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Disclosures: Cuker reports no relevant financial disclosures.
June 29, 2020
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ASH to develop 'living guidelines' for anticoagulant use among patients with COVID-19

Source/Disclosures
Disclosures: Cuker reports no relevant financial disclosures.
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Abnormalities in blood clotting have been linked to increased mortality risk among patients with COVID-19.

Anticoagulation has been considered a promising approach to preventing and treating COVID-19-associated coagulopathy.

To outline the role of anticoagulation for patients with COVID-19, ASH has convened a multidisciplinary panel that will develop guidelines for clinicians.

“These are what we call living guidelines, which means they will be updated as needed based on the availability of new evidence,” Adam Cuker, MD, MS, director of the comprehensive and hemophilia thrombosis program at University of Pennsylvania and an author of ASH’s FAQ on COVID-19 and venous thromboembolism/anticoagulation, said in an interview with Healio. “At the same time, while we’re trying to work quickly and keep things updated, we are not willing to cut corners on the rigorous methodology that we follow.”

Adam Cuker, MD, MS
Adam Cuker 

Cuker spoke with Healio about the goals of the upcoming guidelines, the professionals and volunteers who will comprise the panel, and the mobilization of the medical field in response to the COVID-19 pandemic.

Question: What necessitated guidelines for the use of anticoagulation among patients with COVID-19?

Answer: We’ve been seeing very high rates of thrombosis, especially among patients with COVID-19 in the ICU, that are not being prevented by standard prophylactic intensity anticoagulation. Our natural response to is to increase the dosage of anticoagulation. However, the major risk of anticoagulation is bleeding, which can be serious and even fatal. So, we desperately need evidence and clinical guidance on whether increasing the anticoagulation dose is effective in this population, and at what cost in terms of bleeding risk.

Q: What patient populations will your guidelines address?

A: We’re going to focus on the best approaches to preventing blood clots in critically ill patients with COVID-19 hospitalized in the ICU, those admitted to the general medical ward, patients with COVID-19 after they have been discharged from the hospital, and finally, non-hospitalized patients with COVID-19. For these four populations, our question will be, “Should we be treating these patients with something to prevent blood clots and, if so, what and at what dose?”

Q: How will the guideline panel be created and who will serve on it?

A: It will be multidisciplinary. In addition to adult and pediatric hematologists, we aim to include critical care specialists, hospitalists, infectious disease specialists, possibly a nephrologist and a cardiologist/vascular medicine specialist, and a pharmacist who specializes in anticoagulation. We also plan to have several patient representatives on the panel.

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Q: How will the panel conduct its evidence review and determine the recommendations?

A: Once the panel is assembled, we will prioritize the key questions that we’d like to address. After those questions have been addressed, an evidence review team will conduct a systematic review of published and pre-published literature. The evidence will be assembled and presented to the panel, which will use the GRADE framework to assess the evidence. Based on this, the panel will make recommendations.

Q: COVID-19 has prompted societies in several medical specialties to formulate guidelines very quickly. Is this an unusual way of forming guidelines?

A: Absolutely. In my career, I’ve never seen anything like this. We started out with no evidence. I heard that now, the number of COVID-19-related papers is doubling every 20 days. If we continued at this pace, there would be something like 20 million COVID-19 papers by the end of the calendar year. This trend in data will be flattened, but it is a testament to how quickly the medical community and research community have mobilized around this crisis.

For more information:

Adam Cuker, MD, MS, can be reached at Hospital of the University of Pennsylvania, 3 Dulles, 3400 Spruce St., Philadelphia, PA 19104; email: adam.cuker@pennmedicine.upenn.edu.