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Background: The pharmacological choice for continuous anticoagulation therapy in pediatric patients has classically been unfractionated heparin. However, with heparin there are risks of treatment resistance in pediatrics given differences in developmental hemostasis, and contemporary medications such as bivalirudin offer a valuable alternative. Bivalirudin binds to thrombin and has shown encouraging results compared to heparin in pediatric patients receiving ECMO, but no comparison has been made in patients receiving therapeutic anticoagulation. Three years ago, Children’s Mercy Pediatric Hematology department encouraged bivalirudin use over heparin use for therapeutic anticoagulation requiring a continuous infusion. Objectives: Compare clinical and laboratory outcomes in patients receiving bivalirudin and continuous heparin for therapeutic anticoagulation secondary to a thrombotic event. Methods: A retrospective chart review between 1/1/13 to 12/31/22 was performed and looked specifically at patients who had a pediatric hematology consult for therapeutic anticoagulation who were not on ECMO or CRRT. Patients who were on prophylactic dosing or were using the medication for prophylaxis at therapeutic ranges were excluded. Results: 46 patients received bivalirudin during this time while 135 patients received heparin. The time to therapeutic range was significantly shorter in the bivalirudin group compared to the heparin group (3.7 hours vs 18.6, respectively). Additionally, the bivalirudin group had fewer monitoring labs (0.09 vs 0.15), RBC transfusions (0.0019 vs 0.0097), plasma transfusions (0.00074 vs 0.0048), and dose changes (0.025, 0.54) per medication hour (all p<0.05). Both groups had similar rates of bleeding events (6.5% vs 16.3%; p=0.52) despite bivalirudin having more patients who had concurrent bleeding at the time of anticoagulation induction (21.7% vs 5.2%; p<0.05). None of the bivalirudin patients failed to achieve a therapeutic level while 18.6% of heparin patients required a change in anticoagulation due to failure to achieve therapeutic goal. Finally, when monitoring labs (heparinased PTT and Anti-Xa) were standardized to a percentage of goal there was significantly less variation in the bivalirudin group (p<0.001). The average age was older in the bivalirudin group (9.9 vs 1.1) so to account for this, patients were subdivided into under and over 6 months of age. There were 13 bivalirudin and 64 heparin patients who were under the age of 6 months and 33 bivalirudin and 71 heparin subjects older than 6 months of age. The same differences were noted in both subgroups (shorter time to therapeutic range, fewer monitoring labs, RBC transfusions, and dose changes, and more lab monitoring variability). There was no difference in bleeding events in both subgroups when compared with their age cohort. The bivalirudin group had fewer patients with congenital heart conditions (11% vs 47%) and this difference was still noted after subdividing the age groups. Conclusions: Pediatric patients who received bivalirudin had shorter time to a therapeutic range, less lab variability, fewer dose changes, fewer monitoring labs and fewer transfusions with similar bleeding rates compared to patients who received unfractionated heparin.


Hematology | Pediatrics


Presented at the 2024 Thrombosis & Hemostasis Summit of North America (THSNA); April 4-6, 2024; Chicago, IL.

Single Center Retrospective Comparison of Bivalirudin and Heparin for Therapeutic Anticoagulation in Pediatric Patients