Table 1.
Various anticoagulants, advantages, and disadvantages with their use in COVID-19.
| Anticoagulation use in COVID-19 patients | |||
|---|---|---|---|
| Section A | |||
| Anticoagulants drugs | Pros/benefits | Cons/disadvantages | |
| UFH | • Can be stopped immediately | • Less efficient than LMWH | |
| • Predictable response | • Current studies mostly done on LMWH | ||
| • Anti-inflammatory effect | • Needs frequent lab draws (for therapeutic only) | ||
| • Can be used in acute renal failure | • Needs anti-Xa levels rather than aPTT as later also elevates in COVID-19 patients | ||
| LMWH | • Shorter half life | • Cannot be used if CrCl <30 or acute kidney injury. | |
| • Most available studies on COVID-19 used LMWH | • Lesser anti-inflammatory activity than UFH | ||
| • No need of frequent lab draws (both for prophylactic and therapeutic use) | |||
| DOACs | • Oral pill | • Almost no experience | |
| • Less chance of exposure to COVID-19 patients due to easy dispensing and no need of frequent lab draws | • Multiple drug interactions possible | ||
| Section B | |||
| Common covid-19 scenarios | Recommendations | Indications | |
| B.1 Anticoagulation for Prophylaxis | • If CrCl >30, Inj. LMWH 40 mg Subcutaneous daily | -All hospitalized patients (including non-critically ill). | |
| ▪ Contraindications: [1] Active bleeding [2] platelet count <25 × 109/L [3] Fibrinogen <0.5 g/L | |||
| • If CrCl <30 or acute kidney injury: Heparin 5000 units Subcutaneous three times daily. | ▪ Close monitoring advised in severe renal impairment. | ||
| • Mechanical thromboprophylaxis, only when chemical treatment is contraindicated | ▪ An abnormal PT or APTT is not a contraindication | ||
| B.2 Anticoagulation for therapeutic purposes | |||
| B.2.1 | A COVID-19 patient already on oral anticoagulants at the time of admission | • Switch to therapeutic dose of LMWH (preferred over UFH due to reasons mentioned in section A) | Known history of thrombosis or other indications requiring therapeutic anticoagulation. |
| • Fondaparinux preferred in patient has a history of HIT | Caution: To hold anticoagulation temporarily if platelet count is <30–50 × 109/L or if the fibrinogen is <1.0 g/L | ||
| • Mechanical thromboprophylaxis, only when chemical treatment is contraindicated | |||
| B.2.2 | A COVID-19 patient who develop acute DVT/PE during hospital stay | • LMWH is preferred (preferred over UFH due to reasons mentioned in section A) | Acute thrombosis |
| • UFH only is used only If CrCl <30 or acute kidney injury | |||
| B.3 Empirical therapeutic anticoagulation | • Not recommended | Not indications so far, under study | |
| B.4 Use of tPA for therapeutic anticoagulation | • Not recommended | Not indications so far | |
APTT: Activated partial thromboplastin time CAC: Coagulopathy associated with COVID-19, DIC: Disseminated intravascular coagulation, DOACs: FFP: Fresh frozen plasma, HIT: Heparin induced thrombocytopenia, LMWH: Low molecular weight heparin, PT: Prothrombin time, PCC: Prothrombin complex concentrate, tPA: tissue plasminogen activator, UFH: Unfractionated heparin. This table has been adopted based on the recommendations by ASH and ISTH combined (please visit websites for their individual recommendations).