This prospective, randomized, open-label, multi-center interventional study is designed to compare the safety and efficacy of two LMWH dosing protocols in patients admitted to the University of Iowa Hospitals with COVID-19 who meet the modified ISTH Overt DIC criteria score ≥3. Patients will be randomized to standard prophylactic dose LMWH (standard of care arm) or intermediate-dose LMWH (intervention arm).

Potentially eligible patients will be identified by a healthcare professional per institutional policy on privacy. The healthcare professional will assess the eligibility of the patient by performing a chart review which will include laboratory results and weight as measured on admission to the hospital. After obtaining verbal consent from the patient to be contacted for the study, a member of the research staff will approach the patient to be part of the study. The research staff will obtain informed consent from the patient/LAR before collecting any data and performing any procedures.

5.2 Trial interventions

As standard of care, hospitalized patients with confirmed COVID-19 will be monitored for coagulopathy. Daily blood tests for platelet count, prothrombin time, D-Dimer, and fibrinogen and weekly thromboelastography will be obtained, and a daily Modified ISTH Overt DIC score will be calculated (Exhibit 1). Only patients meeting all inclusion and exclusion criteria will be asked to participate in the trial. Patients will be randomized to one of two arms:

1. Patients randomized to the standard of care arm will receive standard prophylactic dose enoxaparin (40 mg subcutaneously daily if BMI <30 kg/m2; 30 mg subcutaneously twice daily or 40 mg subcutaneously twice daily if BMI ≥ 30 kg/m2).
2. Patients randomized to the intervention arm will receive intermediate-dose enoxaparin (1 mg/kg Subcutaneously daily if BMI <30 kg/m2 or 0.5 mg/kg Subcutaneously twice daily if BMI ≥ 30 kg/m2), with doses rounded up to the nearest dose syringe in hospitalized patients with laboratory confirmed SARS CoV-2 infection.

5.3 Dose Modifications

1. Enoxaparin will be held if platelets decrease to <25,000/mm3. Enoxaparin will resume once platelets increase to ≥25,000/ mm3.
2. Enoxaparin will be held if fibrinogen is <50 mg/dL. Enoxaparin will resume once fibrinogen increases to ≥50 mg/dL.
3. Enoxaparin will be held if estimated Creatinine clearance < 15 ml/min calculated by the modified Cockcroft and Gault formula and resumed once the Creatinine Clearance is ≥15 ml/min.
4. Enoxaparin will be held if there is a clinical suspicion for heparin induced thrombocytopenia.
5. Enoxaparin dose will be reduced by 25% if Creatinine Clearance ≥15 and <30 ml/min calculated by the modified Cockcroft and Gault formula and increased once the estimated Creatinine Clearance is ≥30 ml/min in both the arms.

All participating patients will continue the assigned doses of enoxaparin until hospital discharge or until a clinical event occurs requiring either discontinuation of anticoagulation therapy or full therapeutic dose anticoagulation therapy.

Inclusion Criteria:

• Laboratory confirmed SARS-CoV-2 infection
• Age ≥18 years
• Requires hospital admission for further clinical management
• Modified ISTH Overt DIC score ≥ 3

Exclusion Criteria:

• Indication for full therapeutic-dose anticoagulation
• Acute venous thromboembolism (deep vein thrombosis or pulmonary embolism) within prior 3 months
• Acute cardiovascular event within prior 3 months
• Acute stroke (ischemic or hemorrhagic) within prior 3 months
• Active major bleeding
• Severe thrombocytopenia (<25,000/mm3)
• Increased risk of bleeding, as assessed by the investigator
• Acute or chronic renal insufficiency with Creatinine Clearance < 30 ml/min calculated by the modified Cockcroft and Gault formula
• Weight < 40 kg
• Known allergies to ingredients contained in enoxaparin, allergy to heparin products or history of heparin induced thrombocytopenia

No individual participant data will be shared

From 88 starting in Standard of Care group, 2 withdrew prior to treatment leaving 86 remaining. From 88 starting in Interventional group, 1 withdrew prior to treatment leaving 87 remaining.

30 Days

From 88 starting in Standard of Care group, 2 withdrew prior to treatment leaving 86 remaining. From 88 starting in Interventional group, 1 withdrew prior to treatment leaving 87 remaining.

The trial design was based on data available in early 2020 that suggested a mortality of up to 40% in hospitalized patients with severe COVID-19. Another limitation is that the results cannot be extrapolated to all patients hospitalized with COVID-19, because more than 85% of screened patients did not meet eligibility criteria. Lastly, this study was not designed to examine outcomes beyond 30 days.