Addressing the Challenges of Anticoagulation Amidst the Pandemic

Thrombosis is among the many issues that have come to the forefront during the COVID pandemic. AMDA and its Clinical Issues Subcommittee addressed it quickly through its guidance, Anticoagulation of Patients with COVID 19 in PALTC. “We were getting questions and comments about it on the AMDA Forum, and we wanted to provide a useful overview of what is known and not known so that people could take this information and apply it quickly,” said Victoria Walker, MD, CMD, the subcommittee chair, on a recent AMDA On-The-Go podcast. She further observed, “It was an all-hands-on-deck situation. Our committee was happy to do this.”

The guidance states, “One the one hand, recognized risk factors for thrombosis include advanced age, history of cardiovascular disease, malignancy, and immobility. On the other hand, the PALTC population is very vulnerable to polypharmacy adverse events, and these are exacerbated by the addition of drugs that are being used to treat COVID-19 and anticoagulant/antiplatelet therapy. The risks are also exacerbated by immobility, now that patients in most facilities are isolated to their rooms and are unable to ambulate to the dining room, activities, outside, or within the facility.” Additionally, the guidance identified distinctions between the PALTC setting and the hospital that must be considered, and it offered a sample facility policy on anticoagulation for PALTC residents who have COVID-19.

In the podcast, Dr. Walker observed, “The population we serve is disproportionately impacted by this issue.” Whether these people remain on-site for treatment or go to the hospital and come back, or go to facilities from the hospital for rehab, she said, “The issue of what to do with anticoagulation and how long to continue it comes up in all of these settings. We can’t avoid being part of this discussion.”

Dr. Walker said, “In this guidance we list some evidence-based tools for risk assessment for thromboembolism. Using those tools, in addition to using some baseline prognostication tools, can really help put things in perspective for residents and family members when making a decision about what is best for a particular individual.”

Communication is key, and Dr. Walker noted, “The first step is always to sit down and say where we are at and what the options are. Once we talk about known risks, we then can talk about possible interventions based on the individual’s underlying health conditions as well as the impact on staff. ” At this point, she noted, “We can make a decision about which medication will be most appropriate.”

In addition to medications, Dr. Walker said it is important not to forget about “other general prophylaxis things we should and can do to prevent or reduce the risk of clotting.” She added that the consultant pharmacist can help identify potential drug-drug interactions and opportunities for dose modification. Then, she noted, “We need to talk to staff, the resident, and the family about potential side effects we might anticipate and what they might look like.”

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