GGC Medicines


Adult Therapeutics Handbook

Thromboprophylaxis in COVID-19 Patients

Thromboprophylaxis in COVID-19 Patients

This guideline covers thromboprophylaxis specifically in the non-pregnant COVID-19 population. Seek specialist obstetric advice for thromboprophylaxis in pregnant women with suspected or confirmed COVID-19 infection.

For guidance on thromboprophylaxis in patients who are either not suspected of having COVID-19 or are not confirmed COVID-19 positive, see the main Thromboprophylaxis for Medical and Surgical Patients guideline.

Introduction

Patients with COVID-19 are at high risk of developing a venous thromboembolism (VTE) and it is essential that effective thromboprophylaxis is considered for all patients admitted to hospital with suspected or confirmed COVID-19 infection. Using thromboprophylaxis in patients with COVID-19 will likely save lives.

Thromboprophylaxis management in COVID patients differs depending on whether a patient is being treated within a critical care area (intensive care unit, high dependency unit) or a non-critical care area. 

Thromboprophylaxis in critical care

There are two guidelines to consider, depending on whether the patient is on renal replacement therapy or not. Refer to:

Note: The above documents contain some links to NHSGGC StaffNet that are only active if accessing via a NHS computer.

Thromboprophylaxis in non-critical care setting

Contraindications in COVID-19 patients:

  • Platelet count <25 x109/L
  • Patient is receiving anticoagulation for another reason
  • Patient is considered to be at high bleeding risk (e.g. recent intracranial haemorrhage, untreated inherited/acquired bleeding disorders – see main thromboprophylaxis guideline for assessment of bleeding risk)
  • Trauma with high bleeding risk
  • Active bleeding
  • Heparin induced thrombocytopenia - GGC guideline on NHSGGC StaffNet / Acute / Venous thromboembolism / Diagnosis and Treatment (link only active if accessing via NHS computer).
  • Within 12 hours of procedures e.g. surgery, lumbar puncture
  • Acute bacterial endocarditis
  • Persistent hypertension (BP ≥230/120mmHg)
  • Liver failure and INR >2

Drug Therapy

Prescribe enoxaparin SC 40mg once daily (at 6pm).

Renal impairment

Reduce dose to enoxaparin SC 20mg once daily if eGFR <30ml/minute/1.73m2.

Extremes of weight

If weight is <50kg reduce the dose to enoxaparin SC 20mg once daily.

If weight is >120kg, with normal renal function, consider enoxaparin SC 40mg twice daily (unlicensed dose) especially if multiple thrombotic risk factors are present (requires monitoring of anti-Xa levels).

For more information see guidelines on NHSGGC StaffNet / Acute / Venous thromboembolism / Diagnosis and Treatment (link only active if accessing via NHS computer).

COVID-19 positive patients with ischaemic stroke

Prescribe enoxaparin SC 40mg once daily 48 hours after the onset of stroke and continue intermittent pneumatic compression (IPC). If eGFR <30ml/minute/1.73m2 then reduce dose to enoxaparin SC 20mg once daily. 

Stop IPC 14 days after diagnosis of COVID-19 and continue enoxaparin if no adverse effects and patient is still immobile.

Monitoring and additional information

Patients with COVID-19 can develop abnormal coagulation and thrombocytopenia but bleeding symptoms are rare. Prolonged prothrombin time (PT), activated partial thromboplastin time (APTT) and thrombin clotting time (TCT) are not a contraindication to administering thromboprophylaxis as long as fibrinogen is ≥1 (this is measured automatically by the lab if TCT ≥18secs).

For further details of assessment of VTE and bleeding risk, and monitoring requirements (in addition to those listed here), see the main Thromboprophylaxis for Medical and Surgical Patients guideline.

 

Content updated 1st June 2020.