Antithrombosis in Patients with COVID-19 - Episode 3
Transcript: Gregory Piazza, MD, MS: There’s been a lot of buzz in the media, at least early on, about nonsteroidal anti-inflammatory drugs. Then they started to talk about anticoagulants and direct oral anticoagulants [DOACs]. There was a concern that being on a direct oral anticoagulant could increase the risk of having a complicated disease course of COVID-19 [coronavirus disease 2019] and that being on an anticoagulant alone made you a high-risk patient. What do you think about that, Vic?
Victor Tapson, MD, FCCP, FRCP: That’s a great point, Greg. I think this is 1 area where we need more data. There are a lot of areas where we’re starting to speculate and make decisions, and we just don’t have the data. We’ve learned there’s 1 area with DOAC where we need to be careful, and it’s not cancer patients. We have great data in patients with cancer in the SELECT-D study. We have the ADAM VTE study. We have the CARAVAGGIO study. For patients with antiphospholipid antibody syndrome, we need to be careful. When a patient is triple positive, as the TRAPS study and others have shown, we probably need to use warfarin. In every other situation, DOACs seem to be as good or better. I think we need more data. We need to be studying more aggressive anticoagulation.
Some are doing that already. Saskia Middeldorp tweeted that they’re performing ultrasounds on people every 4 or 5 days in the ICU. What’s the dilemma? You expose people more but get the data. We’re getting better at doing tests at Cedars-Sinai, exposing people minimally and getting appropriate tests done, but it’s still hard.
The bottom line to me, Greg—back to your question—is that we don’t have enough data. To me, we should get people on anticoagulation and learn, through some randomized trials that are done quickly, how aggressive we need to be with anticoagulation. Then we can decide—and Alex may want to talk about this—do we send these folks home on a DOAC? I’m comfortable thinking along those lines right now.
Gregory Piazza, MD, MS: I field this question probably 10 times a day from my patients who either have my email address or find me on the patient gateway. Am I at higher risk because I’m on a blood thinner? One of the issues I talk about with my patients is the fact that it really depends on the reason they’re on anticoagulation. If, for example—and this is a patient population you see a lot of, Vic—they have chronic thromboembolic pulmonary hypertension and they’re on anticoagulation, they’re at very high risk if they get COVID-19. We don’t want them to get that. But someone who’s had a calf DVT [deep vein thrombosis] may not be in that high-risk category. As you said, we need more data. I’m hearing things from both sides, actually. DOACs could be protective. DOACs could be harmful. As you said, we need data on that. Alex, what do you think? If you were to venture a guess, are DOACs helpful or harmful in this situation?
Alex Spyropoulos, MD, FACP, FCCP, FRCPC: My personal bias is that we’re mixing up cause and effect in some ways. As Vic suggested, the reason a patient is on an anticoagulant, especially chronically, is because they have underlying cardiovascular and thromboembolic disease. That in and of itself puts you at higher risk for complications, especially if you’re hospitalized from COVID-19—related processes. I think we’re mixing that up.
One thing that I wanted to at least mention to our audience is that if your patient is on antithrombotic therapy, they should remain on antithrombotic therapy. That is a very key message from a public health perspective, because very early on there was some talk about whether we should remove these patients from their underlying anticoagulant regimens. I agree with both you. We just need more data. My bias is that potentially, patients who are on treatment doses of anticoagulants may be protected from underlying hospital-acquired thromboembolic complications, but we just don’t know. We need those data.
Victor Tapson, MD, FCCP, FRCP: I would say that if I had a patient with a DVT or PE [pulmonary embolism], perhaps even provoked—and we know patients who have provoked DVT are more likely to have a recurrence when their anticoagulation is stopped than someone who never had a clot—or at low risk, I might be inclined to consider extending their anticoagulation even longer in the COVID-19 setting. If I got COVID-19 now, even though I’ve never had a thromboembolic problem, I might wish I was on a DOAC during the phases I was getting worse. Maybe I wouldn’t get the microvascular thrombosis. Of course, I’m speculating. But as Alex said, we need data. Don’t stop your blood thinner.
Gregory Piazza, MD, MS: Exactly. There was the same concern about statin medications for lipids. I’ve been getting those questions, though not as frequently as those regarding DOACs. “I read something that said statin medications could be bad or good for COVID-19. What should I do?” I think that the messaging from all the societies right now is to stay on what you’re supposed to be on, and stay the course. The last thing you want to do is stop something that’s preventing you from having a massive PE because you’re worried what it might do regarding COVID-19.
Transcript Edited for Clarity