Can a patient with Covid-19 be on high dose aspirin (acetylsalicylic acid) and heparin?

Anticoagulation and Antiplatelet Therapy in COVID-19 Patients

For patients with COVID-19, the combination of high-dose aspirin and heparin is generally not recommended due to increased bleeding risk, except in specific clinical scenarios where the thrombotic risk clearly outweighs bleeding concerns. 1

Anticoagulation Recommendations in COVID-19

Hospitalized Non-ICU Patients

• Standard prophylactic-dose anticoagulation with LMWH (preferred) or UFH is recommended for all hospitalized COVID-19 patients without contraindications 1
• For patients with pre-existing indications for antiplatelet therapy (e.g., prior ACS):
  • Continue antiplatelet therapy alongside prophylactic-dose anticoagulation 1
  • If therapeutic anticoagulation is required, individualized decisions regarding continuation of antiplatelet therapy should be made based on bleeding risk 1

Critically Ill COVID-19 Patients

• Prophylactic-dose anticoagulation with LMWH is recommended (preferred over UFH to limit staff exposure) 1
• Antiplatelet agents alone are NOT recommended for VTE prevention in COVID-19 patients 1
• For patients already on antiplatelet therapy for prior stroke or ACS:
  • Continue antiplatelet therapy and add prophylactic-dose LMWH 1
  • Avoid combination of therapeutic-dose anticoagulation with antiplatelet therapy unless there is a compelling indication 1

Special Clinical Scenarios

Acute Coronary Syndrome with COVID-19

• Dual antiplatelet therapy (DAPT) is strongly recommended 1
• If prophylactic anticoagulation is also indicated, DAPT can be continued 1
• If therapeutic anticoagulation is required, individualized decisions regarding DAPT continuation should be made based on bleeding risk assessment 1

Prior Stroke with COVID-19

• Continue antiplatelet therapy and add prophylactic-dose LMWH 1
• For carefully selected patients with favorable thrombotic/bleeding risk profiles, therapeutic anticoagulation may be considered alongside antiplatelet therapy 1

Monitoring Recommendations

• Monitor D-dimer levels every 24-48 hours in critically ill patients during the first 7-10 days 1
• For patients on UFH, monitor using anti-Xa assay rather than aPTT due to potential interference from inflammatory state 1
• Regular platelet count monitoring (once or twice weekly) to detect heparin-induced thrombocytopenia 1

Important Considerations and Cautions

• Drug Interactions: Aspirin and other platelet inhibitors may increase bleeding risk when combined with heparin 2
• Heparin Resistance: COVID-19 patients often demonstrate heparin resistance due to high fibrinogen and factor VIII levels 1
• Bleeding Risk: The combination of therapeutic anticoagulation and antiplatelet therapy increases bleeding risk, with major bleeding occurring in 1.9% of patients on therapeutic anticoagulation alone 3
• Efficacy: While intermediate-dose anticoagulation and aspirin have each been associated with lower in-hospital mortality in some observational studies 4, randomized trials have shown mixed results depending on illness severity 3, 5

Evidence-Based Algorithm for Decision Making

1. Assess baseline thrombotic risk:

   • Prior indication for antiplatelet therapy? (ACS, stroke, etc.)
   • D-dimer levels (≥3000 ng/mL indicates higher risk) 6
   • ICU vs. non-ICU setting

2. Determine appropriate anticoagulation strategy:

   • All hospitalized patients: At minimum, prophylactic anticoagulation
   • Non-critically ill: Consider therapeutic anticoagulation if high D-dimer 3
   • Critically ill: Prophylactic anticoagulation (therapeutic dose showed no benefit) 5

3. Evaluate need for antiplatelet therapy:

   • Continue if pre-existing indication
   • Do not initiate for VTE prevention alone 1

4. Assess bleeding risk before combining therapies:

   • High-dose aspirin plus therapeutic heparin generally avoided unless specific indication
   • Monitor for bleeding complications if combination therapy is necessary

The most recent evidence suggests that while both anticoagulation and antiplatelet therapy have roles in managing COVID-19 patients, their combination at high doses should be approached with caution and limited to specific clinical scenarios where the thrombotic risk clearly outweighs bleeding concerns.