Prophylactic or Therapeutic Anticoagulation in Non–Critically Ill COVID-19 Patients?

Based on several large, randomized trials, multiple organizations have recommended therapeutic anticoagulation (i.e., heparin or low-molecular-weight heparin) for non–critically ill patients with COVID-19 who require oxygen and prophylactic-dose anticoagulation for critically ill patients (NEJM JW Gen Med May 1 2023 and JAMA Intern Med Mar 22; [e-pub]). In an international, open-label study conducted from 2020 to 2022, researchers randomized 3400 hospitalized, non–critically ill patients with COVID-19 (oxygen saturation, ≤94% on room air) to prophylactic-dose enoxaparin, therapeutic-dose enoxaparin, or therapeutic-dose apixaban. The therapeutic-dose enoxaparin and apixaban groups were combined due to their similar results and for analysis of outcomes.

The 30-day composite primary outcome (i.e., death, requirement for intensive care, systemic thromboembolism, or stroke) was not significantly different between the combined therapeutic-dose groups and the prophylactic-dose group (11% and 13%; P=0.1). All-cause mortality was significantly lower in the combined therapeutic groups than in the prophylactic group (4.9% vs. 7.0%; number needed to treat, 48). Fewer than 1% of patients experienced thrombosis, systemic embolism, or major bleeding.