Interdisciplinary Approach to Thrombosis Management in COVID-19 at a Large Academic Center

Abstract

There is an increasing recognition of association of COVID-19 with a distinct coagulopathy and increased risk of thrombosis. Unfortunately, effective strategies to prevent and treat thrombosis in this patient population remain uncertain. In the setting of a worsening pandemic, there is an urgent need to provide practical guidance to the clinicians on management of the coagulopathy, while waiting for the results from large systematic trials to establish best practices. At our institution, we convened an interdisciplinary group of 25 experts in the field of thrombosis from different medical specialties to review available literature and brainstorm management strategies. The group provided a 3-tiered anticoagulation algorithm for patients with COVID-19 along with a pathway for multidisciplinary review of difficult or refractory cases, which are described in this manuscript. In these unprecedented times where medical decision making is made difficult by both the novelty of the disease and paucity of robust data, clinical algorithms such as the one presented here may prove to be helpful for frontline providers caring for individual patients.

FIG 1.

Practical approach to prevention and treatment of thrombosis in COVID-19 (simplified to allow easy use of the algorithm). ^aDuring hospital stay: Prophylactic dose LMWH at 0.5 mg/kg/d (monitor anti-Xa level for a creatinine clearance of 15-30 mL/min) or prophylactic UFH at 5,000 units once every 12 hours for a creatinine clearance of < 15 mL/min (can dose adjust UFH for BMI 25-35: 7,500 units once every 12 hours; BMI > 35: 10,000 units once every 12 hours). On discharge: Prophylactic LMWH or prophylactic DOAC (preferred), rivaroxaban 10 mg PO daily or apixaban 2.5 mg PO twice a day × 7 days. ^bDuring hospital stay: Intermediate-dose LMWH at 1 mg/kg/d (monitor anti-Xa level for a creatinine clearance of 15-30 mL/min) or low standard UFH infusion for a creatinine clearance of < 15 mL/min. On discharge: Intermediate LMWH or DOAC (preferred), rivaroxaban 10 mg PO daily or apixaban 2.5 mg PO twice a day × 4 weeks. ^cDuring hospital stay: Therapeutic dose LMWH at 1 mg/kg/12 hours (monitor anti-Xa level for a creatinine clearance of 15-30 mL/min) or high standard UFH infusion for a creatinine clearance of < 15 mL/min. On discharge: Therapeutic LMWH or DOAC (preferred), rivaroxaban 20 mg PO daily (use loading dose of rivaroxaban at 15 mg PO twice a day for the first 21 days from the episode of VTE) or apixaban 5 mg PO twice a day (use loading dose of apixaban at 10 mg PO twice a day for the first 7 days from the episode of VTE) × 3 months. ^dAssess risk of bleeding for all patient before starting anticoagulation: Ensure that the platelet count is > 25,000/µL for patients on levels 1 and 2 and > 50,000/µL for patients on level 3 anticoagulation; consider risk-benefit ratio of anticoagulation carefully in patients with active or recent bleeding, surgery, coagulopathy, comorbidities, or concurrent medications associated with high risk of bleeding; consult a coagulation expert, if available, in case of questions. BMI, body mass index; DOAC, direct oral anticoagulant; ICU, intensive care unit; LMWH, low molecular weight heparin; PO, per os; UFH, unfractionated heparin; ULN, upper limit of normal; VTE, venous thromboembolism.