Clinical Outcomes With the Use of Prophylactic Versus Therapeutic Anticoagulation in Coronavirus Disease 2019

Abstract

Objectives: To determine the impact of anticoagulation on inhospital mortality among coronavirus disease 2019-positive patients with the a priori hypothesis that there would be a lower risk of inhospital mortality with use of preemptive therapeutic over prophylactic dose enoxaparin or heparin. Design Setting: Retrospective cohort study from April 1, 2020, to April 25, 2020. The date of final follow-up was June 12, 2020 Two large, acute-care hospitals in Western Connecticut. Patients: Five hundred and one inpatients were identified after discharge as 18 years or older and positive for severe acute respiratory syndrome coronavirus 2. The final sample size included 374 patients after applying exclusion criteria. Demographic variables were collected via hospital billing inquiries, whereas the clinical variables were abstracted from patients’ medical records. Exposure: Preemptive enoxaparin or heparin at a therapeutic or prophylactic dose. Main Results: When comparing treatments through multivariable analysis, risk of inhospital mortality was 2.3 times greater in patients receiving preemptive therapeutic anticoagulation (95% CI = 1.0–4.9; p = 0.04). Additionally, the average treatment effects were higher (β = 0.11, p = 0.01) in the therapeutic group. Conclusions: An increase in inhospital mortality was observed among patients on preemptive therapeutic anticoagulation. Thus, in the management of coronavirus disease 2019 and its complications, we recommend further research and cautious use of preemptive therapeutic over prophylactic anticoagulation.

High versus Standard Intensity of Thromboprophylaxis in Hospitalized Patients with COVID-19: A Systematic Review and Meta-Analysis

“…Among the 8318 articles initially retrieved through our literature search, 21 fulfilled the inclusion criteria and were included in our analysis [ 11 , 12 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ]. The PRISMA 2020 flow diagram for systematic reviews and meta-analyses study selection is presented in Supplementary File, Figure S1 .…”

“…The PRISMA 2020 flow diagram for systematic reviews and meta-analyses study selection is presented in Supplementary File, Figure S1 . A total of 7 studies reported data for intermediate versus prophylactic dose [ 11 , 27 , 28 , 29 , 30 , 34 , 35 ], while 17 studies reported data for therapeutic versus prophylactic dose of thromboprophylaxis [ 12 , 23 , 24 , 25 , 26 , 29 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ]. Three studies contributed data for both intermediate versus prophylactic and therapeutic versus prophylactic dose analyses [ 29 , 34 , 35 ].…”

Comparison of standard prophylactic and preemptive therapeutic low molecular weight heparin treatments in hospitalized patients with COVID-19

“…Additionally, Paoliss et al reported that receiving therapeutic LMWH therapy was associated with a lower in-hospital mortality compared to the prophylactic LMWH (13). In contrast, in the study of Motta et al, the mortality was 2.3 times higher in patients, who received therapeutic dose LMWH than those, who received prophylactic dose LMWH (14). Musoke et al emphasized the higher mortality and increased bleeding complications in those receiving therapeutic dose anticoagulant therapy (15).…”

“…There is an increasing number of studies indicating that LMWH is effective in reducing mortality in patients with COVID-19 (6, 7). However, only a few studies compared therapeutic and prophylactic doses of LMWH treatments (13)(14)(15)(16)(17)(18)(19). Whereas some studies showed advantages (7,11) and disadvantages (12-16) of therapeutic LMWH, others found no difference on clinical outcomes/mortality (17)(18)(19).…”

A COVID-19 patient with recurrent acute limb ischaemia despite two successive types of therapeutic dose anticoagulation and thrombolysis

“… 10 On the other hand, pre-emptive therapeutic anticoagulation is associated with 2.3 times higher risk of mortality compared with those on prophylactic dose. 11 The current literature on the characteristics of patients that warrant intermediate or therapeutic dose anticoagulation is sparse. Ongoing international trials such as the Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia, Antithrombotic Therapy to Ameliorate Complications of COVID-19, and Anti-thrombotics for Adults Hospitalized With COVID-19 aim to address the question whether therapeutic dose anticoagulation is warranted in moderately to critically ill patients.…”