In this episode, I’ll discuss the Chest authors’ guidelines on the prevention, diagnosis, and treatment of venous thromboembolism in patients with COVID-19.
The Chest Guideline authors have published a set of recommendations on the prevention, diagnosis and treatment of venous thromboembolism in patients with COVID-19.
The following are some highlights from the guidelines that are relevant to hospital pharmacists:
In acutely ill hospitalized patients with COVID-19, we suggest anticoagulant
thromboprophylaxis with low-molecular-weight heparin (LMWH) or fondaparinux over anticoagulant thromboprophylaxis with unfractionated heparin (UFH); and we recommend anticoagulant thromboprophylaxis with LMWH, fondaparinux or UFH over anticoagulant thromboprophylaxis with a direct oral anticoagulant (DOAC).
The guideline authors chose to favor LMWH and fondaparinux over UFH because once-daily administration will limit staff exposure. Since many COVID-19 patients have a high risk of rapid clinical deterioration, the guideline authors caution against the use of DOACs. A secondary issue with DOACs is the number of potential drug interactions with antivirals and investigational medications.
In critically ill patients with COVID-19, we suggest anticoagulant thromboprophylaxis with LMWH over anticoagulant thromboprophylaxis with UFH; and we recommend anticoagulant thromboprophylaxis with LMWH or UFH over anticoagulant thromboprophylaxis with fondaparinux or a DOAC.
Again the authors favor LMWH over UFH in order to limit staff exposure. The authors strongly caution against the use of DOACs in critically ill patients for 3 main reasons:
1. Hemodynamic instability
2. The high likelihood of drug-drug interactions
3. The high incidence of acute kidney injury
In acutely ill hospitalized patients with COVID-19, we recommend current standard dose anticoagulant thromboprophylaxis over intermediate (LMWH BID or increased weight-based dosing) or full treatment dosing, per existing guidelines.
In critically ill patients with COVID-19, we suggest current standard dose anticoagulant thromboprophylaxis over intermediate (LMWH BID or increased weight-based dosing) or full treatment dosing, per existing guidelines.
Both of these recommendations were made because of the absence of high-quality studies with data showing that a larger than standard dose of anticoagulation is safe or effective in this patient population.
In critically ill patients with COVID-19, we suggest against the addition of mechanical
prophylaxis to pharmacological thromboprophylaxis.
This recommendation is simply the same as in non-COVID-19 patients, not because of any data that would suggest a risk of harm.
For acutely ill hospitalized COVID-19 patients with proximal DVT or pulmonary embolism (PE), we suggest initial parenteral anticoagulation with therapeutic weight adjusted LMWH or intravenous UFH. The use of LWMH will limit staff exposure and avoid the potential for heparin pseudo-resistance. In patients without any drug-to- drug interactions, we suggest initial oral anticoagulation with apixaban or rivaroxaban. Dabigatran and edoxaban can be used after initial parenteral anticoagulation. Vitamin K antagonist therapy can be used after overlap with initial parenteral anticoagulation.
The authors note this is a downgrade from the most recent ACCP recommendation regarding the use of oral anticoagulants in patients hospitalized with COVID-19. They choose to do this because of the high risk of rapid clinical deterioration in these patients and potential for drug interactions.
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