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?Guidance on VTE Treatment and Prophylaxis in COVID-19 or COVID –19 PUI patientsAll COVID-19 positive or PUI patients receive anticoagulation (at prophylaxis or treatment dosing) unless contraindicated Patients with confirmed COVID-19 positive status who are on home oral anticoagulation and have high D-dimer levels or have more severe COVID should be switched to treatment dose enoxaparin or heparin while admitted, when possibleRefer to “Interim COVID-19 Anticoagulation Guidance” LBH Algorithm to determine anticoagulation dosing: VTE Prophylaxis Dosing (Standard Dosing vs Intermediate Dosing) OR Therapeutic Dosing (Full Intensity)Enoxaparin is preferred due to decreased frequency in administration and monitoring, however, utilize UFH in patients with CrCl < 11 mL/minEnoxaparin and anti-Xa Levels:Should NOT be routinely ordered for patient receiving enoxaparin. Can be considered in subgroups to assure therapeutic and non-toxic levels in patients with CrCl < 30 mL/min Dosing When to Draw Target Level1 mg/kg twice daily/once daily 4 hours after 3rd dose0.5 - 1 units/mL1.5 mg/kg once daily4 hours after 3rd dose1-2 units/mLVTE Prophylaxis 4 hours after 3rd dose0.2-0.5 units/mLGuidance on Post-Discharge Anticoagulation in COVID-19 patients Therapeutic Anticoagulation ContinuationFor all COVID+ patients diagnosed with VTE while inpatient and who received treatment dose anticoagulation For all COVID+ patients with high suspicion of VTE who received treatment dose anticoagulationConsider one of the following, based on renal function/insurance coverageApixaban 10mg PO BID for 7 days then 5mg PO BID for up to 3 months Rivaroxaban 15mg PO BID for 21 days, then 20mg PO QPM for up to 3 months Warfarin - Only if contraindicated to DOAC due to need for close follow-up and desire to limit exposure to healthcare workers and other patientsMinimum duration of therapy is 3 months, outpatient provider to reassess continuation of therapy beyond 90 daysTreatment should continue for 3 months for high suspected VTE, regardless if later investigation reveals no VTE (per AC forum)Patients with other indications for anticoagulation (e.g. atrial fibrillation, prosthetic heart valve, etc.): resume normal home anticoagulation therapy Prophylactic Dosing Continuation Extended-duration prophylaxis (after hospitalization): should not be considered for all COVID-19 patientsMay consider in patients with persisting risk factors for VTE:Age >60Repeat D-dimer prior to discharge >2x ULNAnticipated prolonged immobilityLow bleeding riskCaution for patients on dual antiplatelet therapy, clinically significant bleeding in the last 3 months, severe head trauma in the last 3 months, patients with platelets <50x109/L, and history of hemorrhagic strokeIMPROVE Score >4, OR score 2-3 plus D-dimer >2x ULN 24H-48H prior to discharge13811255080000If YES for extended duration prophylaxis, start oral agent after hospital discharge:Rivaroxaban 10mg QDay x30 days (consider shorter duration or discontinuation if risk factors diminish)Consider AC Clinic referral for DOAC follow-upEnoxaparin 40 mg SQ once daily, prophylactic doses may also be used (e.g. SAR)References:Tang N, Bai J, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020; DOI: N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020; 18(4):844-847.Thachil J, Tang N, Gando S, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020; DOI: B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up. J Am Coll Cardiol. 2020; DOI: FA, Kruip MA, van der Meer NM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020; DOI: AT, Barnes GD, Wakefield TW, et al. Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 pandemic. J Vasc Surg. 2020; DOI: . [Internet]. Washington, DC: American Society of Hematology. c2020. COVID-19 and coagulopathy: frequently ask questions. 2020 Apr 14 [cited 2020 Apr 24]. Available from: . [Internet]. Washington, DC: American Society of Hematology. c2020. COVID-19 and VTE/anticoagulation: frequently ask questions. 2020 Apr 17 [cited 2020 Apr 24]. Available from: Internal Medicine [Internet]. New Haven: Yale School of Medicine. c2020. YNHHS COVID-19 treatment adult algorithm. 2020 Apr 15 [cited 2020 Apr 24]. Available from: Emory Critical Care Center [Internet]. Atlanta: Emory Healthcare, c2020. Guidelines for the prevention and treatment of VTE in critically ill patients with COVID-19. 2020 Apr 21 [cited 2020 Apr 24]. Available from: Spyropoulos AC, Lipardi C, Xu J, et al. Modified IMPROVE VTE risk score and elevated D-dimer identify a high venous thromboembolism risk in acutely ill medical population for extended thromboprophylaxis. TH Open. 2020; 4(1):e59-65.MacDougall K, Spyropoulos AC. New paradigms of extended thromboprophylaxis in medically ill patients. J Clin Med. 2020; 9(4), 1002.Gibson CM, Spyropoulos AC, Cohen AT, et al. The IMPROVEDD VTE risk score: incorporation of D-dimer into the IMPROVE score to improve venous thromboembolism risk stratification. TH Open. 2017; 1(1): e55-65. ................
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