American Society of Hematology 2021 guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19

Abstract

Background: Coronavirus disease 2019 (COVID-19)–related critical illness and acute illness are associated with a risk of venous thromboembolism (VTE). Objective: These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for thromboprophylaxis for patients with COVID-19–related critical illness and acute illness who do not have confirmed or suspected VTE. Methods: ASH formed a multidisciplinary guideline panel and applied strict management strategies to minimize potential bias from conflicts of interest. The panel included 3 patient representatives. The McMaster University GRADE Centre supported the guideline-development process, including performing systematic evidence reviews (up to 19 August 2020). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, including GRADE Evidence-to-Decision frameworks, to assess evidence and make recommendations, which were subject to public comment. Results: The panel agreed on 2 recommendations. The panel issued conditional recommendations in favor of prophylactic-intensity anticoagulation over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19–related critical illness or acute illness who do not have confirmed or suspected VTE. Conclusions: These recommendations were based on very low certainty in the evidence, underscoring the need for high-quality, randomized controlled trials comparing different intensities of anticoagulation. They will be updated using a living recommendation approach as new evidence becomes available.

Prophylactic anticoagulation for patients in hospital with covid-19

“…In contrast, some clinicians who were already prescribing standard dose thromboprophylaxis with LMWH (such as dalteparin 5000 IU once daily) increased the dose to an intermediate (5000 IU twice daily) or even therapeutic level (200 IU/kg). Early national and international guidance based on expert opinion has been inconsistent 891011…”

Coagulation factors directly cleave SARS-CoV-2 spike and enhance viral entry

“…Effective anticoagulation is a critical area of investigation to improve outcomes in coronavirus infection. Vitamin K antagonists, including heparin, are commonly used for preventing venous thromboembolism in COVID-19, although no strong evidence yet supports any specific anticoagulant (Cuker et al, 2021). Retrospective analysis suggested that low molecular weight heparin benefits patients with signs of coagulopathy (Tang et al, 2020).…”

Risk factors for transfer from Respiratory Intermediate Care Unit to Intensive Care Unit in COVID-19

“…In our population, 81% of the patients underwent anticoagulant therapy with enoxaparin. The importance of COVID-19 vascular involvement and the potential role of anticoagulant and antiplatelet drugs has been underlined in several studies [ 18 , 19 ], and at the time of writing, anticoagulants are still a cornerstone of COVID-19 treatment protocols [ 20 ].…”