Advantages and disadvantages of different anticoagulants for treatment of venous thromboembolism in children and adolescents

	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	Data on long-term safety in children are limited May reduce bone density, but risk is likely lower than with unfractionated heparin or vitamin K agonist	Generally not used for long-term management	Limited experience Data on long-term safety in children are lacking	Extensive experience with long-term use May reduce bone density
Special considerations:
Kidney failure	For patients with mild renal insufficiency, dose adjustment and close monitoring may be necessary For those with severe renal failure, LMWH should be avoided	Dose adjustment is not necessary	Limited data on use in children with renal impairment For patients with mild renal insufficiency, dose adjustment is not necessary For those with severe kidney failure, DOACs should be avoided	Dose adjustment is not necessary
Liver failure	Dose adjustment is not necessary	Dose adjustment is not necessary	For dabigatran, dose adjustment is not necessary Rivaroxaban should not be used in patients with severe hepatic failure	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 1^st trimester), because it crosses the placenta, is a teratogen, and causes fetal anticoagulation

This table summarizes the advantages and disadvantages of the major classes of anticoagulants used in pediatric patients. Enoxaparin is the most commonly used LMWH agent in children. Warfarin is the most common VKA agent. Dabigatran and rivaroxaban are the only DOACs that are approved for use in pediatric patients. The choice of anticoagulant agent is influenced by patient comorbidities, drug interactions, clinician preference and experience (eg, familiarity with newer DOAC agents), and other considerations specific to each drug (eg, cost, availability, formulation, ease of administration, and need for monitoring). Decisions should be individualized weighing the benefits and risks and considering the values and preferences of the individual patient/family. For additional details, refer to separate UpToDate content on management of venous thromboembolism in children.

LMWH: low molecular weight heparin; DOACs: direct oral anticoagulants; IV: intravenous; N/A: not applicable.

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