Antithrombotic Treatment in COVID-19
Recommendations
3.1 Antithrombotic therapy for non-hospitalized patients
3.2 Antithrombotic therapy for non–critically ill, hospitalized patients
3.3 Antithrombotic therapy for critically ill, hospitalized patients
3.4 Antithrombotic therapy for patients discharged from hospital
Tables and Figures
TABLE 1. Dose levels of the anticoagulants used in the studies cited in the guideline
| Drug | Prophylactic | Intermediate | Therapeutic |
| UFH | 000 U SQ BID or TID | 7500 U SQ BID or TID | Intravenous, adjusted to APTT or anti-Xa |
| LMWH | Enoxaparin 40 mg SQ QD, dalteparin 5000 IU SQ QD, tinzaparin 4500 IU SQ QD, bemiparin 3500 IU SQ QD | Enoxaparin 40 mg SQ BID or 80 mg SQ QD, or 0.5 mg/kg SQ QD | Enoxaparin 1 mg/kg SQ BID, dalteparin 200 IU/kg SQ QD, tinzaparin 175 IU/kg SQ QD, bemiparin 115 IU/kg SQ QD |
| DOAC | Rivaroxaban 10 mg PO QD, apixaban 2.5 mg PO BID | Not applicable | Rivaroxaban 20 mg PO QD, apixaban 5 mg PO BID |
FIGURE 2. Summary of recommendations
Recommendation Grading
Overview
Title
Antithrombotic Treatment in COVID-19
Authoring Organization
Publication Month/Year
July 4, 2022
Last Updated Month/Year
April 1, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
Antithrombotic agents reduce risk of thromboembolism in severely ill patients. Patients with coronavirus disease 2019 (COVID-19) may realize additional benefits from heparins. Optimal dosing and timing of these treatments and benefits of other antithrombotic agents remain unclear. In October 2021, ISTH assembled an international panel of content experts, patient representatives, and a methodologist to develop recommendations on anticoagulants and antiplatelet agents for patients with COVID-19 in different clinical settings. We used the American College of Cardiology Foundation/American Heart Association methodology to assess level of evidence (LOE) and class of recommendation (COR). Only recommendations with LOE A or B were included. Panelists agreed on 12 recommendations: three for non-hospitalized, five for non–critically ill hospitalized, three for critically ill hospitalized, and one for post-discharge patients. Two recommendations were based on high-quality evidence, the remainder on moderate-quality evidence. Among non–critically ill patients hospitalized for COVID-19, the panel gave a strong recommendation (a) for use of prophylactic dose of low molecular weight heparin or unfractionated heparin (LMWH/UFH) (COR 1); (b) for select patients in this group, use of therapeutic dose LMWH/UFH in preference to prophylactic dose (COR 1); but (c) against the addition of an antiplatelet agent (COR 3). Weak recommendations favored (a) sulodexide in non-hospitalized patients, (b) adding an antiplatelet agent to prophylactic LMWH/UFH in select critically ill, and (c) prophylactic rivaroxaban for select patients after discharge (all COR 2b). Recommendations in this guideline are based on high-/moderate-quality evidence available through March 2022. Focused updates will incorporate future evidence supporting changes to these recommendations.
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Hospital, Outpatient
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Treatment, Management
Diseases/Conditions (MeSH)
D000991 - Antithrombins, D017934 - Coronavirus
Keywords
antithrombotic, Coronavirus, covid-19, COVID
Source Citation
Schulman S, Sholzberg M, Spyropoulos AC, Zarychanski R, Resnick HE, Bradbury CA, Broxmeyer L, Connors JM, Falanga A, Iba T, Kaatz S, Levy JH, Middeldorp S, Minichiello T, Ramacciotti E, Samama CM, Thachil J; International Society on Thrombosis and Haemostasis. ISTH guidelines for antithrombotic treatment in COVID-19. J Thromb Haemost. 2022 Jul 8:10.1111/jth.15808. doi: 10.1111/jth.15808. Epub ahead of print. PMID: 35906716; PMCID: PMC9349907.