Weigh venous thromboembolism (VTE) prevention strategies in COVID-19

Ensure ALL hospitalized patients with COVID-19 receive VTE prophylaxis. Generally choose once-daily enoxaparin over BID or TID subcutaneous heparin...
Abdelwahab Ward, BS Pharm, PharmD

Clinicians are scrambling to optimize venous thromboembolism (VTE) prophylaxis for hospitalized patients with COVID-19. Data suggest these patients have a higher VTE risk than other hospitalized patients. Plus D-dimer and other markers are often elevated in COVID-19 especially in severe cases. But there’s little evidence about optimal VTE prophylaxis in patients with COVID-19. Rely on a practical approach.

Ensure ALL hospitalized patients with COVID-19 receive VTE prophylaxis. Generally choose once-daily enoxaparin over BID or TID subcutaneous heparin to reduce nursing exposure to COVID-19 patients. If anticoagulation is contraindicated (for example, platelet count < 25 × 109/L, fibrinogen < 0.5 g/L, or active bleeding), patients should be treated by leg compression. Use standard prophylaxis doses for extended‐duration thromboprophylaxis in most COVID-19 patients and continue to adjust doses for renal function and weight. Enoxaparin 40 mg SQ once daily (20 or 30 mg SQ once daily if CrCl < 30 mL/min). If BMI ≥ 40 kg/m2, consider increasing the prophylactic dose by 30% (e.g., 40 mg SQ q12h). If BMI ≥ 50 kg/m2, consider enoxaparin 60 mg SQ q12h.

Some experts step up doses when using VTE prophylaxis for select COVID-19 cases, such as an ICU patient with worsening clinical status and a D-dimer greater than 6 times the upper limit of normal. The thinking is that thrombosis may be more common than bleeding in COVID-19-associated coagulopathy. But weigh individual clot and bleeding risks, there’s not good evidence for the ideal prevention strategy in these patients.

AFTER discharge. Don’t routinely continue VTE prophylaxis AFTER discharge for COVID-19 patients. There’s not a clear benefit over bleeding risks in MEDICAL patients. But there aren’t COVID-19-specific data. Ensure safety parameters are in place if extended-duration prophylaxis is considered in specific situations. For example, some specialists may use (Eliquis 2.5 mg BID or Xarelto 10 mg once daily) for 14 day to 4 weeks in a COVID-19 patient at low bleeding risk with multiple VTE risks (reduced mobility, history of VTE, with co-existing conditions such as cancer, D-dimer level > 2 times upper level of normal, age ≥ 75 years, etc) who is discharged early in their recovery due to hospital space. Verify that the VTE prophylaxis indication, duration, and follow-up are well documented in the discharge plan.

References

  1. Moores LK, Tritschler T, Brosnahan S, et al. Prevention, Diagnosis, and Treatment of VTE in Patients With Coronavirus Disease 2019: CHEST Guideline and Expert Panel Report. Chest. 2020;158(3):1143-1163.
  2. Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review. J Am Coll Cardiol. 2020;75(23):2950-2973.
  3. Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the anticoagulation forum. J Thromb Thrombolysis. 2020;50(1):72-81.
  4. Spyropoulos AC, Levy JH, Ageno W, et al. Scientific and Standardization Committee communication: Clinical guidance on the diagnosis, prevention, and treatment of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020;18(8):1859-1865.
Abdelwahab Ward, BS Pharm, PharmD