So as the call day brings another round of severe ICU COVID respiratory failure pts, I am pondering anti-coagulation. Like everything with this virus, it seems the therapeutic recommendations change monthly. In the spring and summer of 2020 we were therapeutically anticoagulating all severe covid pts with elevated d-dimers (seemed like all of them). Anecdotally - I have witnessed numerous bleeding complications since then.

Then this paper was published:

https://www.healio.com/news/hematology-oncology/20201231/therapeutic-anticoagulation-ups-mortality-risk-among-patients-hospitalized-with-covid19

Increased risk of mortality in the anticoagulation arm (35% vs 15%). Although not a RDBPCT - it has changed care to prophylactic anticoagulation in severe COVID pts at our hospital. We aren't fully anticoagulating unless evidence of thrombosis is found or CRRT is being performed.

Anyway - curious to others thoughts. Another example of the roller coaster that is COVID.

Do you have a link to the article? It seems like those with the highest D-dimers and the worst hospital courses would be on full anticoagulation as opposed to prophylactic, and you would expect higher mortality in those patients. If the study was trying to match patients for disease severity and D-dimer level and still showed higher mortality in the full anticoagulation group, then I would probably change my practice immediately

Should be in my post above. Did it not go thru?

I couldn't find a Methods section in the article or anything discussing patient characteristics

https://www.thrombosisresearch.com/article/S0049-3848(20)30587-9/fulltext


Sorry. There's full paper. Took me a while to find it. At a glance - 3% more of the therapeutic arm age 70-79. 5% more of the prophylactic arm age 30-39.

Thanks! The paper is a bit more nuanced. The found no difference in ICU patients between prophylactic and full anticoagulation, and a trend toward better outcomes on full anticoagulation for the first 3 days. In non-ICU patients the benefit of prophylactic doses disappeared when they considered high v low d-dimers.

So the best I can take away is don't use therapeutic anticoagulation in non-ICU hospitalized patients unless the D-dimer is very elevated (3 microgram/ml or 3000 ng/ml). I've been using about 750 ng/ml as my cutoff for full anticoagulation based on absolutely nothing, so I'll probably up that threshold to 3000 based on this

https://www.ahajournals.org/doi/pdf/10.1161/JAHA.120.018624

And this paper says we should anticoagulate before hospitalizing. However, most agree that stable outpatients don't need anticoagulants, so I guess we have to somehow predict who will be hospitalized before they are sick enough to actually be hospitalized

The RECOVERY trial just came out with a press release regarding toci in severe COVID. They found a mortality benefit in these patients. Absolute risk reduction for mortality was 4%, so a number needed to treat to prevent one death was 25 overall.

https://www.recoverytrial.net/files/recovery-press-release-tocilizumab_final.pdf

Think that deserves its own thread