Summary of COVID-19 medicines guidance: Stroke

This page summarises and signposts to medicine related guidance we’re aware of from professional and government bodies relating to coronavirus and stroke.

This page has been put together rapidly in relation to the COVID-19 pandemic.

Whilst we have tried to ensure that the information on this page is complete, please report a concern if you feel anything is omitted or inaccurate.

To see our professional guidance summaries for other clinical areas, click here

Advice in this area includes:

NHS England/NHS Improvement: Clinical guide for the management of stroke patients during the coronavirus pandemic Last updated 16 April 2020

  • During the pandemic, priorities include rapid thrombolysis and early reversal of anticoagulation and management of raised BP in patients with intracerebral haemorrhage (<1 hour).
  • Patients awaiting carotid endarterectomy should, if able, be discharged upon dual antiplatelet therapy if appropriate and await carotid intervention

NHS England/ NHS Improvement: Clinical guide for the management of anticoagulant services during the coronavirus pandemic Last updated 1 April 2020

  • Take the opportunity to review if long-term warfarin therapy is still indicated eg in patients with prior DVT or PE for whom the risk of recurrence is now considered low.
  • Consider if patients taking warfarin are suitable for treatment with a DOAC instead; if a DOAC is unsuitable, could they be switched to LMWH instead? (Note that in view of recognised supply issues with LMWH, these should only be used if there are no other appropriate options).
  • Consider prioritising patients with poor control of INR as this cohort will need the most frequent INR checks. Address non-adherence if this an underlying reason for poor INR control.
  • Consider if patients could be trained to self-test INR in their own homes.
  • As a last resort, for individual patients for whom INR testing is not possible and therefore warfarin cannot be dosed safely, warfarin therapy could be temporarily stopped after weighing the benefit and risk and discussion with the patient. Regular review should be undertaken with a view to restarting warfarin therapy as soon as it is safe to do so. (Note: patients with mechanical heart valves MUST stay on warfarin).

British Society for Haematology: INR testing for out-patients on warfarin during COVID-19 restrictions Last updated 26 March 2020

  • Advice for out-patient INR testing during COVID-19 restrictions.
  • Assess whether a DOAC that does not require monitoring can be used instead of warfarin. Note that antiplatelet therapy is not an effective alternative to anticoagulation.
  • Patients who are stably anticoagulated on warfarin with a time-in-therapeutic range of >60% can generally have long INR test intervals of 8 weeks or in some cases longer.
  • Patients in self-isolation because of possible COVID-19 exposure who are stably anticoagulated and would be due a routine test, can usually have the test safely postponed until after the period of isolation

European Society of Cardiology: ESC Guidance for the Diagnosis and Management of CV Disease during the COVID-19 Pandemic Last updated 10 June 2020

  • Guidance from the European Society of Cardiology on the diagnosis and management of cardiovascular disease during the COVID-19 pandemic.
  • Has management/treatment pathways for cardiovascular conditions, including pulmonary embolism and arrhythmias.
  • Also has a section on considerations on the use of anticoagulants in COVID-19 Patients.

Primary Care Cardiovascular Society: COVID-19 Learning Bites

  • The Primary Care Cardiovascular Society has produced a number of COVID-19 ‘learning bites’, including ‘Maintaining anticoagulation efficacy and safety during the COVID-19 crisis – should I be switching my warfarin to a DOAC?’

Royal Pharmaceutical Society: Guidance for the safe switching of warfarin to direct oral anticoagulants (DOACs) for patients with non-valvular AF and venous thromboembolism (DVT / PE) during the coronavirus pandemic Last updated 26 March 2020

  • Includes information on how to decide if it is appropriate to switch individual patients to DOACs, choice of DOAC, monitoring etc.
  • Advice on how to manage patients considered unsuitable for a DOAC.
  • Includes a counselling checklist for patients commenced on a DOAC.

Administration update (8th July 2020): administrative amendments made to the page only.