Effect of Anticoagulant Therapy for 6 Weeks vs 3 Months on Recurrence and Bleeding Events in Patients Younger Than 21 Years of Age With Provoked Venous Thromboembolism
Authors: Neil A. Goldenberg, John M. Kittelson, Thomas C. Abshire, Marc Bonaca, James F. Casella, Rita A. Dale, Jonathan L. Halperin, Frances Hamblin, Craig M. Kessler, Marilyn J. Manco-Johnson, Robert F. Sidonio, Alex C. Spyropoulos, P. Gabriel Steg, Alexander G. G. Turpie, Sam Schulman, James A French, John H Fargo, Shelley E Crary, Riten Kumar, Rachel F Grace, Cameron C Trenor, Hope P Wilson, Lee M Hilliard, Gary M Woods, Kavita Patel, Neil A Goldenberg, Eric J Lowe, Julie A Jaffray, Guy A Young, Madhvi A Rajpurkar, Jennifer G Davila, Arash Mahajerin, James Cooper, Sriya W Gunawardena, Ayesha N Zia, Janna M Journeycake, Shannon L Carpenter, Michael M Guerrera, Yaser A Diab, Cristina C Tarango, Ralph A Gruppo, Suchitra S Acharya, Marcella D Torres, Linda G Shaffer, Robert C Mignacca, Kristina M Haley, Michael Recht, Courtney D Thornburg, Nirmish R Shah, Craig A Mullen, Deanna S Mitchell, Charles Nakar, Marisol Betensky, Courtney E Lawrence, Clifford M Takemoto, Clara Lo, Ajovi B Scott-Emuakpor, Roshni Kulkarni, Alexandra J Borst, Sarah H O'Brien, Fernando F Corales-Medina, Shalu Narang, Nicole E Kucine, Michael Wang, Arun R Panigrahi, Kerry K McGowan, Stuart L Cramer, Smita C Dandekar, Frederico Xavier, Kristina M Knoll, Anupam R Verma, Amy E Geddes, Sanjay P Ahuja, Kerry M Hege, Deepti A Raybagkar, Anjali A Sharathkumar, Lakshmi V Srivath, Osman Khan, Colleen H Druzgal, Mihir D Bhatt, Anthony Chan, Leonardo R Brandao, Patricia Massicotte, C. Heleen van Ommen, Christoph Male, Paul Monagle, Taizo A Nakano, William B Mitchell, William R Hiatt, Jeffrey Weitz
Journal: JAMA (2022)

Among patients younger than 21 years of age, the optimal duration of anticoagulant therapy for venous thromboembolism is unknown. To test the hypothesis that a 6-week duration of anticoagulant therapy for provoked venous thromboembolism is noninferior to a conventional 3-month therapy duration in patients younger than 21 years of age. Randomized clinical trial involving 417 patients younger than 21 years of age with acute, provoked venous thromboembolism enrolled at 42 centers in 5 countries from 2008-2021. The main exclusions were severe anticoagulant deficiencies or prior venous thromboembolism. Patients without persistent antiphospholipid antibodies and whose thrombi were resolved or not completely occlusive upon repeat imaging at 6 weeks after diagnosis underwent randomization. The final visit for the primary end points occurred in January 2021. Total duration for anticoagulant therapy of 6 weeks (n = 207) vs 3 months (n = 210) for provoked venous thromboembolism. The primary efficacy and safety end points were centrally adjudicated symptomatic recurrent venous thromboembolism and clinically relevant bleeding events within 1 year blinded to treatment group. The primary analysis was noninferiority in the per-protocol population. The noninferiority boundary incorporated a bivariate trade-off that included an absolute increase of 0% in symptomatic recurrent venous thromboembolism with an absolute risk reduction of 4% in clinically relevant bleeding events (1 of 3 points on the bivariate noninferiority boundary curve). Among 417 randomized patients, 297 (median age, 8.3 [range, 0.04-20.9] years; 49% female) met criteria for the primary per-protocol population analysis. The Kaplan-Meier estimate for the 1-year cumulative incidence of the primary efficacy outcome was 0.66% (95% CI, 0%-1.95%) in the 6-week anticoagulant therapy group and 0.70% (95% CI, 0%-2.07%) in the 3-month anticoagulant therapy group, and for the primary safety outcome, the incidence was 0.65% (95% CI, 0%-1.91%) and 0.70% (95% CI, 0%-2.06%). Based on absolute risk differences in recurrent venous thromboembolism and clinically relevant bleeding events between groups, noninferiority was demonstrated. Adverse events occurred in 26% of patients in the 6-week anticoagulant therapy group and in 32% of patients in the 3-month anticoagulant therapy group; the most common adverse event was fever (1.9% and 3.4%, respectively). Among patients younger than 21 years of age with provoked venous thromboembolism, anticoagulant therapy for 6 weeks compared with 3 months met noninferiority criteria based on the trade-off between recurrent venous thromboembolism risk and bleeding risk. ClinicalTrials.gov Identifier: NCT00687882.