Table 1 -.
General management recommendations for persistently antiphospholipid antibody positive patients with new COVID-19 infection.
| Inpatient | Outpatient | |
|---|---|---|
| No history of thrombosis and/or not on long-term anticoagulation | Start at least prophylactic dose anticoagulation with LMWH or UFH. | Consider prophylactic dose anticoagulation depending on additional non-aPL VTE risk factors |
| History of thrombosis on long-term anticoagulation | Switch to therapeutic dose LMWH or intravenous UFH. | Continue anticoagulation with regular INR monitoring if on warfarin with INR checks as appropriate |
| Pregnant—not on anticoagulation | Start at least prophylactic dose anticoagulation with LMWH or UFH. | Consider prophylactic dose anticoagulation, given the increased risk of thrombosis during pregnancy and postpartum (at least 6 weeks after delivery) |
| Pregnant—on anticoagulation (LMWH or UFH) with or without low dose aspirin | Continue anticoagulation: At least prophylactic dose LMWH or UFH for patients on prophylactic dose anticoagulation; and therapeutic dose LMWH or UFH for patients on therapeutic dose anticoagulation | Continue anticoagulation based on the original dosing strategy |
Prophylactic dose LMWH is preferred over UFH as a) once daily versus twice or three times daily injections: more convenient for the patient and fewer subcutaneous administrations required from nursing staff (hence less avoidable direct contact with a patient with COVID-19 infection) and b) lower risk of heparin-induced thrombocytopenia. LMWH is generally preferable to VKAs in hospitalized patients because of potential variability of the INR due to acute illness-related factors. LMWH is also preferable to oral anticoagulants (VKAs and DOACs) in patients with thrombocytopenia or coagulopathy, in view of its shorter half-life. For all patients, there should be a low threshold to investigate suspected thrombosis. VTE prevention patient information should be provided for inpatients and outpatients.
aPL: antiphospholipid antibodies, DOACs: direct oral anticoagulants, LMWH: low-molecular-weight heparin, UFH: unfractionated heparin, VTE: venous thromboembolism, INR: international normalized ratio.