Publication: Pragmatic recommendations for the management of anticoagulation and venous thrombotic disease for hospitalized patients with COVID-19 in low- And middle-income countries
Issued Date
2021-03-01
Resource Type
ISSN
14761645
00029637
00029637
Other identifier(s)
2-s2.0-85103274686
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Mahidol University
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SCOPUS
Bibliographic Citation
American Journal of Tropical Medicine and Hygiene. Vol.104, No.3 (2021), 99-109
Suggested Citation
Hanan Y. Ahmed, Alfred Papali, Tewodros Haile, Gentle S. Shrestha, Marcus J. Schultz, Ganbold Lundeg, Kevan M. Akrami Pragmatic recommendations for the management of anticoagulation and venous thrombotic disease for hospitalized patients with COVID-19 in low- And middle-income countries. American Journal of Tropical Medicine and Hygiene. Vol.104, No.3 (2021), 99-109. doi:10.4269/ajtmh.20-1305 Retrieved from: https://repository.li.mahidol.ac.th/handle/20.500.14594/77311
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Title
Pragmatic recommendations for the management of anticoagulation and venous thrombotic disease for hospitalized patients with COVID-19 in low- And middle-income countries
Other Contributor(s)
Faculty of Tropical Medicine, Mahidol University
Tribhuvan University
Addis Ababa University
University of California, San Diego
Universidade Federal da Bahia
Mahidol University
Amsterdam UMC - University of Amsterdam
Mongolian National University of Medicinal Sciences
Division of Pulmonary and Critical Care Medicine
Tribhuvan University
Addis Ababa University
University of California, San Diego
Universidade Federal da Bahia
Mahidol University
Amsterdam UMC - University of Amsterdam
Mongolian National University of Medicinal Sciences
Division of Pulmonary and Critical Care Medicine
Abstract
New studies of COVID–19 are constantly updating best practices in clinical care. Often, it is impractical to apply recommendations based on high-income country investigations to resource limited settings in low- and middle-income countries (LMICs). We present a set of pragmatic recommendations for the management of anticoagulation and thrombotic disease for hospitalized patients with COVID-19 in LMICs. In the absence of contraindications, we recommend prophylactic anticoagulation with either low molecular weight heparin (LMWH) or unfractionated heparin (UFH) for all hospitalized COVID-19 patients in LMICs. If available, we recommend LMWH over UFH for venous thromboembolism (VTE) prophylaxis to minimize risk to healthcare workers. We recommend against the use of aspirin for VTE prophylaxis in hospitalized COVID-19 and non–COVID-19 patients in LMICs. Because of limited evidence, we suggest against the use of “enhanced” or “intermediate” prophylaxis in COVID-19 patients in LMICs. Based on current available evidence, we recommend against the initiation of empiric therapeutic anticoagulation without clinical suspicion for VTE. If contraindications exist to chemical prophylaxis, we recommend mechanical prophylaxis with intermittent pneumatic compression (IPC) devices or graduated compression stockings (GCS) for hospitalized COVID-19 patients in LMICs. In LMICs, we recommend initiating therapeutic anticoagulation for hospitalized COVID-19 patients, in accordance with local clinical practice guidelines, if there is high clinical suspicion for VTE, even in the absence of testing. If available, we recommend LMWH over UFH or Direct oral anticoagulants for treatment of VTE in LMICs to minimize risk to healthcare workers. In LMIC settings where continuous intravenous UFH or LMWH are unavailable or not feasible to use, we recommend fixed dose heparin, adjusted to body weight, in hospitalized COVID-19 patients with high clinical suspicion of VTE. We suggest D-dimer measurement, if available and affordable, at the time of admission for risk stratification, or when clinical suspicion for VTE is high. For hospitalized COVID-19 patients in LMICs, based on current available evidence, we make no recommendation on the use of serial D-dimer monitoring for the initiation of therapeutic anticoagulation. For hospitalized COVID-19 patients in LMICs receiving intravenous therapeutic UFH, we recommend serial monitoring of partial thromboplastin time or anti-factor Xa level, based on local laboratory capabilities. For hospitalized COVID-19 patients in LMICs receiving LMWH, we suggest against serial monitoring of anti-factor Xa level. We suggest serial monitoring of platelet counts in patients receiving therapeutic anticoagulation for VTE, to assess risk of bleeding or development of heparin induced thrombocytopenia.