Table 1. Recommendations Recommendation... | American Society of Hematology

Table 1.

Recommendations

Recommendation	Remarks
Recommendation 1a: the ASH guideline panel suggests using prophylactic-intensity over intermediate-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 ⨁○○○). Recommendation 1b: the ASH guideline panel suggests using prophylactic-intensity over 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 ⨁○○○).	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 ICU due to COVID-19. Examples include patients requiring hemodynamic support, ventilatory support, and renal replacement therapy. This does not include patients admitted to the ICU for other reasons who incidentally test positive for COVID-19. An individualized assessment of the patient’s risk of thrombosis and bleeding is important when deciding on anticoagulation intensity. RAMs to estimate thrombotic risk have been validated in hospitalized patients with COVID-19 (critically or noncritically ill), with modest prognostic performance. No RAMs for bleeding have been validated for patients with COVID-19. The panel acknowledges that higher-intensity anticoagulation may be preferred for patients judged to be at low bleeding risk and high thrombotic risk. At present, there is no direct high-certainty evidence comparing different types of anticoagulants. The selection of a specific agent (eg, LMWH and UFH) may be based on availability, resources required, familiarity, the aim of minimizing the use of personal protective equipment or exposure to staff to patients with COVID-19, as well as patient-specific factors (eg, renal function, history of heparin-induced thrombocytopenia, and concerns about gastrointestinal tract absorption). LMWH and UFH were used in the identified studies and may be preferred because of a preponderance of evidence with these agents. There are no studies of intermediate- or therapeutic-intensity fondaparinux, argatroban, or bivalirudin in this population. These recommendations do not apply to patients who require anticoagulation to prevent thrombosis of extracorporeal circuits such as those on ECMO or CRRT.
Recommendation 2a: the ASH guideline panel suggests using prophylactic-intensity over intermediate-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 ⨁○○○). Recommendation 2a: the ASH guideline panel suggests using therapeutic-intensity over prophylactic-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 ⨁○○○).	Patients with COVID-19–related acute illness are defined as those with clinical features that would typically result in admission to an inpatient medical ward without requirement for intensive 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. RAMs to estimate thrombotic risk have been validated in hospitalized patients with COVID-19 (critically or noncritically ill), with modest prognostic performance. No RAMs for bleeding have been validated for patients with COVID-19. The panel acknowledges that lower-intensity anticoagulation may be preferred for patients judged to be at high bleeding risk and low risk of thrombosis. At present, there is no direct high-certainty evidence comparing different types of anticoagulants for patients with COVID-19. LMWH or UFH may be preferred because of a preponderance of evidence with these agents. There are no studies of therapeutic-intensity fondaparinux, argatroban, or bivalirudin in this population.
Recommendation 3: the ASH guideline panel suggests against using postdischarge outpatient anticoagulant thromboprophylaxis for patients with COVID-19 who are being discharged from hospital and who do not have suspected or confirmed VTE or another indication for anticoagulation (conditional recommendation based on very low certainty in the evidence about effects ⨁○○○).	An individualized assessment of the patient’s risk of thrombosis and bleeding and shared decision-making are important when deciding on whether to use postdischarge thromboprophylaxis. The panel acknowledged that postdischarge thromboprophylaxis may be reasonable for patients judged to be at high thrombotic risk and low bleeding risk.

Recommendation	Remarks
Recommendation 1a: the ASH guideline panel suggests using prophylactic-intensity over intermediate-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 ⨁○○○). Recommendation 1b: the ASH guideline panel suggests using prophylactic-intensity over 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 ⨁○○○).	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 ICU due to COVID-19. Examples include patients requiring hemodynamic support, ventilatory support, and renal replacement therapy. This does not include patients admitted to the ICU for other reasons who incidentally test positive for COVID-19. An individualized assessment of the patient’s risk of thrombosis and bleeding is important when deciding on anticoagulation intensity. RAMs to estimate thrombotic risk have been validated in hospitalized patients with COVID-19 (critically or noncritically ill), with modest prognostic performance. No RAMs for bleeding have been validated for patients with COVID-19. The panel acknowledges that higher-intensity anticoagulation may be preferred for patients judged to be at low bleeding risk and high thrombotic risk. At present, there is no direct high-certainty evidence comparing different types of anticoagulants. The selection of a specific agent (eg, LMWH and UFH) may be based on availability, resources required, familiarity, the aim of minimizing the use of personal protective equipment or exposure to staff to patients with COVID-19, as well as patient-specific factors (eg, renal function, history of heparin-induced thrombocytopenia, and concerns about gastrointestinal tract absorption). LMWH and UFH were used in the identified studies and may be preferred because of a preponderance of evidence with these agents. There are no studies of intermediate- or therapeutic-intensity fondaparinux, argatroban, or bivalirudin in this population. These recommendations do not apply to patients who require anticoagulation to prevent thrombosis of extracorporeal circuits such as those on ECMO or CRRT.
Recommendation 2a: the ASH guideline panel suggests using prophylactic-intensity over intermediate-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 ⨁○○○). Recommendation 2a: the ASH guideline panel suggests using therapeutic-intensity over prophylactic-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 ⨁○○○).	Patients with COVID-19–related acute illness are defined as those with clinical features that would typically result in admission to an inpatient medical ward without requirement for intensive 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. RAMs to estimate thrombotic risk have been validated in hospitalized patients with COVID-19 (critically or noncritically ill), with modest prognostic performance. No RAMs for bleeding have been validated for patients with COVID-19. The panel acknowledges that lower-intensity anticoagulation may be preferred for patients judged to be at high bleeding risk and low risk of thrombosis. At present, there is no direct high-certainty evidence comparing different types of anticoagulants for patients with COVID-19. LMWH or UFH may be preferred because of a preponderance of evidence with these agents. There are no studies of therapeutic-intensity fondaparinux, argatroban, or bivalirudin in this population.
Recommendation 3: the ASH guideline panel suggests against using postdischarge outpatient anticoagulant thromboprophylaxis for patients with COVID-19 who are being discharged from hospital and who do not have suspected or confirmed VTE or another indication for anticoagulation (conditional recommendation based on very low certainty in the evidence about effects ⨁○○○).	An individualized assessment of the patient’s risk of thrombosis and bleeding and shared decision-making are important when deciding on whether to use postdischarge thromboprophylaxis. The panel acknowledged that postdischarge thromboprophylaxis may be reasonable for patients judged to be at high thrombotic risk and low bleeding risk.