Should anticoagulation be given to COVID-19 patients who are managed at home, and if so, when? 

Posted on May 12, 2020 by Lisa Szostek

Summary

  • No, unless other indications for anticoagulation exist.
  • COVID-19 has been associated with inflammation and prothrombotic state. Moderate to severe cases may be complicated with coagulopathy and disseminated intravascular coagulation (DIC). 
  • Anticoagulation is recommended for hospitalized patients and has been shown to improve prognosis but outpatient management is not as clear and no clinical trials have addressed thromboprophylaxis in outpatients with COVID-19.
  • The US CDC recommends anticoagulant or antiplatelet therapy should not be initiated in outpatients for prophylaxis of venous thromboembolism or arterial thrombosis unless there are other indications.
  • A recent study indicated that outpatient  venous thromboembolism (VTE) prophylaxis should not be initiated but assessment for VTE risk and bleeding is reasonable.
  • The BCCDC treatment regulations for COVID-19 do not address anticoagulation in patients managed at home.

I.   Coagulopathy and COVID-19

 

  • Elevated levels of coagulation markers (D-dimers, prothrombin time, platelet count, fibrinogen) is common in patients with moderate to severe COVID-19. (1)
  • Moderate to severe COVID-19 may be complicated with coagulopathy and disseminated intravascular coagulation (DIC) and abnormal coagulation results are associated with poor prognosis. (1,2). Anticoagulation therapy is recommended for hospitalized patients and improves prognosis (1,3).

 

  • The pathophysiology of coagulopathy in COVID-19 is currently unknown but suggested mechanisms include a specific effect from SARS-CoV-2, a cytokine storm that precipitates a systemic inflammatory response, and liver dysfunction and antiphospholipid antibodies (4).

II.   Anticoagulation and COVID-19

  • There are currently no trials that address thromboprophylaxis in outpatients with COVID-19.
  • The BCCDC has recommended VTE prophylaxis for hospitalized patients with COVID-19 but currently does not have guidelines regarding anticoagulation therapy for patients managed at home. (3)
  • The US CDC states that for outpatients anticoagulant or antiplatelet therapy should not be initiated for prophylaxis of VTE or arterial thrombosis unless there are other indications. It also recommends that there are no data to support measurement of coagulation markers in outpatients.  (5)
  • A study indicated that VTE prophylaxis should not be initiated but that assessment for the risk of VTE and bleeding is reasonable. If there is an elevated risk of VTE and no high risk of bleeding that pharmacologic prophylaxis may be considered. (4)
  • Patients with COVID-19 who are taking anticoagulant or antiplatelet therapy for underlying medical conditions should continue their treatment unless significant bleeding develops or other contraindications are present. (5)
  • Patients with COVID-19 who are discharged from the hospital should not be given routine VTE prophylaxis except for certain high-risk patients. (5)
  • If thromboprophylaxis is used in an outpatient, a regimen such as rivaroxaban 10 mg BID for 31 to 39 days is recommended. (6)

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Tang, N., Li, D., Wang, X., Sun, Z. 2020. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. Journal of Thrombosis and Haemostasis. 18:4. DOI: 10.1111/jth.14768
  2. Han,H., Yang, L., Liu, F., Wu, K.L., Li, J., Liu, X.H., Zhu, C.L. 2020. Prominent changes in blood coagulation of patients with SARS-CoV-2 infection. Clin Chem Lab Med. DOI: 10.1515/cclm-2020-0188.
  3.  Recommendation: Therapies for COVID-19. BCCDC. [cited 2020 May 12]. Available from: http://www.bccdc.ca/health-professionals/clinical-resources/covid-19-care/clinical-care/treatments
  4. Bikdeli, B., et al. 2020. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up. J Am Col Card. DOI: 10.1016/j.jacc.2020.04.031.
  5. Antithrombotic therapy in patients with COVID-19. US CDC. [cited 2020 May 12]. Available from: The US CDC recommends that there are no data to support measurement of coagulation markers (D-dimers, prothrombin time, platelet count, fibrinogen).
  6. COVID-19 and VTE/anticoagulation: Frequently asked questions. American Society of Hematology. [cited 2020 May 12]. Available from: https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.