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Presentation Details
| Rivaroxaban as secondary thromboprophylaxis in pediatric patients with digestive malabsorption Angela F Journell 1, Chelsea E.Peters1, Jessica Meznarich1, 2, Sasidhar Goteti1, 2. 1Primary Children's Hospital, Salt Lake City, UT, USA.2University of Utah, Salt Lake City, UT, USA |
Abstract
Background: Pediatric patients with digestive malabsorptive conditions often require long-term parenteral nutrition via a central venous catheter (CVC), which places them at risk for venous thromboembolism (VTE). Low molecular weight heparin (LMWH), or enoxaparin, has been the standard of care for pediatric patients requiring VTE prophylaxis. For patients requiring chronic anticoagulation, LMWH is often not preferred by patients or their caregivers since it is administered as a subcutaneous injection. Objectives: Our objective was to review the use of rivaroxaban in patients with known digestive malabsorption to determine if rivaroxaban is a safe and effective secondary thromboprophylaxis. Methods: We retrospectively reviewed the electronic medical records of patients <18 years of age with short bowel syndrome who required anticoagulation to prevent VTE between 2022 and 2024. Results: We identified 3 patients with short bowel syndrome who were treated with rivaroxaban for secondary thromboprophylaxis. These patients were trialed on rivaroxaban with measurement of rivaroxaban peak levels drawn 2-4 hours after dosing to ensure steady state was achieved (Figure 1). Ranges for DOAC drug levels have not been established; instead, we used rivaroxaban plasma concentration levels from patient populations studied in adult data for VTE prevention after total hip replacement surgery. (C-max post-dose peak plasma concentration 91-196 ng/ml). Patient 1 was a patient with a history of TPN-dependence due to short bowel syndrome-associated intestinal failure (SBS-associated IF) with a tunneled Broviac® in place and a history of a CVC-associated VTE treated with enoxaparin. Anticoagulation was switched to rivaroxaban due to intolerance towards injections. She tolerated rivaroxaban without any bleeding complications or new VTE. Prophylactic anticoagulation was stopped once their CVC was removed. Patient 2 was a 5-year-old female patient with TPN-dependence due to SBS-associated IF with a tunneled Broviac® and a history of CVC-associated VTE treated with enoxaparin. Due to continued TPN-dependence, secondary prophylaxis anticoagulation was deemed necessary. Rivaroxaban was trialed due to discomfort with enoxaparin injections and noncompliance. At age 7, she redeveloped a CVC-associated thrombus when rivaroxaban was held for bacteremia and thrombocytopenia. Her anticoagulation was then transitioned to therapeutic enoxaparin. Patient 3 was a 4-year-old male patient with TPN-dependence due to SBS-associated IF with a tunneled Broviac® in place and a history of non-occlusive CVC-associated VTE treated with enoxaparin. Rivaroxaban was used as secondary prophylaxis due to discomfort with enoxaparin injections. At age 6, anticoagulation was stopped due to bleeding concerns with GI ulcers found on colonoscopy, thought to be anastomotic ulcers. Conclusion: Our case series summarizes three pediatric patients with short bowel syndrome who were treated with rivaroxaban and utilized rivaroxaban peak levels to ensure expected prophylactic ranges were achieved. We used a weight-based pediatric dose recommendation for thromboprophylaxis after the Fontan procedure. In our experience, two patients with short bowel syndrome and chronic CVC were treated with rivaroxaban for secondary thromboprophylaxis for >1 year at varying doses without recurrent VTE or major bleeding events. Rivaroxaban can be considered for thromboprophylaxis in selected patients with digestive malabsorptive conditions with close therapeutic drug level monitoring.
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No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author.