A dynamic, D-dimer-based thromboprophylaxis strategy in patients with COVID-19

Bhoopat, Lantarima; Martynova, Anastasia; Choi, April; Pattaranithima, Pattharawin; Han, Semi; Du, Senxi; Syed, Ibrahim; Chan, Catherine; Oh, Esther E.; Borok, Zea; Liebler, Janice; Lee Wilson, Melissa; Tantiyavarong, Pichaya; O'Connell, Casey

Background While Coronavirus disease 2019 (COVID-19) is associated with increased risk for venous thromboembolism (VTE) during hospitalization despite prophylactic anticoagulation, there is a lack of evidence-based guidelines for dose escalation of anticoagulation for patients hospitalized with COVID-19. Methods This single-center retrospective cohort study was part of a quality improvement program evaluating safety and efficacy of anticoagulation protocols at our large, metropolitan public hospital. We implemented a D-dimer-based guideline for dosing unfractionated heparin (UFH) or low molecular weight heparin (LMWH) in COVID-19 hospitalized patients that allowed for up-titration from standard prophylactic dosing to escalated prophylactic dosing or therapeutic dosing based on patient risk and presence of known or highly suspected VTE. Primary endpoints were International Society on Thrombosis and Haemostasis (ISTH)-defined major and clinically relevant non-major bleeding (CRNMB) events and in-hospital survival. Findings Among 262 COVID-19-infected patients hospitalized between March 15th and June 15th, 2020, 125 (73.1%) were male. Highest anticoagulation dose was: 65.3% prophylactic, 13.4% escalated prophylactic, 21.4% therapeutic. The dose was uptitrated in 83 (31.6%) patients. Bleeding events were comparable between the therapeutic (12.5%) and escalated prophylactic groups (11.4%), but significantly higher than in the prophylactic group (1.2%). In-hospital survival at 28 days was superior among patients whose anticoagulation was uptitrated to either escalated prophylactic or therapeutic (77.6%), compared to those receiving fixed prophylactic (56.7%) or fixed therapeutic (26.7%) dosing (p = 0.001). Conclusion A dynamic, D-dimer based dose escalation of anticoagulation for hospitalized patients with COVID-19 may improve in-hospital mortality without increasing fatal bleeding.