Anticoagulation for COVID-19 Patients: A Bird's-Eye View

Abstract

Coronavirus disease 2019 (COVID-19) is a systemic disease that can be life-threatening involving immune and inflammatory responses, and that can result in potentially lethal complications, including venous thrombo-embolism (VTE). Forming an integrative approach to thrombo-prophylaxis and coagulation treatment for COVID-19 patients ensues. We aim at reviewing the literature for anticoagulation in the setting of COVID-19 infection to provide a summary on anticoagulation for this patient population. COVID-19 infection is associated with a state of continuous inflammation, which results in macrophage activation syndrome and an increased rate of thrombosis. Risk assessment models to predict the risk of thrombosis in critically ill patients have not yet been validated. Currently published guidelines suggest the use of prophylactic intensity over intermediate intensity or therapeutic intensity anticoagulant for patients with critical illness or acute illness related to COVID-19 infection. Critically ill COVID-19 patients who are diagnosed with acute VTE are considered to have a provoking factor, and, therefore, treatment duration should be at least 3 months. Patients with proximal deep venous thrombosis or pulmonary embolism should receive parenteral over oral anticoagulants with low-molecular-weight heparin or fondaparinux preferred over unfractionated heparin. In patients with impending hemodynamic compromise due to PE, and who are not at increased risk for bleeding, reperfusion may be necessary. Internists should remain updated on new emerging evidence regarding anticoagulation for COVID-19 patients. Awaiting these findings, we invite internists to perform individualized decisions that are unique for every patient and to base them on clinical judgment for risk assessment.

COVID-19 and Pulmonary Thrombosis—An Unresolved Clinical Puzzle: A Single-Center Cohort Study

“…The clinical significance of subsegmental PT as an incidental finding is unknown [ 12 , 13 ]. In hospitalized patients, low-molecular weight heparin is recommended in doses based on clinical severity but not on CTPA or PT findings [ 14 ].…”

Safety and Efficacy of Low Molecular Weight Heparin for Thromboprophylaxis in the Elderly: A Network Meta-Analysis of Randomized Clinical Trials

“…For reasons of better safety and efficacy, many guidelines recommend LMWHs for the treatment and prevention of VTE (Rhodes et al, 2017;Farge et al, 2019) as well as for the elderly during the perioperative period (Kozek-Langenecker et al, 2018). Furthermore, since the outbreak of COVID-19, LMWH has been widely used for anticoagulation in older COVID-19 patients (Kreidieh and Temraz, 2021). In patients with proximal DVT and PE, LMWHs are preferred over oral anticoagulants and UFH (Hozayen et al, 2021).…”

Roles of host proteases in the entry of SARS-CoV-2

“…Even a major protease involved in S processing is inhibited, it is possible that the virus is able to utilize other proteases (TTSPs, elastases or cathepsins) for the infection, and some of them may be upregulated as a result of the inflammatory processes which occur with the disease (Belouzard et al 2010). Because inflammation is a main feature of COVID-19, inhibitors of host cell proteases associated inflammation have also been explored as treatment for COVID-19 in preclinical studies and clinical trials (Behzadifard and Soleimani 2022;Menendez 2022;Kreidieh and Temraz 2021).…”