What Do the Current Clinical Guidelines Recommend Regarding Post-acute Management of VTE in Pediatric Patients?

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Dr. Kumar:
Hello, my name is Riten Kumar, and I'm a pediatric hematologist at Boston Children's Hospital. Thank you for joining this educational program. We are now going to talk about the published clinical guidelines and their recommendations on secondary thromboprophylaxis in children, with a history of venous thromboembolism. There are several guidelines that we can refer to. The one that we use very commonly are the American College of Chest Physician Guidelines, also known the CHEST guidelines, which were published in 2012. The CHEST guidelines have the following recommendations for children with a history of venous thromboembolism.

They recommend that in children with ongoing but potentially reversible risk factors for venous thromboembolism, such as a child with nephrotic syndrome, who has not gone into remission, or a child with asparaginase-associated thrombosis, who still requires exposure to asparaginase, the CHEST guidelines suggest continuing anticoagulant therapy beyond three months in either therapeutic or prophylactic dosing. In children with central venous line associated venous thromboembolism, who continue to require a central venous line, the CHEST guidelines suggest that after the initial three months of anticoagulation either prophylactic doses of Vitamin K antagonists or low molecular weight heparin be used 'til the central venous line is removed. The CHEST guidelines also make some recommendations about patients who have recurrent idiopathic thrombosis or thrombosis in the setting of anatomic thrombophilias. In children with a recurrent unprovoked venous thromboembolic event, the CHEST guidelines recommend indefinite anticoagulation with Vitamin K antagonists and in children with the recurrent venous thromboembolism secondary to a structural venous anomaly, such as thoracic outlet syndrome or May-Thurner Syndrome, the CHEST guidelines suggest indefinite anticoagulation 'til surgical interventions can be performed.

These include decompressive surgery for thoracic outlet syndrome, or stenting for a May-Thurner anatomy. I will point out that the CHEST guidelines do not make any reference to direct oral anticoagulants, since when they were published in 2012, there was no data to support the use of direct oral anticoagulants children. The other guidelines that we commonly refer to are the American Society of Hematology, or the ASH guidelines, which were published in 2018. Unfortunately, the ASH guidelines do not make any recommendations for secondary thromboprophylaxis in children. The only recommendation they make which is relevant to our talk today, is that they recommend using low molecular weight heparin or Vitamin K antagonists in children with venous thromboembolism. Again, similar to the ACCP guidelines, the ASH guidelines make no reference to direct oral anticoagulants since they were published in 2018, and dabigatran and rivaroxaban were only approved for pediatric use in 2020 and 2021. Thank you for your time and for watching this educational program.

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