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 | |
|---|---|---|---|
| Standard | Enoxaparin 40 mg subcutaneously every 24 hours | Enoxaparin 40 mg subcutaneously every 12 hours | IV heparin per DVT/PE nomogram or enoxaparin 1 mg/kg subcutaneously every 12 hours |
| Renal failure | CrCl 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