Letters to the Editor

In Reply: COVID-19 coagulopathy

Simon R. Mucha, MD, Siddharth Dugar, MD, Keith McCrae, MD, Douglas Joseph, DO, John Bartholomew, MD, Gretchen L. Sacha, PharmD, RPh, BCCCP and Michael Militello, PharmD, RPh, BCPS
Cleveland Clinic Journal of Medicine December 2020, 87 (12) 712; DOI: https://doi.org/10.3949/cjm.87c.12002

We would like to thank Dr. Katyal for his interest in our article.1 The comments highlight the ongoing uncertainties and urgent need for better data from prospective randomized controlled trials, such as those being developed under the National Heart, Lung, and Blood Institute’s “Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV)” program, to guide optimal management of COVID-19-associated coagulopathy.

As Dr. Katyal correctly points out, the current guidelines from the American College of Chest Physicians recommend standard venous thromboembolism prophylaxis.2 In contrast, an expert panel of the American College of Cardiology failed to reach consensus on their recommendation for standard vs intensified prophylaxis or empiric therapeutic-dose anticoagulation,3 while the authors of the interim guidance from the Anticoagulation Forum recommend high-intensity prophylactic dosing for all critically ill patients.4

Our approach represents an attempt to balance the potential risks and benefits of intensified prophylaxis by selecting patients at greatest risk of thrombosis for intensified prophylaxis, while we await the results of prospective randomized controlled trials. We are encouraged, however, by recent reports of low overall bleeding risk even with empiric therapeutic anticoagulation.5

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