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Oral anticoagulation in paediatric patients: dose requirements and complications
R C Tait1, E J Ladusans, M El-Metaal
1Department of Haematology, Royal Manchester Children's Hospital, Pendlebury.
Insights
Safe oral anticoagulation is achievable in children using warfarin, with predictable dosing based on weight and age. This study demonstrates feasibility and minimal complications in pediatric patients.
Area of Science:
- Pediatric Cardiology
- Pharmacology
- Clinical Therapeutics
Background:
- Current pediatric oral anticoagulant guidelines are lacking, leading to reliance on adult regimens without proven efficacy or safety.
- Congenital heart disease is a primary indication for anticoagulation in children, often associated with mechanical valve prostheses.
Purpose of the Study:
- To evaluate the safety and efficacy of oral anticoagulation control in pediatric patients.
- To determine the predictability of warfarin dosing in children.
Main Methods:
- A prospective, two-year study involving 45 children (9 months to 18 years) on oral anticoagulation.
- Monitoring of International Normalized Ratios (INRs) and warfarin dose adjustments over 602 patient months.
- Analysis of factors influencing warfarin dose, including weight and age.
Main Results:
- Target INRs were achieved in 62% (low target) and 39% (high target) of visits.
- Warfarin dose requirements correlated with weight and were influenced by age.
- Thrombotic events were absent; hemorrhagic events were infrequent (2.1%) and minor.
Conclusions:
- Outpatient oral anticoagulation with warfarin is feasible and safe in children.
- Pediatric warfarin requirements are moderately predictable, with control comparable to adults.
Abstract:
The lack of oral anticoagulant guidelines specific to paediatric practice has led to the adoption of adult regimens, often without scientific evidence of efficacy or safety. A two year prospective study of anticoagulant control was carried out in 45 children aged 9 months to 18 years, the majority of whom were receiving primary prophylactic anticoagulation. The main indication was congenital heart disease, either with (n = 8) or without (n = 34) mechanical valve prosthesis. During a follow up period of 602 patient months the average interval between visits was three weeks. Target international normalised ratios (INRs) were achieved on 62% and 39% of visits for children with low target INR (2.0-3.0) and high target INR (3.0-4.0) respectively. However warfarin dose was altered on only 22% of visits. Warfarin doses required to achieve a stable INR of 2.0-3.0 in 33 children were strongly correlated with weight [dose (mg/d) = 0.07 x weight (kg) + 0.54] but independently influenced by age. No thrombotic complications were recorded, and haemorrhagic events were infrequent (2.1% of visits) and, with one exception, minor. Safe outpatient oral anticoagulation is feasible in children, whose warfarin requirements appear moderately predictable and whose control is no more erratic than that of adults.