ISTH guidelines for antithrombotic treatment in COVID‐19

Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID‐19) may realize additional benefits from heparins. Optimal dosing and timing of these treatments and benefits of other antithrombotic agents remain unclear. In October 2021, I...

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Published in:Journal of thrombosis and haemostasis Vol. 20; no. 10; pp. 2214 - 2225
Main Authors: Schulman, Sam, Sholzberg, Michelle, Spyropoulos, Alex C., Zarychanski, Ryan, Resnick, Helaine E., Bradbury, Charlotte A., Connors, Jean Marie, Falanga, Anna, Iba, Toshiaki, Kaatz, Scott, Levy, Jerrold H., Middeldorp, Saskia, Minichiello, Tracy, Ramacciotti, Eduardo, Samama, Charles Marc, Thachil, Jecko, Broxmeyer, Lisa, International Society on Thrombosis and Haemostasis
Format: Journal Article
Language:English
Published: England Elsevier Inc 01.10.2022
Elsevier Limited
John Wiley and Sons Inc
Subjects:
Aftercare
anticoagulants
Anticoagulants - adverse effects
Coronaviruses
COVID-19
critical illness
Dosage
Fibrinolytic Agents - adverse effects
Heparin
Heparin - adverse effects
Heparin, Low-Molecular-Weight
Hospitalization
Humans
Molecular weight
Patient Discharge
Patients
platelet aggregation inhibitors
Platelet Aggregation Inhibitors - adverse effects
Recommendations and Guidelines
Rivaroxaban
Thromboembolism
anticoagulants
COVID‐19
critical illness
platelet aggregation inhibitors
COVID-19
ISSN:1538-7836, 1538-7933, 1538-7836
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Abstract Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID‐19) may realize additional benefits from heparins. Optimal dosing and timing of these treatments and benefits of other antithrombotic agents remain unclear. In October 2021, ISTH assembled an international panel of content experts, patient representatives, and a methodologist to develop recommendations on anticoagulants and antiplatelet agents for patients with COVID‐19 in different clinical settings. We used the American College of Cardiology Foundation/American Heart Association methodology to assess level of evidence (LOE) and class of recommendation (COR). Only recommendations with LOE A or B were included. Panelists agreed on 12 recommendations: three for non‐hospitalized, five for non–critically ill hospitalized, three for critically ill hospitalized, and one for post‐discharge patients. Two recommendations were based on high‐quality evidence, the remainder on moderate‐quality evidence. Among non–critically ill patients hospitalized for COVID‐19, the panel gave a strong recommendation (a) for use of prophylactic dose of low molecular weight heparin or unfractionated heparin (LMWH/UFH) (COR 1); (b) for select patients in this group, use of therapeutic dose LMWH/UFH in preference to prophylactic dose (COR 1); but (c) against the addition of an antiplatelet agent (COR 3). Weak recommendations favored (a) sulodexide in non‐hospitalized patients, (b) adding an antiplatelet agent to prophylactic LMWH/UFH in select critically ill, and (c) prophylactic rivaroxaban for select patients after discharge (all COR 2b). Recommendations in this guideline are based on high‐/moderate‐quality evidence available through March 2022. Focused updates will incorporate future evidence supporting changes to these recommendations.
AbstractList Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID‐19) may realize additional benefits from heparins. Optimal dosing and timing of these treatments and benefits of other antithrombotic agents remain unclear. In October 2021, ISTH assembled an international panel of content experts, patient representatives, and a methodologist to develop recommendations on anticoagulants and antiplatelet agents for patients with COVID‐19 in different clinical settings. We used the American College of Cardiology Foundation/American Heart Association methodology to assess level of evidence (LOE) and class of recommendation (COR). Only recommendations with LOE A or B were included. Panelists agreed on 12 recommendations: three for non‐hospitalized, five for non–critically ill hospitalized, three for critically ill hospitalized, and one for post‐discharge patients. Two recommendations were based on high‐quality evidence, the remainder on moderate‐quality evidence. Among non–critically ill patients hospitalized for COVID‐19, the panel gave a strong recommendation (a) for use of prophylactic dose of low molecular weight heparin or unfractionated heparin (LMWH/UFH) (COR 1); (b) for select patients in this group, use of therapeutic dose LMWH/UFH in preference to prophylactic dose (COR 1); but (c) against the addition of an antiplatelet agent (COR 3). Weak recommendations favored (a) sulodexide in non‐hospitalized patients, (b) adding an antiplatelet agent to prophylactic LMWH/UFH in select critically ill, and (c) prophylactic rivaroxaban for select patients after discharge (all COR 2b). Recommendations in this guideline are based on high‐/moderate‐quality evidence available through March 2022. Focused updates will incorporate future evidence supporting changes to these recommendations.
Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID-19) may realize additional benefits from heparins. Optimal dosing and timing of these treatments and benefits of other antithrombotic agents remain unclear. In October 2021, ISTH assembled an international panel of content experts, patient representatives, and a methodologist to develop recommendations on anticoagulants and antiplatelet agents for patients with COVID-19 in different clinical settings. We used the American College of Cardiology Foundation/American Heart Association methodology to assess level of evidence (LOE) and class of recommendation (COR). Only recommendations with LOE A or B were included. Panelists agreed on 12 recommendations: three for non-hospitalized, five for non-critically ill hospitalized, three for critically ill hospitalized, and one for post-discharge patients. Two recommendations were based on high-quality evidence, the remainder on moderate-quality evidence. Among non-critically ill patients hospitalized for COVID-19, the panel gave a strong recommendation (a) for use of prophylactic dose of low molecular weight heparin or unfractionated heparin (LMWH/UFH) (COR 1); (b) for select patients in this group, use of therapeutic dose LMWH/UFH in preference to prophylactic dose (COR 1); but (c) against the addition of an antiplatelet agent (COR 3). Weak recommendations favored (a) sulodexide in non-hospitalized patients, (b) adding an antiplatelet agent to prophylactic LMWH/UFH in select critically ill, and (c) prophylactic rivaroxaban for select patients after discharge (all COR 2b). Recommendations in this guideline are based on high-/moderate-quality evidence available through March 2022. Focused updates will incorporate future evidence supporting changes to these recommendations.Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID-19) may realize additional benefits from heparins. Optimal dosing and timing of these treatments and benefits of other antithrombotic agents remain unclear. In October 2021, ISTH assembled an international panel of content experts, patient representatives, and a methodologist to develop recommendations on anticoagulants and antiplatelet agents for patients with COVID-19 in different clinical settings. We used the American College of Cardiology Foundation/American Heart Association methodology to assess level of evidence (LOE) and class of recommendation (COR). Only recommendations with LOE A or B were included. Panelists agreed on 12 recommendations: three for non-hospitalized, five for non-critically ill hospitalized, three for critically ill hospitalized, and one for post-discharge patients. Two recommendations were based on high-quality evidence, the remainder on moderate-quality evidence. Among non-critically ill patients hospitalized for COVID-19, the panel gave a strong recommendation (a) for use of prophylactic dose of low molecular weight heparin or unfractionated heparin (LMWH/UFH) (COR 1); (b) for select patients in this group, use of therapeutic dose LMWH/UFH in preference to prophylactic dose (COR 1); but (c) against the addition of an antiplatelet agent (COR 3). Weak recommendations favored (a) sulodexide in non-hospitalized patients, (b) adding an antiplatelet agent to prophylactic LMWH/UFH in select critically ill, and (c) prophylactic rivaroxaban for select patients after discharge (all COR 2b). Recommendations in this guideline are based on high-/moderate-quality evidence available through March 2022. Focused updates will incorporate future evidence supporting changes to these recommendations.
Author Minichiello, Tracy
Broxmeyer, Lisa
Bradbury, Charlotte A.
Zarychanski, Ryan
Samama, Charles Marc
Spyropoulos, Alex C.
Falanga, Anna
Schulman, Sam
Iba, Toshiaki
Thachil, Jecko
Kaatz, Scott
Resnick, Helaine E.
Levy, Jerrold H.
Ramacciotti, Eduardo
Connors, Jean Marie
International Society on Thrombosis and Haemostasis
Sholzberg, Michelle
Middeldorp, Saskia
AuthorAffiliation 3 Departments of Medicine, and Laboratory Medicine and Pathobiology St Michael's Hospital Li Ka Shing Knowledge Institute University of Toronto Toronto Ontario Canada
1 Department of Medicine Thrombosis and Atherosclerosis Research Institute McMaster University Hamilton Ontario Canada
11 University of Milan Bicocca Monza Italy
15 Department of Internal Medicine and Radboud Institute of Health Sciences Radboud University Medical Centre Nijmegen the Netherlands
9 Division of Hematology Brigham and Women's Hospital Boston Massachusetts USA
19 Department of Anaesthesia Centre—Université de Paris—Cochin Hospital Intensive Care and Perioperative Medicine GHU AP‐HP Paris France
2 Department of Obstetrics and Gynecology I.M. Sechenov First Moscow State Medical University Moscow Russia
17 Science Valley Research Institute São Paulo Brazil
14 Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic) Duke University School of Medicine Durham North Carolina USA
7 Resnick, Chodorow & Associ
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– name: 6 Sections of Hematology/Oncology and Critical Care University of Manitoba Winnipeg Manitoba Canada
– name: 13 Division of Hospital Medicine Henry Ford Hospital Detroit Michigan USA
– name: 5 Department of Medicine Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead New York USA
– name: 12 Department of Emergency and Disaster Medicine Juntendo University Tokyo Japan
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  orcidid: 0000-0003-0460-6491
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BackLink https://www.ncbi.nlm.nih.gov/pubmed/35906716$$D View this record in MEDLINE/PubMed
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2022 International Society on Thrombosis and Haemostasis
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Issue 10
Keywords anticoagulants
COVID‐19
critical illness
platelet aggregation inhibitors
COVID-19
Language English
License 2022 International Society on Thrombosis and Haemostasis.
This article is being made freely available through PubMed Central as part of the COVID-19 public health emergency response. It can be used for unrestricted research re-use and analysis in any form or by any means with acknowledgement of the original source, for the duration of the public health emergency.
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Notes Manuscript handled by: Walter Ageno
Final decision: Walter Ageno, 05 July 2022
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– reference: 36271456 - J Thromb Haemost. 2022 Nov;20(11):2708-2709. doi: 10.1111/jth.15855
– reference: 36271457 - J Thromb Haemost. 2022 Nov;20(11):2710-2711. doi: 10.1111/jth.15854
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Snippet Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID‐19) may realize additional...
Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID-19) may realize additional...
SourceID pubmedcentral
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wiley
elsevier
SourceType Open Access Repository
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StartPage 2214
SubjectTerms Aftercare
anticoagulants
Anticoagulants - adverse effects
Coronaviruses
COVID-19
critical illness
Dosage
Fibrinolytic Agents - adverse effects
Heparin
Heparin - adverse effects
Heparin, Low-Molecular-Weight
Hospitalization
Humans
Molecular weight
Patient Discharge
Patients
platelet aggregation inhibitors
Platelet Aggregation Inhibitors - adverse effects
Recommendations and Guidelines
Rivaroxaban
Thromboembolism
Title ISTH guidelines for antithrombotic treatment in COVID‐19
URI https://dx.doi.org/10.1111/jth.15808
https://onlinelibrary.wiley.com/doi/abs/10.1111%2Fjth.15808
https://www.ncbi.nlm.nih.gov/pubmed/35906716
https://www.proquest.com/docview/2715607376
https://www.proquest.com/docview/2696858634
https://pubmed.ncbi.nlm.nih.gov/PMC9349907
Volume 20
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