Table 4 CDC and societal recommendations regarding thrombotic prophylaxis and treatment in COVID-19

CDC

Active hemorrhage or severe thrombocytopenia*

Not mentioned

ISTH-IG

Hold when signs of active bleeding or platelet count < 25 × 10⁹/L. Abnormal PT or PTT is not a contraindication to thromboprophylaxis.

Not mentioned

ACF

Active bleeding or profound thrombocytopenia*

Recommends intermittent pneumatic compression in patients with contraindication to pharmacological thromboprophylaxis. Mentions that it is reasonable to consider both mechanical and pharmacological thromboprophylaxis in critically ill patients if no contraindication exists for each modality.

ASH

Thromboprophylaxis is recommended even with abnormal coagulation tests in the absence of active bleeding and held only if platelet count < 25 × 10⁹/L or fibrinogen < 0.5 g/L. Abnormal PT or PTT is not a contraindication to thromboprophylaxis. Therapeutic anticoagulation may need to be held if platelet count < 30–50 × 10⁹/L or fibrinogen < 1.0 g/L.

Recommends mechanical thromboprophylaxis (i.e., pneumatic compression devices) when pharmacological thromboprophylaxis is contraindicated.

ACCP

Not mentioned

Suggest the use of mechanical thromboprophylaxis in critically ill patients who have a contraindication to pharmacological thromboprophylaxis. Suggest against the additional use of mechanical thromboprophylaxis in critically ill patients receiving pharmacological prophylaxis while mentioning that its addition is likely not to cause harm.

SCC-ISTH

No specific recommendations. Reports that 50% of respondents report holding if platelet count < 25 × 10⁹/L.

Mechanical thromboprophylaxis (intermittent pneumatic compression devices preferred) should be used when pharmacological therapy contraindicated. Multimodal thromboprophylaxis with mechanical methods (i.e., intermittent pneumonic compression devices) should be considered (60% of respondents).

ACC

In patients with moderate or severe COVID-19 on chronic therapeutic anticoagulation who develop suspected or confirmed DIC without overt bleeding, it is reasonable to consider the indication of anticoagulation and risk of bleeding for adjusting dose or discontinuation of anticoagulation. The majority of authors recommended reducing the intensity of anticoagulation unless there was an exceedingly high risk of thrombosis.

Mechanical thromboprophylaxis (intermittent pneumatic compression) should be considered in immobilized patients if pharmacological prophylaxis is contraindicated. Majority of panel members (55%) considered the use of both pharmacological thromboprophylaxis and intermittent pneumatic compression reasonable while acknowledging a lack of high-quality evidence.