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Finding the Right Balance in COVID-19 Thromboprophylaxis

“We have certainly heard of cases where full-dose anticoagulation has unfortunately led to major bleeding events,” he said. “It is important to note that while these patients are at elevated risk for thrombotic events, risk for bleeding is likely elevated in many as well, particularly in the critically ill patients with abnormal hemostatic parameters.”

“Predicting the patients that may benefit from more intensive anticoagulation is very challenging and we need more studies and data to determine the right patients who may benefit from intensified anticoagulation,” Madhavan said.

Weinberg also expressed concern for an elevated bleeding risk in patients receiving full-dose anticoagulation.

“Everyone is talking about the thrombosis but no one is talking about the bleeding,” he said. “But there definitely is bleeding, including clinically significant bleeding, and [data] will be published soon.”

Weinberg highlighted a small, retrospective paper, in which 11% of COVID-19 patients with a high risk for VTE, based on their Padua Prediction Score, also had a high risk of bleeding.

“I can tell you from the data I know that’s unpublished yet, it pans out,” he said.

Both LMWH and direct oral anticoagulants (DOACs) offer the advantage of not needing regular monitoring for efficacy, however, LMWH may be a better solution for hospitalized COVID-19 patients, Madhavan said.

“Given their longer half-life, the effect of DOACs can stick around the body and increase the likelihood of bleeding, especially in circumstances where procedures are needed/likely,” he said.

The expert panel also point outs that DOACs can potentially interact with a number of medications, including investigational COVID-19 treatments.

For these reasons, Madhavan is switching his hospitalized COVID-19 patients, especially those that have the chance to decompensate, from DOACs to LMWH.

“For more stable patients that are likely to be discharged soon, keeping them on DOACs is not an unreasonable strategy,” he added.

Although the Centers for Disease Control recently indicated a higher risk for severe COVID-19 in patients taking blood thinners, there is no evidence that antiplatelet agents or anticoagulants increase the risk of contracting or of developing severe COVID-19, the panel members said.

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