Breakthrough venous thromboembolic events in five patients with COVID‐19 on direct oral anticoagulants

Abstract

What is known and objective Coronavirus disease 2019 (COVID‐19) is associated with increased risk of venous thromboembolism (VTE). Guidance for VTE prophylaxis continues to evolve, including addressing direct oral anticoagulants (DOACs) continued upon hospitalization. Case summaries We present 5 patients hospitalized for COVID‐19 while on DOACs. Four patients had atrial fibrillation and had a previous VTE. Four patients developed acute VTE and one developed stroke‐like symptoms. Monitoring D‐dimer assisted with the detection of VTE. Three patients died, and two were discharged alive. What is new and conclusion Therapeutic failure with DOACs appears to be commonplace in COVID‐19. Further research is needed to determine whether there is an underlying cause to this association.

Edoxaban for the treatment of pulmonary embolism in hospitalized COVID-19 patients

“…The major concerns in the use of NOACs among COVID-19 patients lie in drug interactions with antiviral agents [ 25 ] and their longer duration of action than heparins, which could result in an increased risk of bleeding in critically ill patients [ 7 ]; moreover, some case reports suggest the possibility that COVID‐19 may lead to higher rates of NOACs failure [ 9 , 26 ], probably due to lower anti-inflammatory effects compared to heparinoids [ 27 ]. According to the current guidelines [ 7 ], our study cohort started the parental anticoagulant therapy with fondaparinux or LWMH at PE diagnosis.…”

“…The optimal treatment of PE in the clinical contest of COVID-19 is still debated [ 7 ]. Even if non-vitamin K oral anticoagulant (NOACs) shares the same indication of parental anticoagulation with low molecular weight heparin (LMWH) or fondaparinux in general population [ 8 ], few clinical experiences on the NOACs use for the PE treatment have been reported in COVID-19 patients, with a recent case series describing a relatively high percentage of NOACs failure in COVID‐19 patients [ 9 ]. The aim of our study was to describe the real-world safety and effectiveness of edoxaban for PE treatment among COVID-19 patients.…”

A fatal case of extensive gastrointestinal necrosis due to portal and mesenteric vein thrombosis in the post-acute phase of COVID-19

“…Anticoagulant therapy could improve the prognosis of COVID-19 patients with elevated plasma D-dimer level. However, because breakthrough venous thrombotic events have often been reported with anticoagulant therapy in COVID-19 patients [14,15], the appropriate dose (i.e., for therapeutic or prophylactic purposes) and duration of anticoagulant therapy also remain to be established for hospitalized COVID-19 patients, especially in patients with hemorrhagic complication such as the present case [16]. Behnood B et al have recommended extended prophylaxis for up to 45 days to prevent thrombotic events, especially in high-risk patients (e.g., reduced mobility, elevated D-dimer level) [17].…”

Similarities and perspectives on the two C’s—Cancer and COVID‐19

“… More research is needed to understand the exact mechanisms of thrombosis in the two C’s, which would help identify therapeutic strategies. Interesting research prospects in this context are whether early commencement of anticoagulant therapy (heparins) at prophylactic doses may decrease the thrombotic risk in the two C’s due to their possible anti‐inflammatory, endothelial quiescent, and anti‐neoplastic effects. Whether direct oral anticoagulants have a heparin‐like non‐anticoagulant role would be worth exploring, although the absence of protection displayed by patients with COVID‐19 recently is disappointing 55 …”

“…sence of protection displayed by patients with COVID-19 recently is disappointing 55. CON CLUS IONIn summary, the two C's, cancer and COVID-19, share some unique clinical and laboratory features that open more questions about the pathophysiological roles of hemostasis and thrombosis in inflammatory and neoplastic diseases.…”