Recommendations
| Recommendation . | Remarks . |
|---|---|
| Recommendation 1. The ASH guideline panel suggests using prophylactic-intensity over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19–related critical illness who do not have suspected or confirmed VTE (conditional recommendation based on very low certainty in the evidence about effects ⊕◯◯◯) | • Between the time this recommendation was published online (27 October 2020) and when it was published in Blood Advances, a press release (https://www.nih.gov/news-events/news-releases/nih-activ-trial-blood-thinners-pauses-enrollment-critically-ill-covid-19-patients) describing the results of a planned interim analysis of 3 randomized controlled trials, REMAP-CAP, ACTIV-4, and ATTACC (NCT 02735707, 04505774, and 04372589, respectively), was issued. In these trials, therapeutic-intensity anticoagulation was compared with prophylactic-intensity anticoagulation for patients with COVID-19–related critical illness. The ASH guideline panel plans to update this recommendation when the full results of REMAP-CAP, ACTIV-4, and ATTACC become available. Clinicians should weigh the potential benefits and harms based on the most up-to-date available evidence in caring for their patients. • Patients with COVID-19–related critical illness are defined as those suffering from an immediately life-threatening condition who would typically be admitted to an intensive care unit. Examples include patients requiring hemodynamic support, ventilatory support, and renal replacement therapy. • An individualized assessment of the patient’s risk of thrombosis and bleeding is important when deciding on anticoagulation intensity; risk-assessment models to estimate thrombotic and bleeding risk are available, but they have not been validated for patients with COVID-19; the panel acknowledges that higher-intensity anticoagulation may be preferred for patients judged to be at high thrombotic risk and low bleeding risk • At present, there is no direct high-certainty evidence comparing different types of anticoagulants; the selection of a specific agent (eg, low-molecular-weight heparin, unfractionated heparin, etc) may be based on availability, resources required, familiarity, and the aim of minimizing PPE use or staff exposure to COVID-19–infected patients as well as patient-specific factors (eg, renal function, history of heparin-induced thrombocytopenia, concerns about gastrointestinal tract absorption) • This recommendation does not apply to patients who require anticoagulation to prevent thrombosis of extracorporeal circuits such as those on ECMO or CRRT |
| Recommendation 2. The ASH guideline panel suggests using prophylactic-intensity over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19–related acute illness who do not have suspected or confirmed VTE (conditional recommendation based on very low certainty in the evidence about effects ⊕◯◯◯) | • Between the time this recommendation was published online (27 October 2020) and when it was published in Blood Advances, a press release (https://www.nih.gov/news-events/news-releases/full-dose-blood-thinners-decreased-need-life-support-improved-outcome-hospitalized-covid-19-patients) describing the results of a planned interim analysis of 3 randomized controlled trials, REMAP-CAP, ACTIV-4, and ATTACC (NCT 02735707, 04505774, and 04372589, respectively), was issued. In these trials, therapeutic-intensity anticoagulation was compared with prophylactic-intensity anticoagulation for moderately ill hospitalized patients with COVID-19. The ASH guideline panel plans to update this recommendation when the full results of REMAP-CAP, ACTIV-4, and ATTACC become available. Clinicians should weigh the potential benefits and harms based on the most up-to-date available evidence in caring for their patients. • Patients with COVID-19–related acute illness are defined as those with clinical features that would typically result in admission to a medicine inpatient ward without requirement for advanced clinical support. Examples include patients with dyspnea or mild to moderate hypoxia. • An individualized assessment of the patient’s risk of thrombosis and bleeding is important when deciding on anticoagulation intensity; risk-assessment models to estimate thrombotic and bleeding risk are available, but they have not been validated for patients with COVID-19; the panel acknowledges that higher-intensity anticoagulation may be preferred for patients judged to be at high thrombotic risk and low bleeding risk • At present, there is no direct high-certainty evidence comparing different types of anticoagulants; the selection of a specific agent (eg, low-molecular-weight heparin, unfractionated heparin, etc) may be based on availability, resources required, familiarity, and the aim of minimizing PPE use or staff exposure to COVID-19–infected patients as well as patient-specific factors (eg, renal function, history of heparin-induced thrombocytopenia, concerns about gastrointestinal tract absorption) |
| Recommendation . | Remarks . |
|---|---|
| Recommendation 1. The ASH guideline panel suggests using prophylactic-intensity over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19–related critical illness who do not have suspected or confirmed VTE (conditional recommendation based on very low certainty in the evidence about effects ⊕◯◯◯) | • Between the time this recommendation was published online (27 October 2020) and when it was published in Blood Advances, a press release (https://www.nih.gov/news-events/news-releases/nih-activ-trial-blood-thinners-pauses-enrollment-critically-ill-covid-19-patients) describing the results of a planned interim analysis of 3 randomized controlled trials, REMAP-CAP, ACTIV-4, and ATTACC (NCT 02735707, 04505774, and 04372589, respectively), was issued. In these trials, therapeutic-intensity anticoagulation was compared with prophylactic-intensity anticoagulation for patients with COVID-19–related critical illness. The ASH guideline panel plans to update this recommendation when the full results of REMAP-CAP, ACTIV-4, and ATTACC become available. Clinicians should weigh the potential benefits and harms based on the most up-to-date available evidence in caring for their patients. • Patients with COVID-19–related critical illness are defined as those suffering from an immediately life-threatening condition who would typically be admitted to an intensive care unit. Examples include patients requiring hemodynamic support, ventilatory support, and renal replacement therapy. • An individualized assessment of the patient’s risk of thrombosis and bleeding is important when deciding on anticoagulation intensity; risk-assessment models to estimate thrombotic and bleeding risk are available, but they have not been validated for patients with COVID-19; the panel acknowledges that higher-intensity anticoagulation may be preferred for patients judged to be at high thrombotic risk and low bleeding risk • At present, there is no direct high-certainty evidence comparing different types of anticoagulants; the selection of a specific agent (eg, low-molecular-weight heparin, unfractionated heparin, etc) may be based on availability, resources required, familiarity, and the aim of minimizing PPE use or staff exposure to COVID-19–infected patients as well as patient-specific factors (eg, renal function, history of heparin-induced thrombocytopenia, concerns about gastrointestinal tract absorption) • This recommendation does not apply to patients who require anticoagulation to prevent thrombosis of extracorporeal circuits such as those on ECMO or CRRT |
| Recommendation 2. The ASH guideline panel suggests using prophylactic-intensity over intermediate-intensity or therapeutic-intensity anticoagulation for patients with COVID-19–related acute illness who do not have suspected or confirmed VTE (conditional recommendation based on very low certainty in the evidence about effects ⊕◯◯◯) | • Between the time this recommendation was published online (27 October 2020) and when it was published in Blood Advances, a press release (https://www.nih.gov/news-events/news-releases/full-dose-blood-thinners-decreased-need-life-support-improved-outcome-hospitalized-covid-19-patients) describing the results of a planned interim analysis of 3 randomized controlled trials, REMAP-CAP, ACTIV-4, and ATTACC (NCT 02735707, 04505774, and 04372589, respectively), was issued. In these trials, therapeutic-intensity anticoagulation was compared with prophylactic-intensity anticoagulation for moderately ill hospitalized patients with COVID-19. The ASH guideline panel plans to update this recommendation when the full results of REMAP-CAP, ACTIV-4, and ATTACC become available. Clinicians should weigh the potential benefits and harms based on the most up-to-date available evidence in caring for their patients. • Patients with COVID-19–related acute illness are defined as those with clinical features that would typically result in admission to a medicine inpatient ward without requirement for advanced clinical support. Examples include patients with dyspnea or mild to moderate hypoxia. • An individualized assessment of the patient’s risk of thrombosis and bleeding is important when deciding on anticoagulation intensity; risk-assessment models to estimate thrombotic and bleeding risk are available, but they have not been validated for patients with COVID-19; the panel acknowledges that higher-intensity anticoagulation may be preferred for patients judged to be at high thrombotic risk and low bleeding risk • At present, there is no direct high-certainty evidence comparing different types of anticoagulants; the selection of a specific agent (eg, low-molecular-weight heparin, unfractionated heparin, etc) may be based on availability, resources required, familiarity, and the aim of minimizing PPE use or staff exposure to COVID-19–infected patients as well as patient-specific factors (eg, renal function, history of heparin-induced thrombocytopenia, concerns about gastrointestinal tract absorption) |