Prophylaxis and treatment of COVID-19 related venous thromboembolism

Figures & data

Table 1. Overview of guidelines on prophylaxis and treatment of VTE in COVID-19

	Prophylaxis in acutely ill patients (non-ICU)	Prophylaxis in critically ill patients (ICU)	Post-discharge thromboprophylaxis	Treatment of VTE
ISTH	Routine thromboprophylaxis with standard-dose LMWH (or UFH) in all patients. Intermediate dose LMWH may be considered. Modification based on extremes in body weight, severe thrombocytopenia or deteriorating renal function.	Routine thromboprophylaxis with standard-dose UFH or LMWH in all patients. Intermediate dose LMWH can be considered. Patients with obesity should be considered for a 50% increase in dose.	Extended post-discharge thromboprophylaxis should be considered in patients that meet high VTE risk criteria. Duration: at least 14 days, up to 30 days.	Established guidelines should be used, with advantages of LMWH in the inpatient setting and DOACs in the post-hospital discharge setting. Minimum duration of 3 months.
CHEST	Anticoagulant thromboprophylaxis in all patients. Preferred agent LMWH or fondaparinux, followed by UFH, followed by DOAC. Standard prophylactic dose is advised.	Anticoagulant thromboprophylaxis in all patients. Preferred agent LMWH, followed by UFH, followed by fondaparinux or DOAC. Standard prophylactic dose is advised. If anticoagulation is contraindicated, mechanical prophylaxis is advised.	No extended thromboprophylaxis advised.	In shock, systemically administered thrombolysis is suggested. In ICU patients parenteral anticoagulation, LMWH preferred over UFH. In patients without any drug-interactions on general wards a DOAC can be considered. For outpatient management DOACs are recommended. Minimum duration of 3 months.
ESC	Standard dose prophylaxis in all patients.	Standard dose prophylaxis in all patients	Not mentioned.	Following current ESC PE guidelines: UFH, LMWH or DOAC, depending on the possibility of oral treatment, renal function etc. Caution of interaction with DOACs (should be particularly avoided in lopinavir/ritonavir use). Duration not mentioned.
ASH	All patients should receive pharmacologic thromboprophylaxis with LMWH over UFH. Dose adjustment for obesity may be used per institutional guidance. When anticoagulants are contraindicated, use mechanical prophylaxis. Standard prophylaxis dose is advised. Participation in clinical trials on intensified doses is recommended.	See non-ICU patients.	Can be considered based on the individual patients’ VTE risk factors at time of discharge.	LMWH and UFH preferred in critically ill. DOACs should be used with caution (drug-drug interaction). Duration not mentioned.
ERS/ATS	Not mentioned	Not mentioned	No suggestion for or against extended thromboprophylaxis.	Duration of 3 months. No recommendations on type or dose of anticoagulation.
NIH	Hospitalized adults should receive standard prophylaxis conform non-COVID-19 patients.	See non-ICU patients.	Extended VTE prophylaxis can be considered in patients who are at low risk for bleeding and high risk for VTE as per protocols for patients without COVID-19.	Management with therapeutic doses of anticoagulant therapy as per standard of care for patients without COVID-19.
NICE	Pharmacological VTE prophylaxis with standard prophylactic dose of LMWH in all patients (second choice: UFH or fondaparinux). Consider adjusting the dose for extremes of body weight or impaired renal function.	In patients with advanced respiratory support, consider intermediate dose prophylaxis.	Can be considered if the risk of VTE outweighs the risk of bleeding (conform non-COVID-19 protocols).	Not mentioned.

Note: ISTH: International Society on Thrombosis and Haemostasis, CHEST: American College of Chest Physicians, ESC: European Society of Cardiology, ASH: American Society of Hematology, ERS: European Respiratory Society, ATS: American Thoracic Society, NIH: National Institute of Health, NICE: National Institute of Health and Care Excellence.