LMWH | Unfractionated heparin | DOACs | Vitamin K antagonists (eg, warfarin) | |
Predictability of anticoagulant response | Response is highly predictable | Response is less predictable (compared with LMWH) | Response is predictable | Response is unpredictable |
Ease of administration | Does not require IV access, but subcutaneous administration may be bothersome to patients | Requires IV access | Orally administered | Orally administered |
Pediatric-specific oral formulation | N/A (drug is given parenterally) | N/A (drug is given parenterally) | Pediatric formulations are available for dabigatran and rivaroxaban | Available only in tablet form |
Need for laboratory monitoring and dose adjustment | Requires only periodic monitoring | Requires frequent monitoring and dose adjustment | No required monitoring | Requires frequent monitoring and dose adjustment |
Impact of diet on drug's effect | Little impact | Little impact | Little impact | Effectiveness is impacted by vitamin K intake, which can have considerable variation in children's diets |
Reversibility | IV protamine can be used to reverse anti-Xa activity, but reversal is not complete | Can easily be reversed with IV protamine; stopping the infusion is often sufficient to control minor bleeding | Reversal agents for DOACs have not been studied in children, and they are not universally readily available | Can be reversed with vitamin K administration |
Long-term use |
| Generally not used for long-term management |
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Special considerations: | ||||
Kidney failure |
| Dose adjustment is not necessary |
| Dose adjustment is not necessary |
Liver failure | Dose adjustment is not necessary | Dose adjustment is not necessary |
| For patients with mild liver dysfunction and/or elevated baseline prothrombin time, dose adjustment and close monitoring are necessary; for those with severe liver failure, warfarin should be avoided |
Pregnancy | Does not cross the placenta, and does not result in fetal anticoagulation | Does not cross the placenta, and does not result in fetal anticoagulation | Should not be used during pregnancy, due to increased reproductive risks in animal studies | Should not be used during pregnancy (particularly 1st trimester), because it crosses the placenta, is a teratogen, and causes fetal anticoagulation |