Position paper from the Indonesian Society of Thrombosis and Hemostasis (InaSTH), Semarang chapter: Management of coagulopathy in COVID-19

Eko Adhi Pangarsa , Budi Setiawan, Damai Santosa, Ridho M. Naibaho, Daniel Rizky, Suyono -, Mika L. Tobing, Catharina Suharti

Eko Adhi Pangarsa
Hematology Medical Oncology Division, Internal Medicine Department, Faculty of Medicine, Universitas Diponegoro/ Dr. Kariadi Semarang. Email:

Budi Setiawan
Hematology Medical Oncology Division, Internal Medicine Department, Faculty of Medicine, Universitas Diponegoro/ Dr. Kariadi Semarang

Damai Santosa
Hematology Medical Oncology Division, Internal Medicine Department, Faculty of Medicine, Universitas Diponegoro/ Dr. Kariadi Semarang

Ridho M. Naibaho
Hematology Medical Oncology Division, Internal Medicine Department, Faculty Medicine of Diponegoro University / Dr. Kariadi Semarang

Daniel Rizky
Hematology Medical Oncology Division, Internal Medicine Department, Faculty of Medicine, Universitas Diponegoro/ Dr. Kariadi Semarang

Suyono -
Hematology Medical Oncology Division, Internal Medicine Department, Faculty of Medicine, Universitas Diponegoro/ Dr. Kariadi Semarang

Mika L. Tobing
Hematology Medical Oncology Division, Internal Medicine Department, Faculty of Medicine, Universitas Diponegoro/ Dr. Kariadi Semarang

Catharina Suharti
Hematology Medical Oncology Division, Internal Medicine Department, Faculty of Medicine, Universitas Diponegoro/ Dr. Kariadi Semarang
Online First: July 14, 2020 | Cite this Article
Pangarsa, E., Setiawan, B., Santosa, D., Naibaho, R., Rizky, D., -, S., Tobing, M., Suharti, C. 2020. Position paper from the Indonesian Society of Thrombosis and Hemostasis (InaSTH), Semarang chapter: Management of coagulopathy in COVID-19. Bali Medical Journal 9(2): 306-312. DOI:10.15562/bmj.v9i2.1841

A newly emerging pandemic of coronavirus disease 2019 caused by severe acute respiratory coronavirus 2 is responsible for significant morbidity and mortality worldwide. The ongoing substantial research endeavor to comprehend its associated coagulopathy requires proportional progress on guidance establishment. Current review of evidence and statements on management of coagulopathy and thrombotic complications related to this novel disease is expected to be a precursory formulation for prospective guideline development.


World Health Organization. Coronavirus disease (COVID-19) pandemic [Internet]. Available from:

Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, et al. High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020;46(6):1089–98. Available from:

Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020;191:145. Available from: /pmc/articles/PMC7146714/?report=abstract

Wichmann D, Sperhake J-P, Lütgehetmann M, Steurer S, Edler C, Heinemann A, et al. Autopsy findings and venous thromboembolism in patients with COVID-19. Ann Intern Med. 2020; Available from: /pmc/articles/PMC7240772/?report=abstract

Cao W, Li T. COVID-19: towards understanding of pathogenesis. Cell Res. 2020;30(5):367–9. Available from:

World Health Organization. Clinical management of COVID-19: Interim guidance. 2020. WHO/2019-nCoV/clinical/2020.5.

Xiong M, Liang X, Wei YD. Changes in blood coagulation in patients with severe coronavirus disease 2019 (COVID-19): a meta-analysis. Br J Haematol. 2020;189(6):1050–2. Available from:

Zheng Z, Peng F, Xu B, Zhao J, Liu H, Peng J, et al. Risk factors of critical & mortal COVID-19 cases: A systematic literature review and meta-analysis. J Infect. 2020; Available from: /pmc/articles/PMC7177098/?report=abstract

Khan IH, Savarimuthu S, Leung MST, Harky A. The need to manage the risk of thromboembolism in COVID-19 patients. J Vasc Surg. 2020; Available from: /pmc/articles/PMC7224653/?report=abstract

Byrnes JR, Wolberg AS. New findings on venous thrombogenesis. Hamostaseologie. 2017;37(1):25–35. Available from: /pmc/articles/PMC5680039/?report=abstract

Vabret N, Britton GJ, Gruber C, Hegde S, Kim J, Kuksin M, et al. Immunology of COVID-19: Current State of the Science. Immunity. 2020;52(6):910. Available from: /pmc/articles/PMC7200337/?report=abstract

Becker RC. COVID-19 update: Covid-19-associated coagulopathy. J Thromb Thrombolysis. 2020;50(1):54–67. Available from:

Lingeswaran M, Goyal T, Ghosh R, Suri S, Mitra P, Misra S, et al. Inflammation, immunity and immunogenetics in COVID-19: A narrative review. Indian J Clin Biochem. 2020;1. Available from: /pmc/articles/PMC7275846/?report=abstract

Connors JM, Levy JH. COVID-19 and its implications for thrombosis and anticoagulation. Blood. 2020;135(23):2033–40. Available from: /pmc/articles/PMC7273827/?report=abstract

Huertas A, Montani D, Savale L, Pichon J, Tu L, Parent F, et al. Endothelial cell dysfunction: a major player in SARS-CoV-2 infection (COVID-19)? Eur Respir J. 2020; Available from:

Cardot-Leccia N, Hubiche T, Dellamonica J, Burel-Vandenbos F, Passeron T. Pericyte alteration sheds light on micro-vasculopathy in COVID-19 infection. Intensive Care Med. 2020;1. Available from:

Tibirica E, De Lorenzo A. Importance of the evaluation of systemic microvascular flow and reactivity in critically ill patients with coronavirus disease 2019 — COVID-19. Microvasc Res. 2020;131:104028. Available from: /pmc/articles/PMC7280818/?report=abstract

Iba T, Levy JH, Levi M, Connors JM, Thachil J. Coagulopathy of Coronavirus Disease 2019. Crit Care Med. 2020;

Joly BS, Siguret V, Veyradier A. Understanding pathophysiology of hemostasis disorders in critically ill patients with COVID-19. Intensive Care Med. 2020;1. Available from:

Johnson ED, Schell JC, Rodgers GM. The D-dimer assay. Am J Hematol. 2019;94(7):833–9. Available from:

Al-Ani F, Chehade S, Lazo-Langner A. Thrombosis risk associated with COVID-19 infection. A scoping review. Thromb Res. 2020;192:152–60. Available from: /pmc/articles/PMC7255332/?report=abstract

Lippi G, Favaloro EJ. D-dimer is associated with severity of coronavirus disease 2019: A pooled analysis. Thromb Haemost. 2020;120(5):876–7. Available from:

Liang W, Liang H, Ou L, Chen B, Chen A, Li C, et al. Development and validation of a clinical risk score to predict the occurrence of critical illness in hospitalized patients with COVID-19. JAMA Intern Med. 2020; Available from: /pmc/articles/PMC7218676/?report=abstract

Artifoni M, Danic G, Gautier G, Gicquel P, Boutoille D, Raffi F, et al. Systematic assessment of venous thromboembolism in COVID-19 patients receiving thromboprophylaxis: incidence and role of D-dimer as predictive factors. J Thromb Thrombolysis. 2020;50(1):211–6. Available from: /pmc/articles/PMC7246965/?report=abstract

Gervaise A, Bouzad C, Peroux E, Helissey C. Acute pulmonary embolism in non-hospitalized COVID-19 patients referred to CTPA by emergency department. Eur Radiol. 2020;1. Available from: /pmc/articles/PMC7280685/?report=abstract

Garcia-Olivé I, Sintes H, Radua J, Abad Capa J, Rosell A. D-dimer in patients infected with COVID-19 and suspected pulmonary embolism. Respir Med. 2020;169:106023. Available from: /pmc/articles/PMC7219417/?report=abstract

Sakka M, Connors JM, Hékimian G, Martin-Toutain I, Crichi B, Colmegna I, et al. Association between D-Dimer levels and mortality in patients with coronavirus disease 2019 (COVID-19): a systematic review and pooled analysis. JMV-Journal Med Vasc. 2020; Available from: /pmc/articles/PMC7250752/?report=abstract

Zhang L, Yan X, Fan Q, Liu H, Liu X, Liu Z, et al. D-dimer levels on admission to predict in-hospital mortality in patients with Covid-19. J Thromb Haemost. 2020;18(6):1324–9.

Tripodi A, Lippi G, Plebani M. How to report results of prothrombin and activated partial thromboplastin times. Clin Chem Lab Med. 2016;54(2):215–22. Available from:

Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA - J Am Med Assoc. 2020;323(11):1061–9. Available from: /pmc/articles/PMC7042881/?report=abstract

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506. Available from: /pmc/articles/PMC7159299/?report=abstract

Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054–62. Available from: /pmc/articles/PMC7270627/?report=abstract

Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 2020;18(4):844–7.

Fogarty H, Townsend L, Ni Cheallaigh C, Bergin C, Martin-Loeches I, Browne P, et al. COVID-19 coagulopathy in Caucasian patients. Br J Haematol. 2020; Available from: /pmc/articles/PMC7264579/?report=abstract

Long H, Nie L, Xiang X, Li H, Zhang X, Fu X, et al. D-dimer and prothrombin time are the significant indicators of severe COVID-19 and poor prognosis. Biomed Res Int. 2020;2020. Available from: /pmc/articles/PMC7301188/?report=abstract

Zou Y, Guo H, Zhang Y, Zhang Z, Liu Y, Wang J, et al. Analysis of coagulation parameters in patients with COVID-19 in Shanghai, China. Biosci Trends. 2020; Available from:

Shahriarirad R, Khodamoradi Z, Erfani A, Hosseinpour H, Ranjbar K, Emami Y, et al. Epidemiological and clinical features of 2019 novel coronavirus diseases (COVID-19) in the South of Iran. BMC Infect Dis. 2020;20:427. Available from:

Iba T, Levy JH, Connors JM, Warkentin TE, Thachil J, Levi M. The unique characteristics of COVID-19 coagulopathy. Crit Care. 2020;24(1):360. Available from:

Lippi G, Plebani M, Henry BM. Thrombocytopenia is associated with severe coronavirus disease 2019 (COVID-19) infections: A meta-analysis. Clin Chim Acta. 2020;506:145–8. Available from: /pmc/articles/PMC7102663/?report=abstract

Qu R, Ling Y, Zhang Y, Wei L, Chen X, Li X, et al. Platelet‐to‐lymphocyte ratio is associated with prognosis in patients with Corona Virus Disease‐19. J Med Virol. 2020;jmv.25767. Available from:

Bi X, Su Z, Yan H, Du J, Wang J, Chen L, et al. Prediction of severe illness due to COVID-19 based on an analysis of initial Fibrinogen to Albumin Ratio and Platelet count. Platelets. 2020;1–6.

Spiezia L, Boscolo A, Poletto F, Cerruti L, Tiberio I, Campello E, et al. COVID-19-Related Severe Hypercoagulability in Patients Admitted to Intensive Care Unit for Acute Respiratory Failure. Thromb Haemost. 2020;120(6):998–1000.

Gao Y, Li T, Han M, Li X, Wu D, Xu Y, et al. Diagnostic utility of clinical laboratory data determinations for patients with the severe COVID‐19. J Med Virol. 2020;

Tang N, Bai H, Chen X, Gong J, Li D, Sun Z. Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020;18(5). Available from:

Rico-Mesa JS, Rosas D, Ahmadian-Tehrani A, White A, Anderson AS, Chilton R. The role of anticoagulation in COVID-19-induced hypercoagulability. Curr Cardiol Rep. 2020;22(7):53. Available from:

Lin L, Lu L, Cao W, Li T. Hypothesis for potential pathogenesis of SARS-CoV-2 infection–a review of immune changes in patients with viral pneumonia. Emerg Microbes Infect. 2020;9(1):727–32. Available from: /pmc/articles/PMC7170333/?report=abstract

Bikdeli B, Madhavan M V., Jimenez D, Chuich T, Dreyfus I, Driggin E, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(23):2950–73. Available from:

Spyropoulos AC, Levy JH, Ageno W, Connors JM, Hunt BJ, Iba T, et al. Scientific and standardization committee communication: Clinical guidance on the diagnosis, prevention and treatment of venous thromboembolism in hospitalized patients with COVID‐19. J Thromb Haemost. 2020;jth.14929. Available from:

Schünemann HJ, Cushman M, Burnett AE, Kahn SR, Beyer-Westendorf J, Spencer FA, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Prophylaxis for hospitalized and nonhospitalized medical patients. Blood Adv. 2018;2(22):3198–225. Available from: /pmc/articles/PMC6258910/?report=abstract

Rafizadeh R, Turgeon RD, Batterink J, Su V, Lau A. Characterization of venous thromboembolism risk in medical inpatients using different clinical risk assessment models. Can J Hosp Pharm. 2016;69(6):454–9. Available from: /pmc/articles/PMC5242277/?report=abstract

Iba T, Levy JH, Warkentin TE, Thachil J, van der Poll T, Levi M. Diagnosis and management of sepsis-induced coagulopathy and disseminated intravascular coagulation. J Thromb Haemost. 2019;17(11):1989–94. Available from:

Zhai Z, Li C, Chen Y, Gerotziafas G, Zhang Z, Wan J, et al. Prevention and treatment of venous thromboembolism associated with coronavirus disease 2019 infection: A consensus statement before guidelines. Thromb Haemost. 2020;120(6):937–48. Available from: /pmc/articles/PMC7295267/?report=abstract

Barnes GD, Burnett A, Allen A, Blumenstein M, Clark NP, Cuker A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the anticoagulation forum. J Thromb Thrombolysis. 2020;50(1):72–81. Available from: /pmc/articles/PMC7241581/?report=abstract

Decousus H, Tapson VF, Bergmann JF, Chong BH, Froehlich JB, Kakkar AK, et al. Factors at admission associated with bleeding risk in medical patients: Findings from the improve investigators. Chest. 2011;139(1):69–79. Available from:

Shi C, Wang C, Wang H, Yang C, Cai FEI, Zeng F, et al. The potential of low molecular weight heparin to mitigate cytokine storm in severe covid-19 patients: a retrospective clinical study. medRxiv. 2020;2020.03.28.20046144. Available from:

Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost. 2020;18(5):1023–6. Available from:

Spyropoulos AC, Anderson FA, FitzGerald G, Decousus H, Pini M, Chong BH, et al. Predictive and associative models to identify hospitalized medical patients at risk for VTE. Chest. 2011;140(3):706–14. Available from:

Perhimpunan Trombosis Hemostasis Indonesia. Panduan Nasional Tromboemboli Vena. 2018.

Cuker A, Arepally GM, Chong BH, Cines DB, Greinacher A, Gruel Y, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: Heparin-induced thrombocytopenia. Blood Adv. 2018;2(22):3360–92. Available from: /pmc/articles/PMC6258919/?report=abstract

Park J, Lee JM, Lee JS, Cho YJ. Pharmacological and mechanical thromboprophylaxis in critically ill patients: A network meta-analysis of 12 trials. J Korean Med Sci. 2016;31(11):1828–37. Available from: /pmc/articles/PMC5056218/?report=abstract

Moores LK, Tritschler T, Brosnahan S, Carrier M, Collen JF, Doerschug K, et al. Prevention, diagnosis and treatment of venous thromboembolism in patients with COVID-19: CHEST Guideline and Expert Panel Report. Chest. 2020; Available from: /pmc/articles/PMC7265858/?report=abstract

Obi AT, Barnes GD, Wakefield TW, Brown S, Eliason JL, Arndt E, et al. Practical diagnosis and treatment of suspected venous thromboembolism during COVID-19 pandemic. J Vasc Surg Venous Lymphat Disord. 2020;8(4):526. Available from: /pmc/articles/PMC7162794/?report=abstract

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