Current practices of index hospitalization anticoagulant use in pediatric patients with acute myeloid leukemia

Management and prevention of thromboembolism (TE) in pediatric acute myeloid leukemia (AML) are challenging because of prolonged periods of thrombocytopenia and associated bleeding. There are no guidelines for prophylactic or therapeutic anticoagulation for children with AML. This study aimed to understand the use of anticoagulation and its association with bleeding events (BEs) during index hospitalization in children with AML, both with and without thromboses. A retrospective cohort study was performed using the Pediatric Health Information System administrative database of index hospitalizations for patients aged 1 to 21 years from 2016 to 2024 with the diagnosis of AML across 49 children's hospitals. Demographic data, diagnosis of TE, anticoagulation use, and BE were extracted. A total of 3768 patients with AML were included, with 167 (4.4%) experiencing a TE. A total of 171 patients (4.5%) received anticoagulation, with almost half receiving anticoagulation in the absence of a TE diagnosis (presumed prophylaxis). Of patients with a TE, 88 (52.3%) received anticoagulation, with the remainder receiving no anticoagulation. Enoxaparin was the most frequently used anticoagulant, followed by rivaroxaban, but wide institutional variation was observed in the choice of anticoagulant. A total of 750 patients (20%) experienced ≥1 BE. Most patients (705/750 [94%]) with BE received no anticoagulation. Prospective research is needed to determine the safest and most effective use of prophylactic and therapeutic anticoagulation in this patient population.