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©2013 UpToDate ® Print Email Advantages and disadvantages of various anticoagulant agents in children with cancer Anticoagulant Monitoring Advantages Disadvantages/complications Special considerations for children with cancer Unfractionated heparin (UFH) aPTT Anti-Xa Easy reversal Bleeding [1] Bleeding may be exaggerated due to thrombocytopenia and coagulopathy [2] Difficult to monitor aPTT Osteoporosis may be exaggerated in children treated with glucocorticoids (eg, ALL, NHL) [6-8] Osteoporosis [3-5] Heparin-induced thrombocytopenia Low molecular weight heparin (LMWH) Anti-Xa levels Compared with UFH more efficacious and safe Subcutaneous administration Target anti-Xa levels in children are unknown [9] Cost effective Therapeutic range is not established so that bleeding may occur (0 to 5.6 percent) Difficult to reverse anticoagulation in emergency situation Easy to monitor Oral anticoagulants INR Oral administration Dose requirements strongly influenced by age [10] Dietary alterations (due to mucositis, TPN) and antibacterial therapy (PCP prophylaxis or treatment for fever and neutropenia) leads to unpredictable exogenous and endogenous vitamin K levels Difficult monitoring Low cost Efficacy affected by diet [11] * Warfarin metabolism by cytochrome P450 system leading to numerous drug interactions with anticancer agents (eg, corticosteroids) [1] Difficult to adjust dose around time of invasive procedures No stability data on solution or suspension making dosing in young children and in children unable to swallow tablets difficult [12] ALL: acute lymphoblastic leukemia; aPTT: activated partial thromboplastin time; INR: international normalization ratio; LMWH: low molecular weight heparin; PCP: pneumocystis carinii; NHL: non-Hodgkin lymphoma; TPN: total parenteral nutrition; UFH: unfractionated heparin. * Infants may have resistance to warfarin if formula fed (vitamin K enriched), whereas breastfed infants may be oversensitive due to poor vitamin K content in breast milk. References: Monagle P, Chan A, Massicotte P, et al. Antithrombotic therapy in children: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:645S. Athale UH, Wiernikowaski J. Thromboembolic complications in children with cancer. Thromb Res 2006; 118:137. Murphy MS, John PR, Mayer AD, et al. Heparin therapy and bone fractures. Lancet 1992; 340:1098. Avioli LV. Heparin-induced osteopenia: an appraisal. Adv Exp Med Biol 1975; 52:375.

Monagle P, Chan A, Massicotte P, et al. Antithrombotic therapy in children: The Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:645S. Athale UH, Wiernikowaski J. Thromboembolic complications in children with cancer. Thromb Res 2006; 118:137. Murphy MS, John PR, Mayer AD, et al. Heparin therapy and bone fractures. Lancet 1992; 340:1098. Avioli LV. Heparin-induced osteopenia: an appraisal. Adv Exp Med Biol 1975; 52:375. Sackler JP, Liu L. Heparin-induced osteoporosis. Br J Radio 1973; 46:548. Roebuck DJ. Skeletal complications in pediatric oncology patients. Radiographics 1999; 19:873. Halton JM, Atkinson SA, Fraher L, et al. Altered mineral metabolism and bone mass in children during treatment for acute lymphoblastic leukemia. J Bone Miner Res 1996; 11:1774. Arikoski P, Komulainen J, Riikonen P, et al. Impaired development of bone mineral density during chemotherapy: a prospective analysis of 46 children newly diagnosed with cancer. J Bone Miner Res 1999; 14:2002. Revel-Vilk S, Chan AKC. Anticoagulation therapy in children. Semin Thromb Hemost 2003; 29:425. Streif W, Andrew M, Marzinotto V, et al. Analysis of warfarin therapy in pediatric patients: A prospective cohort study of 319 patients. Blood 1999; 94:3007. Andrew M, Monagle P, Brooker L. Oral anticoagulant therapy in pediatric patients. Thromboembolic Complications During Infancy and Childhood, BC Decker Inc, Hamilton 2000. p.321. Buck ML. Anticoagulation with warfarin in infants and children. Ann Pharmacother 1996; 30:1316. Reproduced with permission from: Athale, UH, Chan, AKC. Thromboembolic complications in pediatric hematologic malignancies. Semin Thromb Hemost 2007; 33:416. Copyright © 2007 Thieme Publishers.