Managing anticoagulation in the COVID-19 era between lockdown and reopening phases

Abstract

Patients on anticoagulant treatment are constantly increasing, with an estimated prevalence in Italy of 2% of the total population. The recent spreadout of the COVID-19 pandemic requires a reorganization of Anticoagulation Clinics to prevent person-to-person viral diffusion and continue to offer the highest possible quality of assistance to patients. In this paper, based on the Italian Federation of Anticoagulation Clinics statements, we offer some advice aimed at improving patient care during COVID-19 pandemic, with particular regard to the lockdown and reopening periods. We give practical guidance regarding the following points: (1) rethinking the AC organization, (2) managing patients on anticoagulants when they become infected by the virus, (3) managing anticoagulation surveillance in non-infected patients during the lockdown period, and (4) organizing the activities during the reopening phases.

Prevalence of asymptomatic deep vein thrombosis in patients hospitalized with SARS-CoV-2 pneumonia: a cross-sectional study

“…Peculiar characteristics of this viral infection can cause prolonged immobilization, possible dehydration, a massive inflammatory response of the organism that in more severe cases may evolve towards acute respiratory distress syndrome (ARDS), severe coagulopathy and multi-organ failure, all conditions that increase thromboembolic complications. This condition can be associated with increased risks with the need of higher doses of heparin thromboprophylaxis as previously suggested [10,18,[32][33][34][35][36][37]; furthermore, acquired antithrombin deficiencies may also occur in these clinical situations, thus causing heparin resistance [38,39].…”

“…Internal and Emergency Medicine immobilization, to promptly start LMWH prophylaxis; (c) posology of heparin, that should be increased to reach the correct prophylaxis range which may not be "a fixed dose for all", as already proposed in patients with sepsis [18,[32][33][34]. For the above considerations and highlighting the very high thromboembolic risks of hospitalized COVID-19 patients on standard prophylaxis, we conclude that: (a) routinely compressive ultrasound of the legs should be performed during the first week of hospitalization; (b) LMWH prophylaxis should be started immediately at the onset of acute COVID-19 pneumonia; (c) LMWH prophylaxis should be ensured to all patients, adapting doses in relation to weight, renal function with the target to maintaining upper levels of prophylactic range (aXa = 0.2-0.5 UI/ml) [35,36].…”

“COVID-19: diagnosis, management and prognosis”: a new topical collection of Internal and Emergency Medicine

“…On the other hand, a paper by Poli et al provided some advice aimed at improving the outpatient management of people on anticoagulant treatment during COVID-19 pandemic, with particular regard to the lockdown and reopening periods [39].…”

“…Finally, Testa et al addressed the management of Covid-19 patients on oral anticoagulant drugs, and the high risk of over/under treatment due to the multiple pharmacological interactions, and the possible necessity of mechanical ventilation, and suggested replacing oral anticoagulant therapies with parenteral low-molecular-weight heparin or unfractionated heparin [ 38 ]. On the other hand, a paper by Poli et al provided some advice aimed at improving the outpatient management of people on anticoagulant treatment during COVID-19 pandemic, with particular regard to the lockdown and reopening periods [ 39 ].…”

Pulmonary embolism and screening for concomitant proximal deep vein thrombosis in noncritically ill hospitalized patients with coronavirus disease 2019

“…Alterations in the coagulation system related to COVID infection still represents a challenge for clinicians in every day practice despite the growing number of investigations on this topic, and some issues (i.e., timing and doses of anticoagulants, risk stratification of the hemorrhagic/thrombotic risk in each patient) remain to date to be completely understood [ 4 – 6 ].…”