Severe COVID-19 is associated with high D-dimer levels which appear to predict mortality. It is unknown whether antithrombotic treatments aimed at D-dimer thresholds improve outcomes. When possible, imaging confirmation of suspected VTE should be obtained to guide anticoagulation decisions.
VTE options include Apixaban 2.5mg bid, rivaroxaban 10mg daily or Enoxaparin SQ daily (prevention dose adjusted for weight). (Society of Critical Care Medicine).
Association Between COVID-19 and Thromboembolism
COVID-19 has been associated with inflammation and a prothrombotic state, with increases in levels of fibrin, fibrin degradation products, fibrinogen, and D-dimer. In some studies, elevations in these markers have been associated with worse clinical outcomes. Studies have reported varying incidences of venous thromboembolism (VTE) in patients with COVID-19. A meta-analysis of studies of hospitalized patients with COVID-19 who received VTE prophylaxis found an overall VTE prevalence of 14.1% (95% CI, 11.6–16.9). The VTE prevalence was higher in studies that used ultrasound screening (40.3%; 95% CI, 27.0–54.3) than in studies that did not (9.5%; 95% CI, 7.5–11.7).
Guidelines for the use of antithrombotic therapy in patients with COVID-19 have been released by multiple organizations. The NICE guidelines state: “Consider a treatment dose of a low-molecular-weight heparin (LMWH) for young people and adults with COVID-19 who need low-flow oxygen and who do not have an increased bleeding risk.” Results from clinical trials have provided further information on the safety and efficacy of different antithrombotic strategies for patients with COVID-19.
Residents with COVID-19 illness who are already receiving anticoagulant or antiplatelet therapies for underlying conditions should continue their current medications unless significant bleeding or other contraindications are present. Before prescribing Paxlovid (nirmatrelvir-ritonavir) for mild to moderate COVID-19, the clinician must review any potential drug-drug interaction. There may not be a need to modify (such as aspirin), or it may be necessary to modify the anticoagulant (such as apixaban) or switch to another anticoagulant.
Special Circumstances for Use of New Anticoagulation for Severe COVID-19 in the Skilled Nursing Facility
Residents with SEVERE COVID-19 whose Advance Directives and goals of care discussion with their attending provider and nursing facility team are consistent with “treatment in place” at the nursing facility and no transfers to the hospital, may be considered for anticoagulation. Refer to NIH guidelines on Chronic anticoagulant and antiplatelet therapy.