A global survey on practice changes and barriers to the use of direct oral anticoagulants in children

Abstract We aim to describe the patterns of use, practice changes, and emerging challenges after the approval of direct oral anticoagulants (DOACs) for thrombosis management and prevention in children. This cross-sectional survey-based study involved pediatric thrombosis treaters from different institutions around the world. The survey was distributed between January and August 2024. DOAC use and barriers were compared according to the country’s income (high-income countries [HICs] vs low- and middle-income countries [LMICs], per World Bank classification). In total, 100 of 103 respondents completed the survey, representing 100 different institutions from 96 cities in 53 countries (31% European, 25% North American, 24% Asian, 12% South American, 5% Oceanian, and 3% African). Eighty-five percent of respondents used DOACs (HICs, 89% vs LMICs, 76%; P = .09). Although DOACs were more commonly used than low molecular weight heparin (LMWH) or vitamin K antagonists (VKA) in outpatients, 91% respondents indicated that <50% of their patients were started on DOACs directly, and 62% reported that <50% of children on long-term LMWH/VKA had been switched to DOACs. Lack of pediatric formulations was the most common barrier (39% in HICs, 52% in LMICs); 9% of respondents in HIC vs 29% in LIMC reported no access to DOACs (P = .009), whereas 21% of respondents in HICs vs 3% in LIMCs stated no barriers to their use (P = .02), indicating inequality. Additional barriers included cost and clinician acceptability and limited knowledge, experience, and expertise. The results highlight current gaps in pediatric DOAC use, emphasizing the importance of capacity building, advocacy, and generation of further evidence to inform guidelines and policies.