With input from Dr Monica Vasudev

1186: Direct oral anticoagulant use not tied to reduced risk of severe COVID-19

DG Alerts Excerpts:

Prognosis would not be altered by early outpatient DOAC initiation as per a study in Journal of Internal Medicine. 

Identified as a prominent feature of severe COVID-19, managing hypercoagulability in hospitalized patients has largely been focused, with interim guidelines supporting anticoagulation, suggest researchers led by Benjamin Flam, MD, Karolinska University Hospital, Stockholm, Sweden. Pre-emptive anticoagulation before or at the time of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection to protect against severe disease is theoretically appealing; however, there is a lack of real-world data. Only small studies of COVID-19 patient cohorts have been conducted which have shown mixed results.

A nationwide register-based cohort study was carried out in Sweden between February and May, 2020 to ascertain if the ongoing DOAC use was linked with reduced risk of hospital admission for COVID-19, or a composite of intensive care unit (ICU) admission or death due to COVID-19.

Within the cohort, 103,703 (mean age, 73.6 years) patients had non-valvular atrial fibrillation (AF) who were DOAC users, 90% of whom were using direct factor Xa inhibitors. The comparator groups included 36,875 (mean age, 66.4 years) patients with AF with no DOAC use and 355,699 (mean age, 69.3 years) patients with cardiovascular disease (CVD) with no DOAC use. 

In all, 360 hospital admissions for COVID-19 were reported among DOAC users (crude risk, 0.35%), compared to 95 among non-users with AF (0.26%) and 1,119 among non-users with CVD (0.31%).

A total of 161 composite ICU admission or death due to COVID-19 outcome events occurred among those using DOACs (crude risk, 0.16%), compared to 55 among non-users with AF (0.15%) and 473 among non-users with CVD (0.13%). 

DOAC use, in comparison with non-use, was found not to be associated with reduced risk of hospital admission for COVID-19. Both outcomes appeared to be similar for both DOAC subtypes (direct thrombin inhibitor and direct factor Xa inhibitors). 

The authors state that rather than directing against secondary hypercoagulability, therapies may be directed against thrombogenic inflammation or vasculopathy.

[Reference: https://onlinelibrary.wiley.com/doi/10.1111/joim.13205]

My Comments: We cannot interpolate the results as in COVID-19, it’s thrombo-inflammation and results have to be compared whether they were given early steroids or not to stop inflammation.

 Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA