What is the difference between Non-Vitamin K Antagonist Oral Anticoagulants (NOAC) and Direct Oral Anticoagulants (DOAC) in pediatric patients?

From the Guidelines

In pediatrics, the terms NOAC (Novel Oral Anticoagulants) and DOAC (Direct Oral Anticoagulants) refer to the same class of medications, with DOAC being the preferred terminology today. Currently, DOACs have limited FDA approval for pediatric patients, with rivaroxaban (Xarelto) and dabigatran (Pradaxa) being the only ones approved for specific pediatric indications, as noted in the most recent guidelines 1. Rivaroxaban is approved for venous thromboembolism (VTE) treatment in children after at least 5 days of parenteral anticoagulation, while dabigatran is approved for VTE treatment in children who have received a parenteral anticoagulant for at least 5 days, and for VTE recurrence prevention.

Key Differences and Considerations

• Dosing is weight-based and age-dependent, with rivaroxaban ranging from 2.5-10 mg for infants/children <30 kg to 15-20 mg for those >30 kg, and dabigatran capsules ranging from 75-150 mg twice daily based on weight.
• Other DOACs like apixaban and edoxaban lack pediatric approval despite ongoing studies, highlighting the need for further research in this area 1.
• The appeal of DOACs in pediatrics includes oral administration, fewer drug interactions, no routine monitoring requirements, and potentially improved adherence compared to traditional anticoagulants like warfarin.
• However, challenges remain, including limited pediatric-specific data, lack of readily available reversal agents in all settings, and formulation issues for younger children who cannot swallow tablets or capsules, as discussed in recent studies 1.

Clinical Implications

• The use of DOACs in pediatric patients has shown efficacy and safety results similar to those in adults, according to recent clinical trials 1.
• Traditional anticoagulants (heparin and VKA) remain the standard of care in the management of VTE in pediatric patients, but DOACs are becoming increasingly recommended due to their advantages 1.
• Recommendations for the treatment and management of VTE in pediatric patients vary between guidelines, but the most recent and highest quality studies suggest that DOACs are a viable option for pediatric patients with VTE 1.

From the Research

Difference between NOAC and DOAC in Pediatric Patients

• The terms Non-Vitamin K Antagonist Oral Anticoagulants (NOAC) and Direct Oral Anticoagulants (DOAC) are often used interchangeably to refer to a class of anticoagulant medications that do not require monitoring like warfarin [ 2, 3, 4, 5, 6 ].
• In the context of pediatric patients, both NOAC and DOAC refer to medications such as dabigatran, rivaroxaban, apixaban, and edoxaban, which have been studied for the treatment and prevention of venous thromboembolism (VTE) [ 2, 3, 5 ].
• The key difference lies in the terminology used, with NOAC being a broader term that encompasses all non-vitamin K antagonist oral anticoagulants, while DOAC specifically refers to direct-acting oral anticoagulants that target either thrombin (dabigatran) or factor Xa (rivaroxaban, apixaban, and edoxaban) [ 2, 3 ].
• In pediatric patients, the use of DOACs has been shown to be safe and effective for the treatment of VTE, with studies demonstrating low recurrence rates and reduced thrombotic burden without increased risk of bleeding [ 2, 5 ].
• However, the use of DOACs in pediatric patients is still evolving, and ongoing trials are needed to further elucidate their safety and efficacy in this population [ 2, 3, 5 ].