TABLE 1

Cleveland Clinic approach to anticoagulation prophylaxis and management in COVID-19

Category 1
D-dimer < 3.0 μg/mL FEU Standard prophylaxis		Category 2
D-dimer ≥ 3.0 μg/mL FEU High-intensity prophylaxis		Category 3
Confirmed VTE Full anticoagulation
StandardEnoxaparin 40 mg subcutaneously every 24 hoursEnoxaparin 40 mg subcutaneously every 12 hoursIV heparin per DVT/PE nomogram or enoxaparin 1 mg/kg subcutaneously every 12 hours
Renal failureCrCl 10–30 mL/min:
Enoxaparin 30 mg subcutaneously every 24 hours
CrCl < 10 mL/min or AKIa:
Unfractionated heparin 5,000 U subcutaneously every 12 hours
CRRT:
Unfractionated heparin 500 U/hour through circuit
Circuit clotting:
IV heparin per ACS nomograma		CrCl < 30 mL/min or AKI:
Enoxaparin 40 mg subcutaneously every 24 hours
CrCl < 10 mL/min or AKIa:
Unfractionated heparin 7,500 U subcutaneously every 12 hours
CRRT:
Unfractionated heparin 500 U/hour through circuit
Circuit clotting:
IV heparin per ACS nomograma		IV heparin per DVT/VTE nomogram
Obesity
Standard> 100 kg:
Enoxaparin 40 mg subcutaneously every 12 hours
> 120 kg:
Enoxaparin 60 mg subcutaneously every 12 hours		> 100 kg:
Enoxaparin 60 mg subcutaneously every 12 hours
> 120 kg:
Enoxaparin 80 mg subcutaneously every 12 hours		IV heparin per DVT/PE nomogram
or
Enoxaparin 1 mg/kg subcutaneously every 12 hours, up to 150 mg
Above 150 kg use unfractionated heparin
Renal failure
CrCl < 30 mL/min or AKIb		≤ 120 kg: 7,500 U every 12 hours
> 120 kg: 10,000 U every 12 hours
CRRT:
500 U/h through circuit
Circuit clotting:
IV heparin per ACS nomograma		≤ 120 kg: 7,500 U every 8 hours
> 120 kg: 10,000 U every 8 hours
CRRT:
500 U/h through circuit
Circuit clotting:
IV heparin per ACS nomograma		IV heparin per DVT/PE nomogram

  • ↵a IV heparin ACS nomogram: initial dose 60-U/kg bolus, then 12 U/kg/hour; target aPTT 49–67 seconds; target heparin anti-Xa 0.2–0.5 units/mL.

  • ↵b AKI definition: doubling of creatinine in 48 hours or anuria.

  • ACS = acute coronary syndrome; AKI = acute kidney injury; aPTT = activated partial thromboplastin time; CrCl = creatinine clearance; CRRT = continuous renal replacement therapy; DVT = deep vein thrombosis; FEU = fibrinogen equivalent units; IV = intravenous; PE = pulmonary embolism; VTE = venous thromboembolism