Table 3 CDC and societal recommendations regarding thrombotic prophylaxis and treatment in COVID-19

CDC

LMWH or UFH (standard dosing). Insufficient data to recommend for or against the increase of anticoagulation intensity outside of a clinical trial.

Standard regimens for non-COVID-19 patients.

ISTH-IG

LMWH (standard dosing)

Not mentioned

ACF

Suggests an increased intensity of venous thromboprophylaxis be considered for critically ill patients^# (i.e., LMWH 40 mg SC twice daily, LMWH 0.5 mg/kg subcutaneous twice daily, heparin 7500 SC three times daily, or low-intensity heparin infusion) that they state is based largely on expert opinion.

LMWH over UFH whenever possible to avoid additional laboratory monitoring, exposure, and personal protective equipment. In patients with AKI or creatinine clearance < 15–30 mL/min, UFH is recommended over LMWH.

ASH

LMWH over UFH (standard dosing) to reduce exposure unless risk of bleeding outweighs risk of thrombosis.

LMWH or UFH over direct oral anticoagulants due to reduced drug-drug interactions and shorter half-life.

ACCP

LMWH (standard dosing)

LMWH or fondaparinux over UFH. UFH preferred in patients at high bleeding risk and in renal failure or needing imminent procedures. Recommend increasing dose of LMWH by 25–30% in patients with recurrent VTE despite therapeutic LMWH anticoagulation.

SCC-ISTH

LMWH or UFH. Intermediate intensity LMWH can be considered in high risk critically ill patients (50% of responders) and may be considered in non-critically ill hospitalized patients (30% of respondents). Mentions that there are several advantages of LMWH over UFH including once vs twice or more injections and less heparin-induced thrombocytopenia. Regimens may be modified based on extremes of body weight (50% increase in dose if obese), severe thrombocytopenia*, or worsening renal function.

Not mentioned

ACC

Enoxaparin 40 mg daily or similar LMWH regimen (i.e., dalteparin 5000 u daily) can be administered with consideration of SC heparin (5000 u twice to three times per day) in patients with renal dysfunction (i.e., creatinine clearance < 30 mL/min). Once daily regimens of LMWH may be advantageous over UFH to reduce missed doses associated with worse outcomes, reduce healthcare worker exposure, and conserve personal protective equipment. There is insufficient data to consider routine therapeutic or intermediate dose parenteral anticoagulation with UFH or LMWH. Only a minority of the panel considered intermediate intensity (31.6%; i.e., enoxaparin 1 mg/kg/day, enoxaparin 40 mg BID, UFH with target PTT 50–70) to therapeutic anticoagulation (5.2%) reasonable.

Medication regimen likely to change depending on comorbidities (i.e., renal or hepatic dysfunction, gastrointestinal function, thrombocytopenia). Parenteral anticoagulation (i.e., UFH) may be preferred in many ill patients given it may be withheld temporarily and has no known drug-drug interactions with COVID-19 therapies. LMWH may be preferred in patients who are unlikely to need procedures as there are concerns with UFH regarding the time to achieve therapeutic PTT and increased exposure to healthcare workers. DOACs have advantages including lack of monitoring that is ideal for outpatient management but may have risks in settings of organ dysfunction related to clinical deterioration and lack of timely reversal at some centers.