HelixTalk Episode #109 - Clinical Controversy: Can Obese Patients Take DOACs for Acute VTE?

Date posted: February 25, 2020, 6:00 am

In this episode, we review the pros, cons, and literature regarding the use of DOACs versus warfarin in obese patients with venous thromboembolism.

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Key Concepts

1. The 2016 Scientific and Standardization Subcommittee of the International Society on Thrombosis and Haemostasis (SSC ISTH) guidelines recommend against DOACs in patients with a BMI > 40 kg/m² or body weight > 120 kg.  This recommendation is made strictly on the basis of a lack of clinical data among this patient population.
2. Rivaroxaban and apixaban are the two most studied DOACs among obese patients with venous thromboembolism (VTE).  Both drugs appear to have small or no pharmacokinetic/pharmacodynamic changes among obese patients.
3. The best available clinical data does not suggest worse outcomes among obese patients treated with DOACs instead of warfarin for VTE; however, the quality of this data is not sufficient to completely validate these efficacy and safety findings. 
4. As with non-obese patients, clinical decision making is of paramount importance when selecting an anticoagulant for obese patients with VTE.  Patient-specific factors should be heavily weighted when selecting between a DOAC or warfarin.

References

• Martin K, Beyer-Westendorf J, Davidson BL, Huisman MV, Sandset PM, Moll S. Use of the direct oral anticoagulants in obese patients: guidance from the SSC of the ISTH. J Thromb Haemost. 2016;14(6):1308–1313. doi:10.1111/jth.13323
• Di Minno MN, Lupoli R, Di Minno A, et al. Effect of body weight on efficacy and safety of direct oral anticoagulants in the treatment of patients with acute venous thromboembolism: a meta-analysis of randomized controlled trials. Ann Med. 2015 Feb;47(1):61-8. doi: 10.3109/07853890.2014.982064.
• Kido K, Lee JC, Hellwig T, et al. Use of Direct Oral Anticoagulants in Morbidly Obese Patients. Pharmacotherapy. 2020 Jan;40(1):72-83. doi: 10.1002/phar.2353.
• Coons JC, Albert L, Bejjani A, et al. Effectiveness and Safety of Direct Oral Anticoagulants versus Warfarin in Obese Patients with Acute Venous Thromboembolism. Pharmacotherapy. 2020 Jan 22. doi: 10.1002/phar.2369.