Should a clinically improved COVID‑19 patient discharged to a skilled‑nursing facility after surgery and dexamethasone therapy, with markedly elevated platelet count, receive enoxaparin (Lovenox) thromboprophylaxis?

Enoxaparin Thromboprophylaxis After COVID-19 Recovery in SNF Setting

For a clinically improved COVID-19 patient discharged to a skilled nursing facility, routine extended thromboprophylaxis with enoxaparin is not recommended unless specific high-risk features are present. 1

Primary Recommendation

The most recent and highest-quality evidence—the 2025 American Society of Hematology guidelines and 2022 CHEST guidelines—suggest against routine post-discharge anticoagulant thromboprophylaxis for COVID-19 patients who have clinically improved and do not have suspected VTE or another indication for anticoagulation. 1 This recommendation is based on very low certainty evidence showing little to no difference in mortality, PE, DVT, or major bleeding with extended prophylaxis. 1

Risk Stratification Algorithm

Assess the following high-risk features to determine if extended prophylaxis is warranted: 1

High VTE Risk Factors Favoring Extended Prophylaxis:

• Advanced age (particularly ≥70 years) 1
• Recent ICU stay during hospitalization 1
• Active cancer 1
• Prior history of VTE 1
• Known thrombophilia 1
• Severe immobility or inability to ambulate 1
• Elevated D-dimer >2 times upper limit of normal at discharge 1
• IMPROVE VTE score ≥4 1
• Recent major surgery (particularly abdominal/pelvic) 2

Bleeding Risk Assessment (Contraindications):

• Severe thrombocytopenia (particularly with markedly elevated platelet count, assess for qualitative platelet dysfunction) 2
• Active bleeding 2
• Recent neurosurgery or intracranial bleeding 3
• Severe renal impairment (CrCl <30 mL/min) requires dose adjustment 2

Specific Considerations for This Patient

The markedly elevated platelet count warrants careful evaluation: While thrombocytosis can paradoxically increase thrombotic risk, it may also indicate reactive thrombocytosis from inflammation or post-surgical state. 2 Check baseline coagulation parameters (PT/PTT) and assess for qualitative platelet dysfunction before initiating anticoagulation. 3

Dexamethasone therapy does not contraindicate enoxaparin use. Recent evidence shows dexamethasone does not significantly affect DOAC levels in COVID-19 patients, and no specific interaction with enoxaparin is documented. 4

Post-surgical status is a critical consideration. If this patient had recent major surgery (particularly abdominal/pelvic cancer surgery), extended prophylaxis for up to 4 weeks is strongly recommended regardless of COVID-19 status. 2

Dosing Recommendations If Prophylaxis Is Indicated

Standard prophylactic dose: 40 mg subcutaneously once daily 2

Duration if extended prophylaxis is chosen: 14-30 days post-discharge 1

Dose adjustments:

• Severe renal impairment (CrCl <30 mL/min): Reduce to 30 mg once daily 2
• Obesity (BMI >30 kg/m²): Consider 40 mg every 12 hours or 0.5 mg/kg every 12 hours 2

Evidence Reconciliation

The guidelines present a nuanced position: While the 2022 CHEST and 2025 ASH guidelines recommend against routine extended prophylaxis 1, the 2020 International Society on Thrombosis and Haemostasis guidance suggests extended prophylaxis may be reasonable for selected high-risk patients. 1 The most recent high-quality evidence (2025 ASH) takes precedence, emphasizing individualized risk assessment rather than routine prophylaxis. 1

Key trial data: The MICHELLE and ETHIC trials showed no significant benefit of extended prophylaxis in unselected COVID-19 patients, with very low certainty evidence. 1 However, these trials did not specifically address high-risk subgroups with multiple VTE risk factors. 1

Common Pitfalls

• Do not automatically prescribe extended prophylaxis based solely on COVID-19 diagnosis—clinical improvement and absence of high-risk features argue against routine use. 1
• Do not overlook surgical indications—if recent major cancer surgery occurred, extended prophylaxis is indicated regardless of COVID-19 status. 2
• Do not ignore renal function—failure to adjust dose in severe renal impairment increases bleeding risk 2-3 fold. 2
• Do not assume elevated platelets contraindicate anticoagulation—assess for qualitative dysfunction and bleeding risk, but thrombocytosis alone is not a contraindication. 2, 3