Guidance on diagnosis, prevention and treatment of thromboembolic complications in COVID-19: a position paper of the Brazilian Society of Thrombosis and Hemostasis and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy

Orsi, Fernanda Andrade; De Paula, Erich V.; Santos, Fernanda de Oliveira; Teruchkin, Marcelo Melzer; Campêlo, Dirceu Hamilton Cordeiro; Mello, Tayana Teixeira; Chindamo, Maria Chiara; Macedo, Ariane Vieira Scarlatelli; Rocha, Ana Thereza; Ramacciotti, Eduardo; Nascimento, Ana Clara Kneese; Annichino-Bizzacchi, Joyce; Lourenco, Dayse Maria; Guerra, João Carlos de Campos; Rezende, Suely Meireles; Cavalheiro Filho, Cyrillo

doi:10.1016/j.htct.2020.06.001

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Review article • Hematol., Transfus. Cell Ther. 42 (4) • Oct-Dec 2020 • https://doi.org/10.1016/j.htct.2020.06.001 linkcopy

Guidance on diagnosis, prevention and treatment of thromboembolic complications in COVID-19: a position paper of the Brazilian Society of Thrombosis and Hemostasis and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy

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Hemostatic abnormalities and thrombotic risk associated with coronavirus disease 2019 (COVID-19) are among the most discussed topics in the management of this disease. The aim of this position paper is to provide the opinion of Brazilian experts on the thromboprophylaxis and management of thrombotic events in patients with suspected COVID-19, in the sphere of healthcare in Brazil. To do so, the Brazilian Society of Thrombosis and Hemostasis (BSTH) and the Thrombosis and Hemostasis Committee of the Brazilian Association of Hematology, Hemotherapy and Cellular Therapy (ABHH) have constituted a panel of experts to carefully review and discuss the available evidence about this topic. The data discussed in this document was reviewed by May 9, 2020. Recommendations and suggestions reflect the opinion of the panel and should be reviewed periodically as new evidence emerges.

Keywords:
Venous thromboembolism; Coronavirus disease 2019; Coagulopathy; Prevention; Treatment

	Standard dose	Body weight	Chronic kidney disease
Enoxaparin	40 mg SC daily	80-99 kg: 40-60 mg SC daily ≥100 kg: 80 mg SC daily Or adjustments based on BMI BMI 30-40 kg/m²: 40-60 mg daily BMI > 40 kg/m²: 40 mg SC 12-12 h BMI > 50 kg/m²: 60 mg SC 12-12 h	CrCl 15-29 mL/min: Give 50% of the dose CrCl < 15 mL/min: contraindication; consider UFH
Nadroparin	3800 UI SC daily	>70 kg: 5700 UI SC daily	CrCl 30-50 mL/min: Give 25% of the dose CrCl < 30 mL/min: contraindication; consider UFH
Dalteparin	5000 UI SC daily	100-139 kg: 7500 UI SC daily 140-180 kg: 5000 UI SC twice daily	CrCl = <30 mL/min: 5000 UI SC daily
Bemiparin	3500 UI SC daily	<60 kg: 2500 UI SC daily	CrCl = <30 mL/min: Give 25% of the dose
Tinzaparin	50 UI/kg/dia		CrCl < 20 mL/min: contraindication
Fondaparinux	2.5 mg SC daily		CrCl 20-29 mL/min: 2.5 mg every other day CrCl < 20 mL/min: contraindication; consider UFH
UFH	5000 UI SC twice daily	BMI > 30 kg/m²: 5000-7500 UI SC every 8 h	No change

	Therapeutic dose	Body weight	Chronic kidney disease
Enoxaparin	1 mg/kg SC twice daily		CrCl 15-29 mL/min: 1 mg/kg daily or UFH CrCl < 15 mL/min: avoid, consider UFH
Nadroparin	<50 kg: 3800 IU SC twice daily 50-59 kg: 4750 IU SC twice daily 60-69 kg: 5700 IU SC twice daily 70-79 kg: 6650 IU SC twice daily 80-89 kg: 7600 IU SC twice daily ≥90 kg: 8550 IU SC twice daily		CrCl 30-50 mL/min: Give 25% of the dose CrCl < 30 mL/min: contraindicated
Dalteparin	200 IU/kg SC daily in the first 30 days, then 150 IU/kg SC daily until end of treatment (maximum dose is 18,000 IU per day) Dose should be reduced by 17-33%, if platelet count < 100 × 10⁹/L		CrCl = <30 mL/min: Dose must be adjusted according to anti-FXa activity with a target of 0.5-1.5 UI/mL
Bemiparin	115 IU/kg SC daily		CrCl = <30 mL/min: contraindicated
Tinzaparin	175 IU/kg SC daily		CrCl < 20 mL/min: contraindicated
Fondaparinux	<50 kg: 5 mg SC daily 50-100 kg: 7.5 mg SC daily	>100 kg: 10 mg SC daily	CrCl < 30 mL/min: contraindicated
UFH	Loading dose: 80 IU/kg Maintenance dose: 18 IU/kg/h continuous infusion

location_on

Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH) R. Dr. Diogo de Faria, 775 cj 133, 04037-002, São Paulo / SP - Brasil - São Paulo - SP - Brazil
E-mail: htct@abhh.org.br

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[TFN1] Adapted from Nice Clinical Guidelines 92 - Venous thromboembolism. 2010 (https://www.acutemedicine.org.uk/wp-content/uploads/2015/12/NICE-Reducing-VTE-201015.pdf) and (*) from The ASH COVID Resources. 2020 (https://www.hematology.org/covid-19/covid-19-and-coagulopathy).

1. Active bleeding	6. Acute stroke
2. Acquired bleeding disorders	7. Thrombocytopenia < 25 × 10⁹/L (*)
3. Concurrent use of anticoagulants	8. Uncontrolled systolic hypertension
4. Lumbar puncture/epidural/spinal anesthesia expected within the next 12 h	9. Untreated inherited bleeding disorders
5. Lumbar puncture/epidural/spinal anesthesia within the previous 4 h