Belgian clinical guidance on anticoagulation management in hospitalised and ambulatory patients with COVID-19

Vanassche, Thomas; Orlando, Christelle; Vandenbosch, Kristel; Gadisseur, Alain; Hermans, Cédric; Jochmans, Kristin; Minon, Jean‐Marc; Motte, Serge; Peperstraete, Harlinde; Péters, Pierre; Sprynger, Muriel; Lancellotti, Patrizio; Dehaene, Isabelle; Emonts, Patrick; Vandenbriele, Christophe; Verhamme, Peter; Oury, Cécile

doi:10.1080/17843286.2020.1829252

Cited by 14 publications

(23 citation statements)

References 39 publications

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“…During hospitalization, patients received enoxaparin with a prophylactic (0.5 mg/kg once daily, on the ward) or intermediate (0.5 mg/kg twice daily, in the ICU) dosing regimen, as described in more detail by our group in April 2020 21 and recommended by the Belgian Society of Thrombosis and Hemostasis. 22 Guidelines and data on postdischarge thromboprophylaxis were lacking. Therefore, when there was no indication for therapeutic anticoagulation after discharge (e.g., atrial fibrillation, VTE, mechanical heart valve, and so forth), low dose enoxaparin (0.5 mg/kg once daily) for 2 to 6 weeks after discharge was considered on individualized basis, and especially in high-risk patients (defined as ICU stay, known thrombophilia, obesity, immobilization, heart failure, respiratory failure, age over 70 years, personal or familial history of VTE, active cancer or major surgery in the last 3 months).…”

Section: Hospital Stay and Clinical Decision Making On Postdischarge Thromboprophylaxismentioning

confidence: 99%

Venous Thromboembolism in Patients Discharged after COVID-19 Hospitalization

Engelen

Vandenbriele

Balthazar

et al. 2021

Semin Thromb Hemost

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Background Venous thromboembolism (VTE) is a frequent complication of COVID-19, so that the importance of adequate in-hospital thromboprophylaxis in patients hospitalized with COVID-19 is well established. However, the incidence of VTE after discharge and whether postdischarge thromboprophylaxis is beneficial and safe are unclear. In this prospective observational single-center study, we report the incidence of VTE 6 weeks after hospitalization and the use of postdischarge thromboprophylaxis. Methods Patients hospitalized with confirmed COVID-19 were invited to a multidisciplinary follow-up clinic 6 weeks after discharge. D-dimer and C-reactive protein were measured, and all patients were screened for deep vein thrombosis with venous duplex-ultrasound. Additionally, selected high-risk patients received computed tomography pulmonary angiogram or ventilation–perfusion (V/Q) scan to screen for incidental pulmonary embolism. Results Of 485 consecutive patients hospitalized from March through June 2020, 146 patients were analyzed, of which 39% had been admitted to the intensive care unit (ICU). Postdischarge thromboprophylaxis was prescribed in 28% of patients, but was used more frequently after ICU stay (61%) and in patients with higher maximal D-dimer and C-reactive protein levels during hospitalization. Six weeks after discharge, elevated D-dimer values were present in 32% of ward and 42% of ICU patients. Only one asymptomatic deep vein thrombosis (0.7%) and one symptomatic pulmonary embolism (0.7%) were diagnosed with systematic screening. No bleedings were reported. Conclusion In patients who had been hospitalized with COVID-19, systematic screening for VTE 6 weeks after discharge revealed a low incidence of VTE. A strategy of selectively providing postdischarge thromboprophylaxis in high-risk patients seems safe and potentially effective.

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Section: Hospital Stay and Clinical Decision Making On Postdischarge Thromboprophylaxismentioning

confidence: 99%

Venous Thromboembolism in Patients Discharged after COVID-19 Hospitalization

Engelen

Vandenbriele

Balthazar

et al. 2021

Semin Thromb Hemost

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“…Eighteen (78%) were published in the first half of the year [ 12 – 32 ]. Four (17%) were developed by international organizations [ 14 – 17 ], 8 (35%) from the Americas [ 12 , 18 – 21 , 29 – 31 ], 9 (39%) from Europe [ 13 , 22 – 26 , 32 – 34 ], and 2 (9%) from the Asia-Pacific region [ 27 , 28 ]. Twenty-one (92%) were focused on general population.…”

Section: Resultsmentioning

confidence: 99%

“…Five (22%) had updated versions [ 12 , 14 , 18 , 27 , 32 ]. Twenty (87%) were developed by medical society [ 13 , 15 – 31 , 33 , 34 ] and 7 (30%) were developed by more than one organization [ 15 , 16 , 21 , 22 , 28 , 29 , 34 ]. Eight (35%) were developed by evidence-based approach [ 12 , 14 , 15 , 17 , 20 , 27 , 28 , 31 ].…”

Section: Resultsmentioning

confidence: 99%

“…LMWH is a well-accepted drug in pharmacological prophylaxis. Pharmacological prophylaxis with LMWH is recommended for not only patients hospitalized with COVID-19 by serval guidelines [ 14 , 17 , 21 , 22 , 24 – 26 , 31 , 34 ], but also for patients perceived to have a persistent risk of VTE at the time of discharge (JTH [ 28 ]: ungraded; JTT [ 20 ]: strong, ungraded). Besides, LMWH is preferable in pharmacological prophylaxis for mild, moderate and severely ill COVID-19 patients assessed to have a risk of VTE (NCCET [ 27 ], JTH [ 28 ], and BSIM and RBSLM [ 34 ]: ungraded) and patients with RRT (RCP [ 22 ]: ungraded).…”

Section: Resultsmentioning

confidence: 99%

“…For the applicable population, NIH [ 12 ] (strong, very low) considered that there was not enough evidence to show that nonhospital patients routinely need to be tested for hematology and coagulation indicators, which inpatients usually did (weak, very low). As to its indicative function, D-dimer levels should be monitored and a sudden rise of this marker after an initial decrease in blood with concomitant respiratory failure might suggest VTE (BSIM and RBSLM [ 34 ], PCS [ 25 ]: ungraded), while some guidelines suggest against its guidance in anticoagulant therapy (JTT [ 20 ]: weak, ungraded; BSIM&RBSLM [ 34 ]: ungraded), image obtainment (JACC [ 15 ] and JVS-VL [ 19 ]: ungraded), and diagnostic evaluation (the PERT Consortium [ 29 ], ISTH [ 17 ], BSTH&BAHHCT [ 21 ], SFMV [ 26 ], and RCP [ 22 ]: ungraded).…”

Section: Resultsmentioning

confidence: 99%

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Rigorous Assessment of Guidelines on COVID-19-Related Thrombotic or Thromboembolic Disease: Implications for Clinical Practice of Prevention, Diagnosis, and Treatment

Liang

Wang

Xie

et al. 2021

Evidence-Based Complementary and Alternative Medicine

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Purpose. Severe COVID-19 patients were prone to develop venous thromboembolism. Unfortunately, to date, there is no evidence of any effective medications for thromboembolism in COVID-19. The management of the disease relies on symptomatic and supportive treatments, giving rise to a variety of guidelines. However, the quality of methodology and clinical recommendations remains unknown. Materials and Methods. We searched Medline, Cochrane Library, Web of Science, websites of international organizations and medical societies, and gray literature databases. Four well-trained appraisers independently evaluated the quality of eligible guidelines and extracted recommendations using well-recognized guideline appraisal tools. Furthermore, recommendations were extracted and reclassified according to a composite grading system. Results. The search identified 23 guidelines that offered 108 recommendations. Guidelines scored average on AGREE II criteria, with Scope and Purpose and Clarity of Presentation highest. Only five (22%) guidelines provided high-quality recommendations. The existed clinical recommendations were inconsistent in terms of prophylaxis, diagnosis, and treatment of thromboembolic disease to some extent. Conclusion. Current guidelines for COVID-19 thromboembolism are generally of low quality, and clinical recommendations on thromboembolism are principally supported by insufficient evidence. There is still an urgent need for more well-designed clinical trials as evidence to prevent adverse events and improve prognosis during COVID-19 treatment.

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Thromboprophylaxis in COVID‐19: Weight and severity adjusted intensified dosing

Engelen

Vandenbriele

Spalart

et al. 2022

Research and Practice in Thrombosis and Haemostasis

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Background Venous thromboembolism (VTE) frequently occurs in hospitalized patients with coronavirus disease 2019 (COVID‐19). The optimal dose of anticoagulation for thromboprophylaxis in COVID‐19 is unknown. Aims To report VTE incidence and bleeding before and after implementing a hospital‐wide intensified thromboprophylactic protocol in patients with COVID‐19. Methods On March 31, 2020, we implemented an intensified thromboprophylactic protocol consisting of 50 IU anti‐Xa low molecular weight heparin (LMWH)/kg once daily at the ward, twice daily at the intensive care unit (ICU). We included all patients hospitalized in a tertiary care hospital with symptomatic COVID‐19 between March 7 and July 1, 2020. The primary outcome was the incidence of symptomatic or subclinical VTE and major bleeding during admission. Routine ultrasound screening for VTE was performed whenever logistically possible. Results We included 412 patients, of which 116 were admitted to the ICU. Of 219 patients with standard a prophylactic dose of LMWH, 16 (7.3%) had VTE, 10 of which were symptomatic (4.6%). Of 193 patients with intensified thromboprophylaxis, there were no symptomatic VTE cases, three incidental deep venous thrombosis cases (1.6%), and one incidental pulmonary embolism (0.5%). The major bleeding rate was 1.2% in patients with intensified thromboprophylaxis and 7.7% when therapeutic anticoagulation was needed. Conclusion In hospitalized patients with COVID‐19, there were no additional symptomatic VTEs and a reduction in incidental deep vein thrombosis after implementing systematic thromboprophylaxis with weight‐adjusted prophylactic (ward) to intermediate (ICU), but not therapeutic dosed anticoagulation. This intensified thromboprophylaxis was associated with a lower risk of major bleeding compared with therapeutic dosed anticoagulation.

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Belgian clinical guidance on anticoagulation management in hospitalised and ambulatory patients with COVID-19

Cited by 14 publications

References 39 publications

Venous Thromboembolism in Patients Discharged after COVID-19 Hospitalization

Venous Thromboembolism in Patients Discharged after COVID-19 Hospitalization

Rigorous Assessment of Guidelines on COVID-19-Related Thrombotic or Thromboembolic Disease: Implications for Clinical Practice of Prevention, Diagnosis, and Treatment

Thromboprophylaxis in COVID‐19: Weight and severity adjusted intensified dosing

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