Thromboprophylaxis Use in Paediatric Inflammatory Bowel Disease: An International RAND Appropriateness Panel
Franco Torrente1, Susanna Meade2, Eric I Benchimol3
1Department of Paediatric Gastroenterology, Addenbrooke's Hospital, Cambridge, UK.
Insights
Thromboprophylaxis is recommended for most hospitalized pediatric inflammatory bowel disease (IBD) patients, especially those with severe colitis or Crohn's disease risk factors. New evidence suggests re-evaluating current guidelines for pediatric IBD thromboprophylaxis.
Area of Science:
- Pediatric Gastroenterology
- Thrombosis Prevention
- Inflammatory Bowel Disease
Background:
- Thromboprophylaxis use in pediatric inflammatory bowel disease (IBD) is inconsistent.
- Current guidelines recommend prophylaxis only for children with acute severe colitis and risk factors.
- New evidence necessitates re-evaluation of thromboprophylaxis in hospitalized pediatric IBD patients.
Purpose of the Study:
- To explore expert opinion on thromboprophylaxis appropriateness in hospitalized pediatric IBD patients.
- To assess the impact of varying clinical factors on thromboprophylaxis recommendations.
- To inform potential revisions of current guidelines for pediatric IBD management.
Main Methods:
- Convened a 14-person international RAND panel of pediatric gastroenterologists and experts.
- Utilized a two-round online survey assessing 27 clinical scenarios.
- Applied the RAND disagreement index to identify areas of expert consensus and uncertainty.
Main Results:
- Thromboprophylaxis was deemed appropriate in 20 of 27 scenarios.
- Recommendations included all new-onset acute severe colitis, most ulcerative colitis flares, and Crohn's patients with risk factors.
- Disagreement persisted in scenarios involving Crohn's disease without risk factors.
Conclusions:
- RAND panels provide valuable insights into expert opinion for evidence-limited areas.
- Findings suggest a need to reconsider the role of thromboprophylaxis in pediatric IBD guidelines.
- This study highlights areas requiring further investigation and potential guideline updates.
Background And Aims:
Thromboprophylaxis use in paediatric inflammatory bowel disease [IBD] is inconsistent. Current guidelines only support treating children with acute severe colitis with risk factors. We convened an international RAND panel to explore thromboprophylaxis in paediatric IBD inpatients in the context of new evidence.
Methods:
We convened a geographically diverse 14-person panel of paediatric gastroenterologists alongside supporting experts. An online survey was sent before an online meeting. Panellists were asked to rate the appropriateness of thromboprophylaxis in hospitalised paediatric IBD patients via 27 scenarios of varying ages, gender, and phenotype, with and without thrombotic risk factors. Anonymised results were presented at the meeting. A second modified survey was distributed to all panellists present at the meeting. Results from the second survey constitute the RAND panel results. The validated RAND disagreement index defined disagreement when ≥ 1.
Results:
The combined outcome of thromboprophylaxis being considered appropriate until discharge and inappropriate to withhold was seen in 20 of 27 scenarios, including: all patients with new-onset acute severe colitis; all flares of known ulcerative colitis, irrespective of risk factors except in pre-pubescent patients with limited disease and no risk factors; and all Crohn's patients with risk factors. Disagreement was seen in five scenarios regarding Crohn's without risk factors, where outcomes were already uncertain.
Conclusions:
RAND panels are an established method to assess expert opinion in areas of limited evidence. This work therefore constitutes neither a guideline nor a consensus; however, the findings suggest a need to re-evaluate the role of thromboprophylaxis in future guidelines.
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