a Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
b Service and Central Laboratory of Hematology, Lausanne University Hospital, Lausanne, Switzerland
c Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
d Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
e Cantonal Hospital of St Gallen, St Gallen, Switzerland
f Department of Medical Oncology and Hematology, Zurich University Hospital, Zurich, Switzerland
g Division of Hematology, University Hospitals of Geneva, Geneva, Switzerland
h Division of Hematology, Basel University Hospital, Basel, Switzerland
i Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, Lucerne, Switzerland
j Center for perioperative Thrombosis and Hemostasis, Zurich, Switzerland
Growing evidence from multiple retrospective cohorts indicates that hospitalised COVID-19 patients often could suffer from an excessive coagulation activation leading to an increased risk of venous and arterial thrombosis (including small calibre vessels) and a poor clinical course . Notably, D-dimer level at the time of hospital admission is a predictor of the risk of development of acute respiratory distress syndrome (ARDS) , the risk of intensive care admission and the risk of death . An observational study among COVID-19 patients with elevated D-dimer levels at baseline showed that the 28-day mortality was lower in those receiving heparin than in those who did not .
Based on the available literature and published recommendations from the International Society of Thrombosis and Hemostasis (https://www.isth.org), from the American Society of Hematology (https://www.hematology.org/covid-19) and from the Society for Thrombosis and Haemostasis Research (http://gth-online.org), the Working Party on Hemostasis (Swiss Society of Hematology) proposes the following recommendations for pharmacological thromboprophylaxis in COVID-19 patients in the acute setting. Suggestions will be regularly updated:
- All in-hospital COVID-19 patients should receive pharmacological thromboprophylaxis according to a risk stratification score, unless contraindicated.
- In patients with creatinine clearance >30 ml/min, low molecular weight heparin (LMWH) should be administered according to the prescribing information. An increased dose should be considered in overweight patients (>100 kg).
- In patients with creatinine clearance <30 ml/min, unfractionated heparin (UHF) subcutaneously twice or three times daily or intravenously should be administered according to the prescribing information. An increased dose should be considered in overweight patients (>100 kg).
- Anti-Xa activity should be monitored when indicated (e.g., evidence of renal dysfunction).
- Antithrombin need not be monitored but this could be considered on an individual basis in cases of disseminated intravascular coagulation or sepsis-induced coagulopathy or heparin resistance.
- We suggest regularly monitoring prothrombin time, D-dimers, fibrinogen, the platelet count, lactate dehydrogenase (LDH), creatinine and alanine aminotransferase (ALT) (daily or at least 2−3 times per week).
- In patients in intensive care with a large increase in D-dimers, severe inflammation, or signs of hepatic or renal dysfunction or imminent respiratory failure, intermediate or therapeutic dosing of LMWH or UHF should be considered, according to the bleeding risk.
- Heparin-induced thrombocytopenia (HIT) should be considered in patients with fluctuations in platelet counts or signs of heparin resistance.
- In patients undergoing extracorporeal membrane oxygenation (ECMO) treatment we suggest maintaining UFH at doses bringing anti-Xa activity into the therapeutic range.
- There are no data on the use of direct oral anticoagulants.
No financial support and no other potential conflict of interest relevant to this article was reported.
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Alessandro Casini, Division of Angiology and Haemostasis, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, CH-1205 Geneva, Alessandro.casini[at]hcuge.ch /
Lars M. Asmis, Center for perioperative Thrombosis and Hemostasis, Seefeldstrasse 224, CH-8008 Zurich, lars.asmis[at]hin.ch
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