Patient Treatment Guidelines

Main Content

Anticoagulation Dosing Recommendations for COVID-19 Patients

Last updated: May 15, 2020

The following dosing recommendation chart apply to all COVID-19 positive and rule out adult patients at UMMC.

 Additional monitoring recommendations:

  • Review prior to admission meds to ensure not previously on Therapeutic Anticoagulation

  • Repeat D-dimer and platelet count (CBC) daily

  • Consider checking TEG and fibrinogen as algorithm suggests or there is progressive organ failure or clinical thrombosis

  • Consider de-escalation of Enhanced to Standard prophylaxis when d-dimer <1000 and plts <100k

**Providers - Consider empirically continuing prophylaxis for 14d post-discharge in patients with hypercoagulability. Should consider if patient has ongoing VTE risk factors or may benefit from extended post-hospital VTE prophylaxis.

Anti-Xa serum concentration monitoring

Serum Anti-Xa concentration peak (Heparin, Anti-Xa Lab Order) should be drawn 4 hours after the third or subsequent enoxaparin dose(s) (no sooner than the third dose). Repeat serum Anti-Xa concentration peaks should be performed with each dose adjustment, with any notable change in renal function, and at least once weekly for all ICU COVID-19 patients.  (**When timing orders, consider timing of other meds or labs to minimize nurse exposure.)

*Results can be found in the Special Coag Studies Misc. under the Results Review.

Consider other causes of hypercoagulability:

  • Heparin-induced thrombocytopenic thrombophilia (HITT) if:
    • Platelet drop by 50% over 24h
    • Proven thrombosis or skin necrosis
    • No other causes of thrombocytopenia
  • Antithrombin 3 deficiency if:
    • Liver disease / impaired hepatic synthetic function
    • Prominent nephrotic syndrome
    • Prolonged RRT or ECMO

Prophylactic enoxaparin dose adjustment based on Anti-Xa concentration

  • Anti-Xa < 0.2 IU/mL: Increase enoxaparin dose by 10 - 20 mg to the nearest syringe size
  • Anti-Xa 0.2 - 0.6 IU/mL: no change
  • Anti-Xa > 0.6 IU/mL: Decrease enoxaparin dose by 10 - 20 mg to the nearest syringe size

Therapeutic enoxaparin dose adjustment based on Anti-Xa concentration

  • Anti-Xa < 0.6 IU/mL: Increase enoxaparin dose by 10 - 20 mg to the nearest syringe size
  • Anti-Xa 0.6 – 1 IU/mL: no change
  • Anti-Xa > 1 IU/mL: Decrease enoxaparin dose by 10 - 20 mg to the nearest syringe size

Heparin infusion dose adjustment based on Anti-Xa dose concentration

Anti -Xa levelHold/BolusRate changeRecheck
< 0.2 units/mLbolus 20 units/kgincrease 4 units/kg/hr6 hrs
0.2 - 0.29 units/mLno bolusincrease 2 units/kg/hr6 hrs
0.3 - 0.7 units/mLno changeno change6 hrs, then daily
0.71 - 0.8 units/mno holddecrease by 1 units/kg/hr6 hrs
0.81 - 0.99no holddecrease by 2 units/kg/hr6 hrs
>0.99 units/mLhold for 1 hourdecrease by 3 units/kg/hr lower6 hrs

 

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.