Current Antithrombotic Therapy Strategies in Children with a Focus on Off-Label Direct Oral Anticoagulants—A Narrative Review

Abstract

(1) Background: The incidence of thromboembolic events is relatively low in the general population, but it increases in hospitalized children and those who underwent thrombogenic procedures. Although the evidence regarding direct oral anticoagulants (DOACs) in children with venous thromboembolism (VTE) is growing, DOACs were excluded from existing guidelines due to the lack of reliable data at that moment. Therefore, current evidence on VTE management in children needs to be critically reviewed. (2) Methods: We have conducted a literature search in the Scopus, EMBASE, and MEDLINE databases using prespecified keywords to retrieve studies published between 2010 and 2022. (3) Results: Clinical trials highlighted that rivaroxaban and dabigatran had predictable pharmacokinetic and pharmacodynamic profiles in children, similar to those observed in adults. Dabigatran and rivaroxaban had a similar safety profile to standard therapy but improved thrombotic burden and resolution during follow-up. Most studies involving apixaban and edoxaban are ongoing, and results are awaited. (4) Conclusions: Dabigatran and rivaroxaban could be valid therapeutic options for VTE management in children. In the case of apixaban and edoxaban, results from ongoing clinical studies are required before using them in pediatric VTE.

Post-Coronary Artery Bypass Grafting Outcomes of Patients with/without Type-2 Diabetes Mellitus and Chronic Kidney Disease Treated with SGLT2 Inhibitor Dapagliflozin: A Single-Center Experience Analysis

“…In addition, T2DM vs. non-T2DM cases have an advanced rate of multivessel coronary stenosis, which causes plaque rupture, acute intracoronary thrombosis, and adverse clinical events [22]. In this environment, coronary artery bypass grafting (CABG) is a recommended revascularization strategy to ameliorate clinical issues in T2DM cases with multivessel coronary stenosis [1,23]. This over-inflammatory response could lead to a worse prognosis in CABG-treated cases, particularly in those with T2DM [1,24].…”

How I treat pediatric venous thromboembolism in the DOAC era

“…Since the approval of DOACs in adults in 2008, 10 the off-label use of DOACs in children for treatment of VTE has been increasing even before their pediatric approval in 2021. 2 , 8 , 10 , 11 , 12 , 13 With the completed HOKUSAI-Jr phase 3 (edoxaban) 14 and ongoing CANINES phase 4 (apixaban) trials, 15 the choice of anticoagulants will broaden. In addition to VTE treatment, DOACs have been evaluated for VTE prevention in children with congenital and acquired heart disease and cancer, thereby adding to the growing number of children enrolled in clinical trials ( Table 1 ).…”

To learn or not to learn from real-world experience on direct oral anticoagulants in pediatric patients?

“…As DOACs are increasingly used in pediatric patients, it is of utmost importance to be mindful of their specific limitations in these patients and conceivable differences between individual DOACs. [ 3 , 4 ] DOACs are the first generation of anticoagulants that are thoroughly investigated according to a formal pediatric investigation plan. Rivaroxaban and dabigatran have already been approved by the European Medicine Agency and the US Food and Drug Administration for the treatment of pediatric venous thromboembolism (VTE).…”