Managing Arterial & Venous Thrombotic Events with COVID-19
This content discusses identifying patients at risk, selecting prophylaxis, and managing arterial & venous thrombotic events in COVID-19 patients. It covers VTE risk data, critical illness rates, populations at risk, and prevention strategies including anticoagulation drug options.
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Presentation Transcript
Identifying Patients at Risk, Selecting Identifying Patients at Risk, Selecting Prophylaxis, and Managing Arterial & Prophylaxis, and Managing Arterial & Venous Thrombotic Events with COVID Venous Thrombotic Events with COVID- -19 Geoffrey Barnes, MD, MSc University of Michigan @GBarnesMD 19 May 14, 2020
Disclosures Grants: Pfizer/Bristol-Myers Squibb, Blue Cross Blue Shield of Michigan, NHLBI, AHRQ Consulting: Pfizer/Bristol-Myers Squibb, Janssen, Portola, AMAG Pharmaceuticals
VTE Risk in COVID-19 Author (Location) Population Outcome Measure Rate of Outcome Notes Cui (Wuhan China) ICU Patients DVT 25% Prophy not usually given Klok (Netherlands) ICU Patients DVT or PE 27% Prophy given, dosing changed during study Many subsegmental Lodigiani (Italy) Hospital Patients VTE or Arterial 21.0% cumulative rate Many deaths without imaging 10.1111/JTH.14830 10.1016/j.thromres.2020.04.013 10.1016/j.thromres.2020.04.024
Critical Illness and VTE Risk COVID-19 Status No No Yes Yes Population VTE Risk Critically Ill, no VTE prophy Critically ill, VTE prophy Critically ill, no VTE prophy Critically ill, VTE prophy 13-31% 5.4-23.6% 25% 21-27% Crit Care. 2015; 19(1): 287 10.1016/j.thromres.2020.04.013 10.1111/JTH.14830 10.1016/j.thromres.2020.04.024
Who is at risk of VTE? Updated ICU Data from Netherlands Elevated D-dimer Older age Immobilized Medical conditions (esp infectious) Anyone hospitalized with COVID-19 10.1016/j.thromres.2020.04.041
How to Prevent COVID-19 VTE? Anticoagulation For whom? What drug? What dose? How long?
What Drug to Give? LMWH Once or twice daily increased compliance, less RN/phlebotomy exposure Potential anti-inflammatory properties Strong VTE-prevention evidence base Concerns with renal dysfunction, extreme body weight UFH TID injection or infusion ? compliance and RN/phlebotomy exposure Useful with renal insufficiency Quick on/on for procedures
What Drug to Give? DOAC Oral only increased compliance Renal clearance concern for AKI/CKD Need for procedure?
What dose of anticoagulation? Prophylactic doses LMWH 40mg qDay, 0.5mg/kg daily UFH 5000 units BID-TID Intermediate doses LMWH 30-50mg BID UFH 7500 units TID UFH gtt for Xa goal 0.2-0.3 Treatment dose LMWH 1mg/kg BID (1.5mg/kg daily) UFH gtt for Xa goal 0.3-0.7 DOAC Medications? Rivaroxaban & Betrixaban Prophy Apixaban & Rivaroxaban Treatment https://acforum-excellence.org/Resource- Center/resource_files/1549-2020-05-07-133522.pdf DOI: 10.1016/j.jvsv.2018.08.010 DOI: 10.1016/j.jvsv.2020.04.009
What dose of anticoagulation? Anticoagulation: Reduced mortality Higher intubation risk Limitations: Observational Unmeasured confounding Selection bias? Single center HR 0.86 (0.82-0.89) RCT needed! NCT04367831 NCT04362085 DOI: 10.1016/j.jacc.2020.05.001
Post-hospital Extended VTE Prophylaxis? Post-hospital VTE Prophylaxis: Rivaroxaban 10mg daily 31-39 days Betrixaban 160mg x1, 80mg daily for 35-42 days Enoxaparin 40mg daily 6-14 days DOI 10.1002/jhm.1002 https://acforum-excellence.org/Resource- Center/resource_files/1549-2020-05-07-133522.pdf
Summary COVID-19 and VTE Risk Needs attention! Prophylaxis for all hospitalized with COVID-19 Drug/dose selection rely on evidence-based therapies Explore higher-doses in setting of clinical trials Consider role for post-hospital prophylaxis
Thank you! @GBarnesMD
