Venous thromboembolism prophylaxis of a patient with MYH-9 related disease and COVID-19 infection: A case report

Table 1 Summary of anticoagulation strategy in major clinical trials on coronavirus disease 2019 thromboprophylaxis

Trial	Anticoagulant	Therapeutic dose arm	Prophylactic dose arm
mpRCT (REMAP-CAP, ACTIV-4a, and ATTAC)[17]	Enoxaparin, dalteparin, tinzaparin, UFH	BMI < 40 and CrCl ≥ 30 mL/min: enoxaparin 1 mg/kg SC BID minus 10% or 1.5 mg/kg SC QD minus 10%; Dalteparin 200 units/kg SC QD minus 10% or 100 units/kg SC BID minus 10%; Tinzaparin 175 U/kg SC QD minus 10%; UFH per hospital protocol	BMI < 40 and CrCl ≥ 30 mL/min: enoxaparin 40 mg SQ QD; Dalteparin 5000 units SC QD; Tinzaparin 4500 units SC Q24H; UFH 5000 units SC Q8H-12H
			BMI ≥ 40 and CrCl ≥ 30 mL/min: enoxaparin 40 mg SC BID; Dalteparin 7500 units SC QD; Tinzaparin 8000 units SC QD; UFH 7500 units BID
		BMI ≥ 40 and CrCl ≥ 30 mL/min: enoxaparin 0.8 mg/kg SC BID minus 10%	BMI < 40 and CrCl < 30 mL/min: enoxaparin 30 mg SQ QD
INSPIRATION[18]	Enoxaparin, UFH	CrCl ≥ 30 mL/min: enoxaparin 1 mg/kg SC QD	CrCl ≥ 30 mL/min: enoxaparin 40 mg SC QD
		Obesity1 and CrCl ≥ 30 mL/min: enoxaparin 0.6 mg/kg SC BID
			Obesity1 and CrCl ≥ 30 mL/min: enoxaparin 40 mg SC BID
		15 < CrCl < 30 mL/min: enoxaparin 0.5 mg/kg SC QD
			15 < CrCl < 30 mL/min: enoxaparin 40mg SC QD
		CrCl ≤ 15 mL/min: UFH 10000 units SC BID
			CrCl ≤ 15 mL/min: UFH 5000 units SC BID
HEP-COVID[21]	Enoxaparin, UFH	CrCl ≥ 30 mL/min: enoxaparin 1 mg/kg SC BID	BMI < 30 and CrCl > 15 mL/min: enoxaparin 40 mg SC QD
		15 < CrCl < 30 mL/min: Enoxaparin 0.5 mg/kg SC BID
			BMI > 30 and CrCl ≥ 30 mL/min: enoxaparin 40 mg SC BID
			BMI < 30 and CrCl < 15 mL/min: UFH 5000 U SC BID or TID
			BMI > 30 and CrCl < 15 mL/min
			UFH 7500 SC BID or TID
ACTION[19]	Rivaroxaban, enoxaparin, UFH	Oral route (preferred) CrCl ≥ 30 mL/min: rivaroxaban 20 mg PO QD	BMI < 40 and CrCl ≥ 30 mL/min: enoxaparin 40 mg SC QD; Fondaparinux 2.5 mg SC QD; UFH 5000U SC Q8H or Q12H
		30 < CrCl < 49 mL/min: rivaroxaban 20 mg PO QD
		Parenteral route 1: age < 75 enoxaparin 1 mg/kg SC Q12H, age ≥ 75 enoxaparin 0.75 mg/kg SC Q12H	BMI ≥ 40 and CrCl ≥ 30 mL/min: enoxaparin 60 mg SC QD or 40 mg SC Q12H; UFH 7500U SC Q8H or Q12H
			BMI < 40 and CrCl < 30 mL/min: UFH 5000 U SC Q8H or Q12H
			BMI ≥ 40 and CrCl < 30 mL/min: UFH 7500 U SC BID or TID
		Parenteral route 2 (preferred option in DIC): UFH IV to achieve to achieve a 0·3-0·7 IU/mL anti-Xa concentration
RAPID[20]	Enoxaparin, dalteparin, tinzaparin, UFH	BMI < 40 and CrCl ≥ 30 mL/min: enoxaparin 1 mg/kg SC Q12H or 1.5 mg/kg SC QD; Dalteparin 200 units/kg SC Q24H or 100 units/kg SC Q12H; Tinzaparin 175 U/kg SC Q24H; UFH2	BMI < 40 and CrCl ≥ 30 mL/min: enoxaparin 40 mg SC Q24H; Dalteparin 5000 units SC Q24H; Tinzaparin 4500 units SC Q24H; Fondaparinux 2.5 mg SC Q24H; UFH 5000 units SC Q8-12H
		BMI ≥ 40 and CrCl ≥ 30 mL/min: enoxaparin 1mg/kg SC Q12H; Dalteparin 100 units/kg SC Q12H; Tinzaparin 175 units/kg SC Q24H; UFH2	BMI ≥ 40 and CrCl ≥ 30 mL/min: enoxaparin 40 mg SC Q12H; Dalteparin 5000 units SC Q12H; Tinzaparin 9000 units SC Q24H; UFH 7500 units SC Q8H
		BMI < 40 and CrCl < 30 mL/min: UFH2 or LMWH per hospital protocol	BMI < 40 and CrCl < 30 mL/min: UFH 5000 units SC Q8-12H or LMWH per hospital protocol
		BMI ≥ 40 and CrCl < 30 mL/min: UFH2 or LMWH per hospital protocol
			BMI ≥ 40 and CrCl < 30 mL/min: UFH 7500 units SC Q8H or LMWH per hospital protocol

¹Weight ≥ 120 kg or body mass index ≥ 35 kg/m².

²Unfractionated heparin intravenous bolus with continuous infusion to titrate to institution specific anti-Xa or activated partial thromboplastin time values.

BID: Two times a day; BMI: Body mass index; CrCl: Creatinine clearance; DIC: Disseminated intravascular coagulation; IV: Intravenous; LMWH: Low molecular weight heparin; PO: By mouth; Q12H: Every 12 h; Q24H: Every 24 h; Q8H: Every 8 h; Q8-12H: Every 8-12 h; QD: Daily; SC: Subcutaneous; TID: Three times a day; UFH: Unfractionated heparin.

Table 2 Summary of exclusion criteria regarding thrombocytopenia and bleeding risk in major clinical trials on coronavirus disease 2019 thromboprophylaxis

Trial	Anticoagulant	Thrombocytopenia	Bleeding risk
mpRCT (REMAP-CAP, ACTIV-4a, and ATTAC)[17]	Enoxaparin, Dalteparin, Tinzaparin, UFH	Platelet count < 50 × 109/L	ATTAC: DAPT therapy, intracranial surgery or stroke within 3 mo, history of intracerebral AVM, brain aneurysm of CNS mass lesion, intracranial malignancy, history of intracranial bleeding, history of bleeding disorder, GI bleed within 3 mo, thrombolysis within 7 d, current epidural/spinal catheter, major surgery within 14 d, uncontrolled hypertension or other physician perceived contraindications to anticoagulation
			ACTIV-4a: bleed within last 30 d
			REMAP-CAP: clinical and/or laboratory bleeding risk to contraindicate anticoagulation
INSPIRATION[18]	Enoxaparin, UFH	Platelet count < 50 × 109/L	Major bleeding within 30 d, major surgery or ischemic stroke within 2 wk, head trauma within 30 d, neurosurgery within 3 mo, intracranial malignancy or AVM
HEP-COVID[21]	Enoxaparin, UFH	Platelet count < 25 × 109/L	Recent bleed within 1 mo, active GI or intracranial malignancy, DAPT therapy, IMPROVE bleed score of ≥ 7
ACTION[19]	Rivaroxaban, enoxaparin, UFH	Platelet count < 50 × 109/L	Use of ASA (> 100 mg) or P2Y12 inhibitor, chronic NSAIDS use, active bleeding, liver failure, blood dyscrasia, prohibitive hemorrhage risk, history of intracranial bleed, DIC, active cancer
RAPID[20]	Enoxaparin, dalteparin, tinzaparin, UFH	Platelet count < 50 × 109/L within 72 h	History of an inherited or active acquired bleeding disorder, bleeding within 30 d requiring hospital presentation, DAPT therapy, Hgb < 80 g/L

ASA: Aspirin; AVM: Arteriovenous malformation; CNS: Central nervous system; DAPT: Dual antiplatelet therapy; DIC: Disseminated intravascular coagulation; GI: Gastrointestinal; Hgb: Hemoglobin; IMPROVE: International Medical Prevention Registry on Venous Thromboembolism; NSAIDS: Nonsteroidal anti-inflammatory drugs; UFH: Unfractionated heparin.