Guidances & Recommendations

Schulman, S., Sholzberg, M., Spyropoulos, A.C., Zarychanski, R., Resnick, H.E., Bradbury, C., Broxmeyer, L., Connors, J.M., Falanga, A., Iba, T., Kaatz, S., Levy, J., Middeldorp, S., Minichiello, T.A., Ramacciotti, E., Samama, M., Thachil, J. and (2022), ISTH guidelines for antithrombotic treatment in COVID-19. J Thromb Haemost


ISTH had issued guidance documents early in the COVID-19 pandemic to propose antithrombotic strategies in these patients. Following 18 months of multiple randomized control trials testing different treatment regimens, evidence has grown substantially and ISTH has transitioned from the early guidance to a formal practice guideline on the actual proposed regimen of anticoagulation and interest for antiplatelet treatment in COVID-19 patients, be them hospitalized or not, critically ill or not. 


Spyropoulos, A.C., Connors, J.M., Douketis, J.D., Goldin, M., Hunt, B.J., Kotila, T.R., Lopes, R.D., Schulman, S. and (2022), Good practice statements for antithrombotic therapy in the management of COVID-19: Guidance from the SSC of the ISTH. J Thromb Haemost.


This good practice statements from the SSC of the ISTH complements the newly issued practical guidelines, commenting all pieces of evidence available for antithrombotic therapy in COVID-19 patients according to their health condition (patients previously under DOAC, obese individuals, patients with kidney disease…) and in transition period (for example treatment of an acute thrombosis while hospitalized, or transitioning towards discharge). 
Any situation not commented in the guidelines is likely to be discussed in this good practice statements document.


2021 Aug, Godon A, Tacquard CA, Mansour A, Garrigue D, Nguyen P, Lasne D, Testa S, Levy JH, Albaladejo P, Gruel Y, Susen S, Godier A; Gihp, the GFHT. Prevention of venous thromboembolism and haemostasis monitoring in patients with COVID-19: Updated proposals (April 2021): From the French working group on perioperative haemostasis (GIHP) and the French study group on thrombosis and haemostasis (GFHT), in collaboration with the French society of anaesthesia and intensive care (SFAR). Anaesth Crit Care Pain Med. 40(4):100919. doi: 10.1016/j.accpm.2021.100919.

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With the data of 1 year of extensive publication pace around COVID-19 to review, those French societies have updated their recommendation on VTE prevention and hemostasis monitoring of COVID-19 patients. Their proposal aims at standardizing the approach in anticoagulation management for COVID-19 patients and standardizing also the diagnostic practices, with the minimal test set to be performed.


2021 Oct 25.Greinacher A, Langer F, Makris M, Pai M, Pavord S, Tran H, Warkentin TE. Vaccine-induced immune thrombotic thrombocytopenia (VITT): Update on diagnosis and management considering different resources. J Thromb Haemost. doi: 10.1111/jth.15572.

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This Forum document provides an extensive update on current knowledge about VITT, from its early diagnosis tools to the possible ways of managing patients. As highlighted by author, increasing awareness about VITT has reduced by 90% its mortality. Platelet count fall, high DDi are useful indicators to define the likelihood of VITT before any specific diagnostic is undertaken.
Sep 13, 2020. Gerotziafas GT, Catalano M, Colgan MP et al. Guidance for the Management of Patients with Vascular Disease or Cardiovascular Risk Factors and COVID-19: Position Paper from VAS-European Independent Foundation in Angiology/Vascular Medicine. Thromb Haemost. doi: 10.1055/s-0040-1715798.

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The VAS-European Independent Foundation in Angiology/Vascular Medicine draws attention to patients with vascular disease and presents an integral strategy for the management of patients with vascular disease or cardiovascular risk factors (VD-CVR) and COVID-19.

Oct. 12, 2020. American Society of Hematology (ASH) guidelines on the use of anticoagulation in patients with COVID-19

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In June 2020, ASH formed a multidisciplinary, international panel to develop guidelines on the use of anticoagulants in patients with COVID-19. The panel prioritized questions about the use of anticoagulants in critically and acutely ill patients. On October 8, 2020, the panel agreed on the following recommendations described in this article. During October and November, these recommendations and a report on the guideline development process will undergo public review and ASH organizational review and approval, and will be submitted for publication in Blood Advances.

Oct. 12, 2020. Comparison of published guidelines for management of coagulopathy and thrombosis in critically ill patients with COVID 19: implications for clinical practice and future investigations

Source: Opens external link in current windowFlaczyk A, Rosovsky RP, Reed CT, Bankhead-Kendall BK, Bittner EA, Chang MG - Crit Care 2020; 24 :559

This paper compares existing guidelines issued by various learned societies on the management of coagulopathy and thrombosis in critically ill COVID-19 patients.

July 31, 2020. Venous thromboembolism in COVID-19: systematic review of reported risks and current guidelines.

Source: Fontana P, Casini A, Robert-Ebadi H, Glauser F, Righini M, Blondon M.
Opens external link in current windowSwiss Med Wkly. 2020 Jun 21;150:w20301. doi: 10.4414/smw.2020.20301. eCollection 2020 Jun 15.

This article consists in a systematic review of reported risk of venous thromboembolism associated with COVID-19 and a review of current guidelines on venous thromboembolism prophylaxis.

July 10, 2020. Prevention of thrombotic risk in hospitalized patients with COVID-19 and hemostasis monitoring.

Source: Susen S, Tacquard CA, Godon A, Mansour A, Garrigue D, Nguyen P, Godier A, Testa S, Levy JH, Albaladejo P, Gruel Y; GIHP and GFHT.
Opens external link in current windowVersion 2. Crit Care. 2020 Jun 19;24(1):364. doi: 10.1186/s13054-020-03000-7. PMID: 32560658

This paper includes joint GIHP-GFHT recommendations for prevention of thrombotic risk in patients with COVID-19 and haemostasis monitoring. Of note, this paper proposes an algorithm to determine the antithrombotique dose regimen according to patient’s status and ventilation procedure.

June 2, 2020. Scientific and Standardization Committee Communication: Clinical Guidance on the Diagnosis, Prevention and Treatment of Venous Thromboembolism in Hospitalized Patients with COVID-19

Source: Opens external link in current windowSpyropoulos AC, Levy JH, Ageno W et al.  J Thromb Haemost 2020 May 27. doi: 10.1111/jth.14929.

This guidance, developed by a multidisciplinary panel of experts in thrombosis and hemostasis, provides practical guidance for the management of VTE in hospitalized patients with suspected or confirmed COVID-19 infection. Objectives are to provide an approach to the diagnosis of VTE; address thromboprophylaxis strategies in ICU and non-ICU settings, including the duration of prophylaxis; and provide guidance on the treatment of VTE.

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-up

Source: Opens external link in current windowJournal of the American College of Cardiology April 2020. DOI: 10.1016/j.jacc.2020.04.031

The JACC Journals and the ACC worked to provide COVID-19 clinical guidance for global cardiovascular clinicians. Herein, authors have reviewed the current understanding of the pathogenesis, epidemiology, management and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, and of those with preexisting thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.
This publication is endorsed by the International Society on Thrombosis and Haemostasis (ISTH), the North American Thrombosis Forum (NATF), the European Society of Vascular Medicine (ESVM), and the International Union of Angiology (IUA). Supported by the ESC Working Group on the Pulmonary Circulation and Right Ventricular Function
A Commentary, recently published by SC Cannegieter and FA Klok in RPTH, address the clinical guidance and research priorities of JACC guidance.

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ISTH interim guidance on recognition and management of coagulopathy in COVID-19.

Source: Opens external link in current windowThachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, et al. J Thromb Haemost. 2020 Mar 25; doi: 10.1111/jth.14810

The ISTH interim guidance recommends measuring D-dimer, prothrombin time and platelet count in all patients suspected of COVID-19 infection, in order to stratify risk of developing coagulopathy and to help in management.
An algorithm based on simple coagulation tests is proposed, including measurement of fibrinogen which may help to assess disseminated intravascular coagulation (DIC) in these patients. Finally, low molecular weight heparin (LMWH) treatment may be used in some COVID-19 patients.

Additionally to the guidance, two letters from same panel of authors provide more information and highlight specific topics:

Opens external link in current windowType and dose of heparin in COVID-19. Thachil J, Tang N, Gando S et al. J Throm Haemost 2020.

Opens external link in current windowLaboratory haemostasis monitoring in COVID-19. Thachil J, Tang N, Gando S et al. J Throm Haemost 2020.

Chinese expert consensus on diagnosis and treatment of coagulation dysfunction in COVID-19

Source: Song JC, Wang G, Zhang W, et al. Opens external link in current windowMilitary Medical Research (2020) 7:19. DOI: 10.1186/s40779-020-00247-7

This consensus includes an overview of COVID-19-related coagulation dysfunction, tests for coagulation, anticoagulation therapy, replacement therapy, supportive therapy and prevention. The consensus produced 18 recommendations which are being used to guide clinical work.

Detailed recommendations for interactions with experimental COVID-19 therapies

Source: University of Liverpool. In the course of COVID-19 infection management, a large number of patients are receiving off-label and compassionate use therapies such as chloroquine, hydroxychloroquine, azithromycin, lopinavir-ritonavir, favipiravir, remdesivir, ribavirin, interferon beta. However, many of these experimental therapies may be subject to potential drug-drug interaction.
The University of Liverpool has provided detailed recommendation to prevent potential drug-drug interactions in patients receiving these experimental drugs.
A section dedicated to anticoagulant, antiplatelet and fibrinolytic therapies highlights caution about DOACs, VKAs and anti-PY12 agents. Of note, dose adjustments were suggested for patients receiving DOACs.

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Practical guidance for the prevention of thrombosis and management of coagulopathy and disseminated intravascular coagulation of patients infected with COVID-19.

Source: Opens external link in current windowHunt B, Retter A, McClintock Cl. Thromb UK [Internet]. 2020 Mar [cited 2020 Apr 4];

This guidance from Thrombosis UK, authored by internationally recognized experts, helps with information to manage thrombotic risk, coagulopathy, and DIC in patients with COVID-19. This is a living guidance document that will be updated weekly.

The DIC score is of prognostic value in COVID-19 pneumonia.

Source:Opens external link in current window BSH Haemostasis and Thrombosis Task Force. 2020 Mar 18 [cited 2020 Apr 4];

The British Society on Haematology published guidance established using data published by haematologists from Wuhan, China. This document indicates abnormal coagulation parameters can be a useful predictor of prognosis in pneumonia due to COVID-19.




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