The ASH/ISTH released an update to their treatment of venous thromboembolism in pediatric patients guidelines. This update comes seven years after the original guidelines were released in 2018. The update primarily focuses on whether to treat or skip treatment, as well as which type of treatment is most optimal based on the clinical scenario.

With 24 recommendations, the updated guidelines address questions from the 2018 guidelines that now have updated information, along with the condensing of previous questions and the addition of new questions based on insights gleaned from recent research. 

The update did not adjust 11 of the original 30 recommendations. Table 2 of the 2024 update showcases the recommendations that were not addressed in the 2024 update.

Key Updates of the 2024 Update:
  • Recommendation 1: For pediatric patients with symptomatic deep vein thrombosis (DVT) or pulmonary embolism (PE), the ASH/ISTH guideline panel suggests using anticoagulation rather than no anticoagulation.
  • Recommendation 2: For pediatric patients with clinically unsuspected (previously termed asymptomatic) DVT or PE, the ASH/ISTH guideline panel suggests either using anticoagulation or no anticoagulation.
  • Recommendation 3:  For select pediatric patients with provoked VTE, the ASH/ISTH guideline panel suggests 6 weeks rather than 3 months of anticoagulation. Exclusions to this recommendation include (1) PE, (2) recurrent VTE, (3) persistent occlusive thrombus at 6 weeks, (4) cancer-associated thrombosis, (5) patients with persistent antiphospholipid antibodies (APAs) or major thrombophilia, and (6) ongoing VTE risk factors.
  • Recommendation 4: For pediatric patients with unprovoked DVT or PE, the ASH/ISTH guideline panel suggests using anticoagulation for 6 to 12 months rather than indefinite anticoagulation.
  • Recommendation 5: For pediatric patients with cerebral sinus venous thrombosis (CSVT) with and without hemorrhage secondary to venous congestion, the ASH/ISTH guideline panel suggests using anticoagulation rather than no anticoagulation.
  • Recommendation 6: For pediatric patients with CSVT, the ASH/ISTH guideline panel suggests using anticoagulation alone rather than thrombolysis followed by anticoagulation.
  • Recommendation 7A: For neonates and pediatric patients with right atrial thrombosis (RAT), the ASH/ISTH guideline panel suggests anticoagulation rather than no anticoagulation for patients with high-risk features and low perceived risk of bleeding.
  • Recommendation 7B: For neonates and pediatric patients with RAT and the absence of high-risk features or with unacceptable perceived risk of bleeding, the ASH/ISTH guideline panel suggests no anticoagulation over anticoagulation.
  • Recommendation 8: For neonates and pediatric patients with RAT requiring antithrombotic treatment, the ASH/ISTH guideline panel suggests using anticoagulation alone over thrombolysis followed by anticoagulation.
  • Recommendation 9: For neonates with renal vein thrombosis (RVT), the ASH/ISTH guideline panel suggests using anticoagulation rather than no anticoagulation.
  • Recommendation 10A: For neonates with non–life-threatening RVT, the ASH/ISTH guideline panel recommends anticoagulation alone vs thrombolysis followed by anticoagulation.
  • Recommendation 10B: For neonates with life-threatening RVT, the ASH/ISTH guideline panel suggests using thrombolysis followed by anticoagulation, rather than anticoagulation alone.
  • Recommendation 11A: For neonates and children with occlusive portal vein thrombosis (PVT) and for children with nonocclusive PVT, post–liver transplant PVT, or unprovoked PVT, the ASH/ISTH guideline panel suggests using anticoagulation rather than no anticoagulation.
  • Recommendation 11B: ​​For neonates with nonocclusive PVT, and for children who have already developed portal hypertension (PHTN) secondary to PVT, the ASH/ISTH guideline panel suggests no anticoagulation rather than using anticoagulation.
  • Recommendation 12A: For pediatric patients with superficial vein thrombosis (SVT) secondary to IV cannulation in the upper limb, the ASH/ISTH guideline panel suggests no anticoagulation rather than using anticoagulation.
  • Recommendation 12B: For pediatric patients with SVT in the upper limb, which is not cannula related, or in the lower limbs associated with cancer or varicose veins, the ASH/ISTH guideline panel suggests anticoagulation rather than no anticoagulation.
  • Recommendation 13: For pediatric patients with proximal DVT, the ASH/ISTH guideline panel suggests using anticoagulation alone rather than thrombolysis followed by anticoagulation.
  • Recommendation 14: For pediatric patients with PE and echocardiographic or biochemical evidence of right ventricular dysfunction but without hemodynamic compromise, the ASH/ISTH guideline panel suggests using anticoagulation alone rather than thrombolysis followed by anticoagulation.
  • Recommendation 15: For pediatric patients with PE and hemodynamic compromise the ASH/ISTH guideline panel suggests using thrombolysis followed by anticoagulation rather than anticoagulation alone.
  • Recommendation 16: For pediatric patients with symptomatic CVAD-related thrombosis who no longer require venous access or whose CVAD is nonfunctioning, the ASH/ISTH guideline panel suggests either immediate removal or delayed removal of the CVAD.
  • Recommendation 17: For pediatric patients with VTE, the ASH/ISTH guideline panel suggests using DOACs (rivaroxaban/dabigatran) over SOC anticoagulants (low molecular weight heparin [LMWH], unfractionated heparin [UFH], vitamin K antagonists [VKAs], and fondaparinux).
  • Recommendation 18: For pediatric patients with VTE the ASH/ISTH guideline panel suggests using rivaroxaban over SOC anticoagulants (LMWH, UFH, VKA, and fondaparinux).
  • Recommendation 19: For pediatric patients with VTE, the ASH/ISTH guideline panel suggests using dabigatran over SOC anticoagulants (LMWH, UFH, VKA, and fondaparinux).
  • Recommendation 20: For pediatric patients with VTE, the ASH/ISTH guideline panel suggests using either rivaroxaban or dabigatran, although there may be individual populations or jurisdictional availability that would lead clinicians to choose 1 agent over the other.

In addition to the reworked recommendations, the 2024 update features a table (Table 4) outlining the characteristics of anticoagulants/thrombolytics used for acute VTE in pediatrics. Table 5 is a helpful comparison of the advantages and disadvantages of anticoagulants/thrombolytics for pediatric VTE. Additional tables outlining medication dosing were also added to this update.

View the full-text guidelines for a complete look at the ASH/ISTH recommendations and rationale.

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