Multisystem Inflammatory Syndrome (MIS-C) Clinical Pathway — Emergency, ICU and Inpatient

Aspirin/Anticoagulation/VTE Prophylaxis (ASA)

Aspirin/Anticoagulation/VTE Prophylaxis

Data suggests that patients with COVID-19 may be at higher risk for thromboembolic events during active infection and perhaps for some time after. This risk may extend to patients with MIS-C as well, particularly older adolescents.
Consult Cardiology for all patients with coronary aneurysms and as clinically indicated for anticoagulation treatment recommendations.

Aspirin VTE Prophylaxis/ Anticoagulation

Patients ≥ 12 years of age regardless of coronary artery abnormalities
- Enoxaparin 0.5 mg/kg/dose BID, max initial dose: 60 mg subQ q12h
- Monitor anti-Xa’s and adjust dose to a goal range 0.2-0.4 units/mL

All patients < 12 years of age, regardless of coronary artery abnormalities
- Low-dose ASA (3-5 mg/kg/day, max 81 mg)
  - Exceptions to low-dose ASA: Platelets less than 100,000

Patients with coronary ectasia or dilation
- Low-dose ASA (3-5 mg/kg/day, max 81 mg)
  - Exceptions to low-dose ASA: Platelets less than 100,000
- Consult cardiology to review anticoagulation/antiplatelet recommendations, including whether or not to continue LMWH in addition to aspirin on a case-by-case basis
- 2017 AHA Kawasaki Disease Guidelines

Patients with moderate or severe systolic dysfunction (e.g., EF < 30%):
- LMWH for all patients in consultation with cardiology, follow anti-Xa with target of 0.5-1.0
- Cardiology will determine need for additional antiplatelet therapy with aspirin

Duration of treatment with aspirin:
- In patients prescribed ASA as inpatients, low-dose ASA should be continued through at minimum the time of cardiology/rheumatology follow up with ultimate duration to be determined at the outpatient visit.

Duration of treatment with LMWH:
- LMWH should be discontinued when the patient no longer meets high-risk criteria for VTE prophylaxis, per the VTE pathway, or at the time of hospital discharge.
- After LMWH is discontinued, patients should be transitioned to low-dose ASA, with duration as described above. Duration of LMWH for children with moderate or severe cardiac dysfunction should be discussed with the heart failure or cardiology consult team.

Special Considerations for Aspirin:
- Avoid ibuprofen or other NSAID (antagonizes anti-platelet effect of aspirin)
- Adverse effects (rare): GI bleed, tinnitus, Reye’s syndrome
  - Reye’s syndrome – rare, but increased risk with aspirin and viral infection.
  - Consider inactivated influenza vaccine (avoid live vaccines (e.g. varicella) until off aspirin or discuss risk benefit when on low-dose aspirin).

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.