Hematologists face two challenges in the COVID-19 pandemic. First, they continue to treat patients with chronic hematologic conditions, but now must do so with a focus on reducing infection risk while still providing quality care. Second, as clinical data are rapidly collected and distributed, benign hematologists are tasked with characterizing and guiding the management of the hematologic manifestations of the disease. The American Society of Hematology (ASH) has developed a series of recommendations to assist with both.
To address the special needs of hematology patients in the pandemic, ASH recommendations have been created to sensitize us to patient vulnerability or potential vulnerability to the infection and its complications (eg, sickle cell patients with existing lung disease, asplenic patients, immunosuppressed patients) and to provide treatment recommendations that avoid immune suppression or potential COVID-19 exposure within a healthcare facility when possible (eg, aplastic anemia, immune thrombocytopenia, and thrombotic thrombocytopenic purpura).
All recommendations are within standards of care, except for the suggestion—which carries with it the threat of financial toxicity—that one should consider frontline treatment of new-onset immune thrombocytopenia with a thrombopoietic drug, rather than corticosteroids or high-dose intravenous immune globulin. All recommendations are thoughtful and detailed, and we encourage you to review them at https://www.hematology.org/covid-19.
In characterizing the hematologic clinical manifestations of COVID-19, most attention, including attention in the news and on social media, has been on coagulopathy, thrombosis, and anticoagulation management. Recent publications describe a plethora of COVID-19–induced effects on coagulation.1,2 There are reports suggesting that COVID-19 infection is associated with intra-alveolar fibrin deposition, leading to lethal respiratory failure3; reports suggesting that anticoagulation or fibrinolytic therapy can improve clinical outcomes4,5; case series implying that large percentages of severely affected COVID-19 patients suffer clinically significant thromboses6,7; and one case series suggesting association between antiphospholipid antibodies and cerebral infarctions in COVID-19 patients.8
What to make of this? We consider these reports to be anecdotal. The above-linked ASH recommendations provide a framework to organize the confusing collection of reports about COVID-19–associated coagulopathy and how to use antithrombotic therapy in hospitalized COVID-19 patients. We agree with ASH recommendations that patients with COVID-19 who are hospitalized should receive routine pharmacological thromboprophylaxis; therapeutic anticoagulation or fibrinolytic therapy should only be used for a standard indication. Any therapeutic intervention outside the standards should be done with informed consent and as a clinical trial, as represented by two investigations being done outside the US (NCT04345848 and NCT04344756).
As the pandemic crests and recedes, many more reports will be forthcoming. We will try to keep you up to date and informed, filtering information through the sieves of scientific rigor and skepticism while looking forward to getting data that are reliable, validated, and useful. In the meantime, you yourself can examine the quality of data reported by using a filter provided by the NIH.