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Published on: November 26, 2013
ISTH guidelines for antithrombotic treatment in COVID-19
Sam Schulman1,2, Michelle Sholzberg3, Alex C Spyropoulos4,5
1Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.
Insights
Antithrombotic therapy, including heparin, can benefit patients with COVID-19. Guidelines recommend prophylactic heparin for hospitalized patients and suggest therapeutic doses for select cases, while advising against antiplatelet agents.
Area of Science:
- Cardiology
- Hematology
- Infectious Diseases
Background:
- Antithrombotic agents are crucial for managing thromboembolism in critically ill patients.
- The role of heparins and other antithrombotic agents in COVID-19 requires clarification regarding optimal dosing and timing.
- Existing evidence on antithrombotic strategies for COVID-19 patients necessitates expert consensus for clinical guidance.
Purpose of the Study:
- To develop evidence-based recommendations for anticoagulant and antiplatelet therapy in COVID-19 patients across various clinical settings.
- To provide guidance on the use of heparins and other antithrombotic agents for hospitalized and non-hospitalized COVID-19 patients.
- To address optimal dosing, timing, and combination strategies for antithrombotic treatments in the context of COVID-19.
Main Methods:
- An international panel of experts, patient representatives, and a methodologist convened in October 2021.
- Recommendations were developed using the American College of Cardiology Foundation/American Heart Association methodology for assessing Level of Evidence (LOE) and Class of Recommendation (COR).
- Only recommendations with LOE A or B were included, focusing on high- and moderate-quality evidence available through March 2022.
Main Results:
- Twelve recommendations were established for different patient groups: non-hospitalized, non-critically ill hospitalized, critically ill hospitalized, and post-discharge.
- Strong recommendations include prophylactic low molecular weight heparin or unfractionated heparin (LMWH/UFH) for non-critically ill hospitalized patients, with therapeutic doses for select individuals.
- Advice against adding antiplatelet agents to prophylactic LMWH/UFH in non-critically ill hospitalized patients was also provided.
Conclusions:
- The guidelines offer clear recommendations for antithrombotic therapy in COVID-19 patients based on robust evidence.
- Specific guidance is provided for prophylactic and therapeutic heparin use, as well as the judicious use of antiplatelet agents.
- Future updates will incorporate emerging evidence to refine these recommendations for evolving clinical practice.
Abstract:
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.
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