Inpatient Services: COVID-19 and DOACs Management

Transcript: Gregory Piazza, MD, MS: What are some of the strategies that inpatient anticoagulation services should consider to manage these patients with COVID-19 [coronavirus disease 2019] more carefully and optimize their outcomes? You mentioned using anti-Xa levels instead of PTT [partial thromboplastin time] and potentially using direct thrombin inhibitors instead of some of our heparin methods. Talk to us a little about that.

Alex Spyropoulos, MD, FACP, FCCP, FRCPC: The way I would conceptualize this, Greg, is thinking about 2 buckets: the patients who are hospitalized in the medical ward and the patients who are critically ill in the intensive care units and coronary care units. These represent 2 different patient groups. I think we have better data in the critically ill population, both retrospective and prospective data. There are fewer robust data in the hospitalized population, but in general, it does appear that the overall hospitalized COVID-19 population is at greater risk for VT [venous thrombosis] events than we’re used to. That’s the first message.

The second message is—similar to all your hospitalized, medically ill patients—your COVID-19 population should have a coinciding formal VT risk-stratification strategy. Whether you use risk-assessment models, such as the Padua Prediction Score or IMPROVE bleeding risk score, or you use gestalt methods, such as individual risk factors, both models fine. However, in the COVID-19 era, if a patient does not have any absolute contraindications to prophylactic anticoagulation, they should definitely be on chemoprophylaxis. That’s the first lesson to be learned.

The second approach that we’ve used—at Northwell Health, and a lot of our other colleagues across the country—is thinking about more aggressive, even primary, prophylaxis with intermediate doses of heparin that we’re not otherwise used to. There are some protocols out there advocating for intermediate doses of low-molecular-weight heparin, as an example. We also advocate for that, especially in patients whose BMI [body mass index] is over 30. We go to a more aggressive regimen, such as enoxaparin 40 mg twice a day, as 1 example.

The other aspect, of course, is thinking about multimodal strategies, such as adding mechanical prophylaxis and chemoprophylaxis in certain high-risk profiles, even though we all know that the data on mechanical prophylaxis in the medically ill population is quite poor. But we’re in a new era here regarding COVID-19. I think those are the most important points.

The use of therapeutic anticoagulation may be a step too far at this point. We’re initiating a randomized trial, as we speak, at Northwell Health. I know other institutions are also initiating a very similar trial design. We’re assessing whether therapeutic doses of anticoagulants for VTE [venous thromboembolism] prevention offer advantages in terms of efficacy over the standard prophylactic-dose anticoagulants that we’re used to and are mandated by the guidelines. That’s probably 1 of the most important questions in the hospitalized COVID-19 population. Would they benefit from a much more aggressive VT prevention strategy using treatment-dose anticoagulants?

With respect to the use of parenteral anticoagulants, as a system we’re moving toward direct thrombin inhibitors, such as argatroban and bivalirudin in certain situations, especially for device-associated antithrombotic anticoagulant issues. I tend to think that the data behind using D-dimer levels to manage a prophylactic strategy are quite weak, so I wouldn’t advocate for that right now. I would advocate for a strong institution-wide guideline that advocates for, at the very least, routine chemoprophylaxis for all these patients hospitalized with COVID-19, unless they have absolute contraindications to anticoagulation.

Transcript Edited for Clarity