Thanks LeftYahoo, an important retrospective study of anti-coagulation in COVID-19:
This study supports reduction in in-hospital mortality and intubation rates by either therapeutic anti-coagulation (full-dose) or prophylactic (lower dose) anti-coagulation in patients admitted to hospital with COVID-19, who had not been intubated (the severity of COVID-19 was not formally described in the methods but would have been in the protocol). Patients had to have been admitted for at least 24 hours and as intubation was an endpoint of the study, could not have been intubated.
BTW this means that they were not the RemL population ie were not as sick.
I have a few concerns about the way the data is presented but most of those are probably due to the retrospective nature.
They can’t present the actual numbers at one time point that makes sense eg 30d mortality as the read-out doesn’t make sense, If you read the numbers as presented you will see what I mean.
They present cumulative incidence of mortality rather than a Kaplan Meier probability curve, but maybe that is ok. No numbers down the bottom are presented so you don’t know what the numbers left by the plateau at 20-30d are... on the X axis, and the Y axis only goes to 50% (poor form). Interesting to see the plateau in recovery at that time point in this good prognosis group.
But you can drive a truck through the relevant curves so that is good and there is no doubt from their HR and CI that their data is tight and they have a 20% absolute difference (20% to 40%) reduction in mortality as read off their curve at 30 days of follow up. We would be pleased with that.
Patients on full AC were older, more comorbidities, higher inflammatory markers, higher d-dimer levels AND despite all that did the best. Very impressive.
As for the bleeding risk, very low and although double in the full anticoagulation, still very low at 3% (actually 1.9% in no AC). Very impressive.
They published an autopsy series of 26 cases, with 42% showing clots of some sort; 4/5 full AC were on it previously for clotting risk so not necessarily occurring due to Covid infection. Of the 14 on prophylactic AC for the trial, 6 had clots so perhaps prophylactic lower dose didn’t prevent the clots as well, similar rate as in the no AC????
What does this all mean?
In this hospitalised pre-intubation population, anti-coagulation should be used (and prophylactic will be, for sure) and randomised controlled trials should be available to compare full dose vs prophylactic maybe vs no AC (interesting for the ethics groups to consider the no AC option). Most patients in hospital get prophylactic AC so can’t not give it.
For RemL?
Given the recent report of the successful treatment of the child with MIS-C, it is likely that RemL can easily supplant AC in the intubated population (will be given in addition to proph AC in the end I am sure) but avoiding the need for full AC in all but special cases where there is a specific need for full AC for other reasons. Might have trouble stopping full AC because of this paper in the first instance. No problem.
eventually I think that RemL will move into the pre-intubation population (once the intubated indication is secure), if it is clear that particularly young people in this population are suffering long term sequelae of micro clots and lung and heart damage that make RemL the cheaper option.
IMO DYOR
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