Algorithm for the Management of Coagulopathy in COVID-19 Based on Simple Laboratory Markers

* The list of markers is given in the decreasing order of importance.

** Performing fibrinogen assays may not be feasible in many laboratories but monitoring the levels can be helpful after patient admission

*** Although a specific cut-off cannot be defined, a 3-4-fold increase in D-dimer values may be considered significant. Any one of the values in this table may be considered significant

Anticoagulation Forum Interim Guidance Highlights [19]

Pharmacologic VTE prophylaxis for all hospitalized non-pregnant patients with confirmed or highly suspected COVID-19, regardless of VTE risk assessment score unless contraindication exists (i.e. active bleeding profound thrombocytopenia)

In patients with contraindications to pharmacologic VTE prophylaxis, consistent application of intermittent pneumatic compression devices with regular assessment for conversion to pharmacologic prophylaxis

For all non-critically ill hospitalized patients (NOT in an ICU) with confirmed or highly suspected COVID-19, standard dose VTE prophylaxis

For critically ill patients (IN an ICU) with confirmed or highly suspected COVID-19, suggest higher doses of VTE prophylaxis (i.e. Enoxaparin 40mg subq BID, enoxaparin 0.5mg/kg subq BID, heparin 7500U subq TID, or low-intensity heparin infusion)

Recommend LMWH > UFH (Unless creatinine clearance <15 – 30mL/min)

Use anti-Xa assay rather than aPTT to monitor therapeutic UFH in patients with COVID-19 whose aPTT is prolonged at baseline. If not elevated at baseline it is reasonable to monitor therapeutic UFH with either anti-Xa assay or aPTT

Use anti-Xa assay rather than aPTT to monitor therapeutic UFH in patients with COVID-19 and heparin resistance (typically defined as need for >35,000U of heparin per 24hrs) as measured by aPTT

Based on current available evidence, do not use daily d-dimer for purpose of guiding anticoagulant therapy. D-dimer measurement may be used as a marker of illness severity and prognosis.

Do not recommend the use of thrombolytics in patients with COVID-19 outside of a clinical trial setting unless there is another clinical indication for thrombolysis (STEMI, CVA, high-risk (massive)PE with hemodynamic compromise)

My Thoughts/Workflow for LMWH + COVID-19 Positive Patients Being Admitted:

All patients admitted with COVID-19 should receive thromboprophylaxis in the ED in the absence of any contraindications (Active bleeding or platelet count <25,000)

The true prevalence of VTE in the ED is unknown at this time

Treatment and Dosing Decisions: No Clot (DVT/PE) + D-dimer <1 – 2ug/L = Lovenox 0.5mg/kg qD (Prophylaxis dose) No Clot (DVT/PE) + D-dimer >1 – 2ug/L = Lovenox 1.0mg/kg qD (Higher prophylaxis dose) This is a very controversial recommendation and will be dependent on your institution and may change based on newer data Clot (DVT/PE) + any D-dimer = Lovenox 1mg/kg BID (Treatment dose)

If history of HIT or HITT, use a non-heparin alternative

If anticoagulation contraindicated, use mechanical prophylaxis

Pts on outpatient DOACs or warfarin as an outpatient (Atrial fibrillation, history of VTE, prosthetic valve) should be switched to treatment dose LMWH

Anticoagulation at my Shop (San Antonio, TX): For Inpatients: High Risk: D-Dimer >6x ULN (>3ug/L) = Therapeutic Anticoagulation (TAC) Low Risk: D-Dimer <6x ULN (<3ug/L) = Prophylactic Dosing For Outpatients (Deemed High Risk for DVT/PE Discharge Plan): If no DVT/PE and on TAC during hospital stay + High risk (D-Dimer Still >6x ULN) –> 2 weeks of AC post discharge If no DVT/PE and on TAC during hospital stay + High risk (D-Dimer <6x ULN) –> No AC post discharge If confirmed DVT/PE, then normal provoked protocol –> AC for 3 – 6mos



Dosing Guidelines from Massachusetts General Hospital [Link is HERE]

PDF of Massachusetts General Hospital: Mass Gen Anticoag Recs

JACC Recommendations (Published April 17th, 2020)[11]

The data derived for recommendations is primary from small and retrospective analyses

Although older age and comorbidities such as cardiovascular disease have a higher risk for severe disease, young and otherwise healthy patients are also at risk for complications

Elevated D-dimer levels are associated with higher risk of requiring mechanical ventilation, ICU admission, or death