Empiric therapeutic anticoagulation for severe COVID-19
Dr. Anderson
Clinical question: For patients hospitalized with COVID-19, does empiric therapeutic-dose versus prophylactic-dose anticoagulation with enoxaparin affect clinical outcomes?
Background: Patients hospitalized with COVID-19 are at risk for venous and arterial thromboembolism. Multiplatform adaptive and randomized trials have not clearly shown efficacy.
Study design: Randomized multicenter active control trial (HEP-COVID) of therapeutic versus standard/intermediate-dose enoxaparin in hospitalized adults with COVID-19 and D-dimer levels more than four times the upper limit of normal or sepsis-induced coagulopathy scores of four or more.
Setting: Twelve U.S. hospitals enrolling 257 patients.
Synopsis: The primary outcome of 30-day venous or arterial thromboembolism or all-cause death was reduced in non-ICU patients (36.1% versus 16.7%, P=0.004) but not in ICU patients (55.3% versus 51.1%, P=0.71). Major bleeding occurred in 1.6% with standard-dose versus 4.7% with therapeutic-dose enoxaparin (P=0.17).
Bottom line: Therapeutic-dose enoxaparin reduces thromboembolism and death at 30 days compared to standard/intermediate-dose among adults hospitalized with COVID-19 and elevated D-dimer levels. This effect was not seen among ICU patients.
Citation: Spyropoulos AC et al. Efficacy and safety of therapeutic-dose heparin vs standard prophylactic or intermediate-dose heparins for thromboprophylaxis in high-risk hospitalized patients with COVID-19. JAMA Intern Med. 2021 Oct 7;e216203. doi: 10.1001/jamainternmed.2021.6203.
Dr. Anderson is an associate professor of medicine, University of Colorado School of Medicine, and executive director, VHA National Hospital Medicine Program hospital medicine section, Rocky Mountain Regional VA Medical Center, Aurora, Colo.