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.

• Anticoagulation Dosing Recommendations for COVID-19 Patients - PDF

 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