Comparison of advantages and disadvantages of anticoagulants/thrombolytics for pediatric VTE
| Agent . | Advantages . | Disadvantages . | Impact on QOL . |
|---|---|---|---|
| UFH | Short half-life Available reversal agent (protamine) No drug or food interactions Extensive clinical experience Can be used in renal failure Modulatory effect on inflammation | Difficult to titrate in younger patients Variable bioavailability because of binding to plasma proteins Need for frequent dose monitoring Poor correlation between dose and aPTT or anti-FXa levels Need for IV access | No studies |
| LMWH | More predictable dosing (vs UFH and VKAs) Few drug and food interactions Extensive clinical experience | Unpredictable dose-effect response as measured by anti-FXa levels SQ administration Not fully reversible (protamine) Needs careful monitoring in renal impairment | SQ injections are traumatic |
| Fondaparinux | Once daily dosing Excellent bioavailability Lower risk of HIT (vs UFH and LMWH) | SQ administration Difficult to administer small doses (no multidose vial) Long half-life; not fully reversible | No studies |
| Warfarin, acenocoumarol, and phenprocoumon (VKAs) | Oral administration (only after therapeutic anticoagulant with parenteral agent) Once daily dosing Can be used in renal failure Available reversal agent (PCC, vitamin K) | No commercially available liquid formulation Multiple food and drug interactions Stability affected by developmental hemostasis and intercurrent illnesses Need for frequent monitoring Due to long and variable half-life, achieving target therapeutic range can take 5-7 d | At home point-of-care monitoring improves QOL |
| Rivaroxaban | Oral administration (only after ≥5 d of parenteral anticoagulant) Rapid onset and offset of action Stable pharmacological profile Few drug and food interactions No need for routine laboratory monitoring No risk for HIT | Should not be used in children with mechanical valves and APS Limited efficacy and safety data on neonates and infants Rivaroxaban-specific anti-FXa assays not widely available No pediatric data available for reversal agent (andexanet alfa) Concern for increased menstrual bleeding (vs LMWH, fondaparinux, and VKAs) | No studies |
| Dabigatran | Oral administration (only after ≥5 d of parenteral anticoagulant) Rapid onset and offset of action Stable pharmacological profile Wide therapeutic window Few drug and food interactions No need for routine laboratory monitoring No risk for HIT | Should not be used in children with mechanical valves and APS Limited efficacy and safety data on neonates and infants No pediatric data available for reversal agent (idarucizumab) Capsules cannot be crushed and dosage forms for children who cannot swallow capsules are not widely available No administration via enteral tubes or syringes (except for oral solution) | No studies |
| t-PA | More rapid thrombus resolution than anticoagulation alone Rapid onset and offset of action Very short half-life | High risk of bleeding requiring administration in a critical care setting for close monitoring IV administration only | N/A |
| Agent . | Advantages . | Disadvantages . | Impact on QOL . |
|---|---|---|---|
| UFH | Short half-life Available reversal agent (protamine) No drug or food interactions Extensive clinical experience Can be used in renal failure Modulatory effect on inflammation | Difficult to titrate in younger patients Variable bioavailability because of binding to plasma proteins Need for frequent dose monitoring Poor correlation between dose and aPTT or anti-FXa levels Need for IV access | No studies |
| LMWH | More predictable dosing (vs UFH and VKAs) Few drug and food interactions Extensive clinical experience | Unpredictable dose-effect response as measured by anti-FXa levels SQ administration Not fully reversible (protamine) Needs careful monitoring in renal impairment | SQ injections are traumatic |
| Fondaparinux | Once daily dosing Excellent bioavailability Lower risk of HIT (vs UFH and LMWH) | SQ administration Difficult to administer small doses (no multidose vial) Long half-life; not fully reversible | No studies |
| Warfarin, acenocoumarol, and phenprocoumon (VKAs) | Oral administration (only after therapeutic anticoagulant with parenteral agent) Once daily dosing Can be used in renal failure Available reversal agent (PCC, vitamin K) | No commercially available liquid formulation Multiple food and drug interactions Stability affected by developmental hemostasis and intercurrent illnesses Need for frequent monitoring Due to long and variable half-life, achieving target therapeutic range can take 5-7 d | At home point-of-care monitoring improves QOL |
| Rivaroxaban | Oral administration (only after ≥5 d of parenteral anticoagulant) Rapid onset and offset of action Stable pharmacological profile Few drug and food interactions No need for routine laboratory monitoring No risk for HIT | Should not be used in children with mechanical valves and APS Limited efficacy and safety data on neonates and infants Rivaroxaban-specific anti-FXa assays not widely available No pediatric data available for reversal agent (andexanet alfa) Concern for increased menstrual bleeding (vs LMWH, fondaparinux, and VKAs) | No studies |
| Dabigatran | Oral administration (only after ≥5 d of parenteral anticoagulant) Rapid onset and offset of action Stable pharmacological profile Wide therapeutic window Few drug and food interactions No need for routine laboratory monitoring No risk for HIT | Should not be used in children with mechanical valves and APS Limited efficacy and safety data on neonates and infants No pediatric data available for reversal agent (idarucizumab) Capsules cannot be crushed and dosage forms for children who cannot swallow capsules are not widely available No administration via enteral tubes or syringes (except for oral solution) | No studies |
| t-PA | More rapid thrombus resolution than anticoagulation alone Rapid onset and offset of action Very short half-life | High risk of bleeding requiring administration in a critical care setting for close monitoring IV administration only | N/A |
APS, antiphospholipid syndrome; N/A, not applicable.