Efficacy of Bivalirudin for Therapeutic Anticoagulation in COVID-19 Patients Requiring ECMO Support

Abstract

Objectives: The Coronavirus Disease 2019 (COVID-19) pandemic has been associated with cases of refractory acute respiratory distress syndrome (ARDS) sometimes requiring support with extracorporeal membrane oxygenation (ECMO). Bivalirudin can be used for anticoagulation in patients on ECMO support, but its efficacy and safety in patients with COVID-19 is unknown. The authors set out to compare the pharmacologic characteristics and dosing requirements of bivalirudin in patients requiring ECMO support for ARDS due to COVID-19 versus ARDS from other etiologies.

Anticoagulation Strategies in Critically Ill Patients With SARS-CoV-2 Infection: The Role of Direct Thrombin Inhibitors

“…Our data also pointed out that bivalirudin dose administered to SARS-CoV-2 affected patients was higher compared to bivalirudin drug administered to a control group of critically-ill patients negative to SARS-CoV-11 2 infection. This finding is in line with very recent literature [27] and supports the clinical perception that the hypercoagulability status induced by SARS-CoV-2 infection has relevant clinical impact. Indeed, recommendations supporting higher anticoagulation targets when dealing with ECMO and SARS-CoV-2 infection have also been developed [28].…”

Direct Thrombin Inhibition in Extracorporeal Membrane Oxygenation

“…Emerging data give support to their more widespread use in critically ill COVID-19 patients on ECMO support. 5,17 The two most widely used DTIs are bivalirudin and argatroban. Both have the pharmacodynamic advantage of inhibiting Thrombin directly thereby circumventing the requirement of adequate levels of functional AT.…”

“…Interestingly, ECMO patients with ARDS caused by COVID-19 require higher rates of bivalirudin to maintain targeted aPTTs compared to patients with ARDS of other etiology. 5 Cytosorb is a molecular adsorbent, that is increasingly used as a measure to mitigate the inflammatory response in critically ill patients. The use of Cytosorb necessitates upward dose titrations during the first 3 days of application.…”

“…Interestingly, ECMO patients with ARDS caused by COVID-19 require higher rates of bivalirudin to maintain targeted aPTTs compared to patients with ARDS of other etiology. 5…”

“…Several recent reports assessed the use of DTIs in this patient population. 4,5 The use of DTIs represents a viable alternative for systemic anticoagulation in ECMO patients when UFH is contraindicated or not effective. This article focuses on the two most widely used DTIs: bivalirudin and argatroban.…”