From the Guidelines
Patients with COVID-19 and antiphospholipid antibody syndrome (APLA) who cannot stop coumadin should continue their warfarin therapy while receiving COVID-19 treatment, with close monitoring of INR levels and adjustment of warfarin doses as needed, based on the most recent expert panel report from the American College of Chest Physicians 1.
Key Considerations
- The management of these patients requires careful coordination of anticoagulation therapy with COVID-19 treatment to minimize the risk of thrombotic events and bleeding complications.
- For patients with APLA, therapeutic anticoagulation is already achieved with warfarin, which addresses both the hypercoagulable state of APLA and the thrombotic risk of COVID-19.
- The use of low-molecular-weight heparin (LMWH) or unfractionated heparin (UFH) may be considered in hospitalized patients with COVID-19 who are not in the ICU, but this should be individualized based on the patient's risk factors and clinical status 1.
Treatment Approach
- For mild COVID-19, symptomatic treatment with acetaminophen is preferred over NSAIDs to avoid additional bleeding risk.
- For moderate to severe disease requiring antiviral therapy, remdesivir is preferred due to its minimal interaction with warfarin, while nirmatrelvir/ritonavir (Paxlovid) should be avoided due to significant warfarin interactions.
- If the patient requires corticosteroids for severe COVID-19, dexamethasone 6mg daily for up to 10 days can be used with warfarin dose adjustments as needed based on INR monitoring.
Monitoring and Prevention
- Patients should have their INR levels monitored every 2-3 days initially, with adjustments to warfarin doses as needed to maintain therapeutic anticoagulation.
- Patients should maintain adequate hydration and mobility as tolerated to reduce thrombotic risk.
- The use of antiplatelet agents for VTE prevention is not recommended in critically ill or acutely ill hospitalized patients with COVID-19 1.
From the Research
COVID-19 Treatment in Patients with APLA Who Can't Stop Coumadin
- The treatment of COVID-19 in patients with antiphospholipid antibodies (APLA) who are taking coumadin is a complex issue, and there is limited research available on this specific topic 2, 3.
- Patients with APLA are at high risk of recurrent arterial or venous thromboembolism (VTE) despite warfarin administered to achieve an international normalized ratio (INR) of 2.0 to 3.0 3.
- The presence of APLA in COVID-19 patients does not seem to affect the outcomes of critically ill patients with COVID-19 in terms of all-cause mortality and thrombosis 4.
- Antiphospholipid antibody production in COVID-19 is common, with 50% of COVID-19 patients being positive for lupus anticoagulant in some studies, and with non-Sapporo criteria antiphospholipid antibodies being prevalent as well 5.
- The biological significance of antiphospholipid antibodies in COVID-19 is uncertain, as such antibodies are usually transient, and studies examining clinical outcomes in COVID-19 patients with and without antiphospholipid antibodies have yielded conflicting results 6, 5.
Management of APLA in COVID-19 Patients
- The management of APLA in COVID-19 patients is not well established, and more research is needed to determine the best course of treatment 2, 5.
- Clinicians may not screen critically ill patients with COVID-19 for APLA unless deemed clinically appropriate 4.
- Patients with APLA and COVID-19 may require individualized treatment plans, taking into account their specific clinical needs and risk factors 3, 6.
- The use of anticoagulant therapy, such as warfarin, may be necessary to prevent recurrent thrombosis in patients with APLA and COVID-19 3.