Weigh VTE Prevention Strategies in COVID-19

Clinicians are scrambling to optimize venous thromboembolism (VTE) prophylaxis for hospitalized patients with COVID-19.

Data suggest these patients have a higher VTE risk than other hospitalized patients. Plus D-dimer and other markers are often elevated in COVID-19...especially in severe cases.

But there's little evidence about optimal VTE prophylaxis in patients with COVID-19. Rely on a practical approach.

Ensure ALL hospitalized patients with COVID-19 receive VTE prophylaxis. Generally choose once-daily enoxaparin over BID or TID subcutaneous heparin...to reduce nursing exposure to COVID-19 patients.

Use standard prophylaxis doses in most COVID-19 patients...and continue to adjust doses for renal function and weight.

Some experts step up doses when using VTE prophylaxis for select COVID-19 cases...such as an ICU patient with worsening clinical status and a D-dimer greater than 6 times the upper limit of normal.

The thinking is that thrombosis may be more common than bleeding in COVID-19-associated coagulopathy.

But weigh individual clot and bleeding risks...there's not good evidence for the ideal prevention strategy in these patients.

If possible, enroll patients in a clinical trial to capture safety and efficacy data for higher-dosing strategies.

Don't routinely continue VTE prophylaxis AFTER discharge for COVID-19 patients. There's not a clear benefit over bleeding risks in MEDICAL patients. But there aren't COVID-19-specific data.

Ensure safety parameters are in place if extended-duration prophylaxis is considered in specific situations.

For example, some specialists may use it in a COVID-19 patient at low bleeding risk...with multiple VTE risks (elevated D-dimer, etc)...who is discharged early in their recovery due to hospital space.

Verify that the VTE prophylaxis indication, duration, and follow-up are well documented in the discharge plan.

Use our chart, COVID-19 and Thromboembolism: FAQs, to find more answers about treatment and prophylaxis.

Key References

  • Chest Published online Jun 2, 2020; doi:10.1016/j.chest.2020.05.559
  • J Am Coll Cardiol 2020;75(23):2950-73
  • J Thromb Haemost Published online May 27, 2020; doi:10.1111/jth.14929
  • J Thromb Thrombolysis 2020;50(1):72-81
Hospital Pharmacist's Letter. August 2020, No. 360817

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