Suggestions for thromboprophylaxis and laboratory monitoring for in-hospital patients with COVID-19
DOI: https://doi.org/10.4414/smw.2020.20247
Alessandro
Casinia, Lorenzo
Alberiob, Anne
Angelillo-Scherrerc, Pierre
Fontanaa, Bernhard
Gerberd, Lukas
Grafe, Inga
Hegemannf, Wolfang
Kortee, Johanna A.
Kremer Hovingac, Thomas
Lecomptea, Maria
Martinezg, Michael
Naglerc, Jan-Dirk
Studtf, Dimitrios
Tsakirish, Walter
Wuillemini, Lars M.
Asmisj, Working Party on Hemostasis of the Swiss Society of Hematology
aDivision of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
bService and Central Laboratory of Hematology, Lausanne University Hospital, Lausanne, Switzerland
cDepartment of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
dClinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
eCantonal Hospital of St Gallen, St Gallen, Switzerland
fDepartment of Medical Oncology and Hematology, Zurich University Hospital, Zurich, Switzerland
gDivision of Hematology, University Hospitals of Geneva, Geneva, Switzerland
hDDivision of Hematology, Basel University Hospital, Basel, Switzerland
iDivision of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, Lucerne, Switzerland
jCenter 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 [1]. Notably, D-dimer level at the time of hospital admission is a predictor of the risk of development of acute respiratory distress syndrome (ARDS) [2], the risk of intensive care admission and the risk of death [3]. 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 [4].
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.
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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