trials. Riveroxaban is an oral direct factor Xa inhibitor that can achieve an anticoagulant effect without dependence on anti-thrombin. We performed comparative thrombin generation measurements in neonatal cord and adult plasma with different concentrations of unfractionated heparin and rivaroxaban to evaluate the potential of rivaroxaban in neonatal anticoagulation. The impact of heparin or rivaroxaban on the neonatal and adult hemostatic system was determined measuring calibrated automated thrombin generation and activated partial thromboplastin time in platelet-poor plasma pools of 15 adult samples or 15 neonatal cord samples and addition of seven increasing concentrations of heparin or rivaroxaban, respectively, to the pooled samples. Lag time, time to peak and peak height of thrombin generation in neonatal cord samples were significantly less affected by different heparin concentrations than in adult samples, whereas the impact on reduction of endogenous thrombin potential was higher in neonatal cord samples. The impact of rivaroxaban on thrombin generation parameters showed better comparability between neonatal cord and adult samples. Both anticoagulants showed the same differences in activated partial thromboplastin time between adult and neonatal plasma at each concentration. Rivaroxaban shows a very similar pattern in neonatal cord and adult plasma in suppressing thrombin generation and prolonging activated partial thromboplastin time values, suggesting that dose finding may be easier with rivaroxaban in neonates.
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Newall F, Chan AK, Ignjatovic V, Monagle P. Recommendations for developing uniform laboratory monitoring of heparinoid anticoagulants in children. J Thromb Haemost 2012; 10:145-7. [PMID: 22470925 DOI: 10.1111/j.1538-7836.2011.04561.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Fiona Newall
- Clinical Haematology Department, Royal Children's Hospital, Melbourne, Australia.
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Moffett BS, Teruya J, Petit C. Heparin Dosing in Obese Pediatric Patients in the Cardiac Catheterization Laboratory. Ann Pharmacother 2011; 45:876-80. [DOI: 10.1345/aph.1q090] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background: Unfractionated heparin (UFH) dosing may need to be adjusted when used in obese patients. The prevalence of pediatric obesity is increasing and, to our knowledge, no data exist to determine the effect of obesity on UFH therapy in children. Objective: To determine whether obese pediatric patients who receive a weight-based dose of UFH in the cardiac catheterization laboratory exhibit an enhanced response compared with those of normal body habitus. Methods: The records of pediatric patients who underwent a cardiac catheterization procedure from September 2006 to September 2010 at Texas Children's Hospital were reviewed. Patients were included if they had received a bolus dose of UFH during their procedure, and had pre- and post-UFH bolus activated clotting time (ACT) values determined. Patients were identified as obese if their body mass index (BMI) was at the 95th percentile or more for age and sex and were matched by age, sex, and catheterization procedure to a control group of patients with a BMI lower than the 95th percentile. Differences in demographic, UFH, and ACT variables were compared between obese and nonobese paired groups. Results: Seventy-eight patients (39 obese) met study criteria; 46 (58.9%) patients were male. The primary catheterization procedure was radiofrequency ablation (n = 32). There was no statistically significant difference in the mean (SD) dose per kilogram of UFH administered (72.3 [24.9] vs 63.6 [23.6] units/kg; p = 0.12) and no statistically significant difference in the time after the UFH bolus that the ACT was measured (52 [26] vs 56 [26] minutes; p = 0.59) between the 2 groups. No statistically significant difference was noted in the percent change in ACT after UFH bolus in obese compared to nonobese pediatric patients (196% [106] vs 165% [97]; p = 0.17). Conclusions: No significant difference in response to UFH was identified in obese pediatric patients compared to nonobese pediatric patients as measured by ACT in the cardiac catheterization laboratory.
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Affiliation(s)
- Brady S Moffett
- Department of Pharmacy, Texas Children's Hospital, Houston, TX
| | - Jun Teruya
- Departments of Pathology, Immunology, Pediatrics, and Medicine, Baylor College of Medicine, Houston
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The contribution of Tissue Factor Pathway Inhibitor to Thrombin Generation in children receiving Unfractionated Heparin. Thromb Res 2011; 127:275-6. [DOI: 10.1016/j.thromres.2010.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 11/05/2010] [Accepted: 11/15/2010] [Indexed: 11/16/2022]
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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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Newall F, Johnston L, Summerhayes R, Lane G, Cranswick N, Monagle P, Ignjatovic V. Novel interactions between UFH and TFPI in children. Br J Haematol 2010; 151:376-80. [DOI: 10.1111/j.1365-2141.2010.08373.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Newall F, Ignjatovic V, Johnston L, Summerhayes R, Lane G, Cranswick N, Monagle P. research paper: Clinical use of unfractionated heparin therapy in children: time for change? Br J Haematol 2010; 150:674-8. [DOI: 10.1111/j.1365-2141.2010.08302.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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