A systematic review of adherence to anticoagulation regimens in pediatric patients

Abstract

Thromboembolic disease rates are increasing in pediatric patients. Anticoagulation is prescribed for treatment and prevention of thromboembolic disease. While nonadherence to anticoagulation regimens predicts poor health outcomes in adults, data in anticoagulated pediatric patients are limited. We systematically reviewed the rates, outcomes, and predictors of anticoagulation nonadherence in the pediatric population.Out of a total of 3581 unique articles identified for review, 17 studies met inclusion criteria. These studies primarily evaluated patients with cardiac disease treated with vitamin K antagonists. Overall nonadherence rates varied from 3% to 42%, based upon population, definition of adherence, and measurement strategy. Patient age, goal international normalized ratio (INR), and number of concurrent potentially interacting medications correlated with nonadherence. Data examining the relationship between nonadherence and health outcomes were included in only two studies. Limitations of current literature, as well as critical knowledge gaps that require future study, are discussed.

Results of an international survey on adherence with anticoagulation in children, adolescents, and young adults: Communication from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis

“…9 Similar to non-adherence rates in other populations, an estimated 3%-42% of children and adolescents prescribed anticoagulants demonstrate medication non-adherence. 10 For example, in a study of children discharged from hospital after pulmonary embolism or deep vein thrombosis covered by Texas Medicaid, 33% of participants missed 20% or more of doses, as measured by pharmacy refill information. While data on the association between anticoagulation non-adherence and poor health outcomes in young patients are limited, the literature in adult patients implies that there is likely a threshold for adherence beyond which morbidity and mortality are adversely impacted.…”

“…While data on the association between anticoagulation non-adherence and poor health outcomes in young patients are limited, the literature in adult patients implies that there is likely a threshold for adherence beyond which morbidity and mortality are adversely impacted. 10 Because anticoagulation for pediatric venous thromboembolism is typically managed by pediatric subspecialists (i.e., hematologists or cardiologists) rather than by primary care physicians, pediatric subspecialty teams play a critical role in promoting adherence. Thus, improving patient outcomes requires that these teams are equipped with the evidence, skills, and resources necessary to promote adherence.…”

“…While higher medication adherence, or greater concordance between a patient’s behavior and the agreed upon treatment regimen (i.e., prescribed medications, laboratory monitoring), promotes successful health outcomes in disease states including pediatric leukemia, many children and adolescents face barriers to adherence 9 . Similar to non‐adherence rates in other populations, an estimated 3%–42% of children and adolescents prescribed anticoagulants demonstrate medication non‐adherence 10 . For example, in a study of children discharged from hospital after pulmonary embolism or deep vein thrombosis covered by Texas Medicaid, 33% of participants missed 20% or more of doses, as measured by pharmacy refill information.…”

“…For example, in a study of children discharged from hospital after pulmonary embolism or deep vein thrombosis covered by Texas Medicaid, 33% of participants missed 20% or more of doses, as measured by pharmacy refill information. While data on the association between anticoagulation non‐adherence and poor health outcomes in young patients are limited, the literature in adult patients implies that there is likely a threshold for adherence beyond which morbidity and mortality are adversely impacted 10 . Because anticoagulation for pediatric venous thromboembolism is typically managed by pediatric subspecialists (i.e., hematologists or cardiologists) rather than by primary care physicians, pediatric subspecialty teams play a critical role in promoting adherence.…”

Barriers to medication adherence in children, adolescents, and young adults prescribed anticoagulation

“…Although the risk factors, associated medical conditions, and sites of thrombosis vary across individuals, therapeutic anticoagulant medications (i.e., oral vitamin K antagonists, subcutaneously injected low molecular weight heparin, newer direct oral anticoagulants) are prescribed to promote thrombus resolution while preventing thrombus extension, embolization, or formation at new sites 7 . Anticoagulant adherence is presumed to be critical for maximizing health outcomes, yet 2%–42% of children and AYAs demonstrate non‐adherence or medication taking that differs from the prescribed treatment regimen 8–10 …”