A Review of the Pharmacokinetics, Pharmacodynamics, Efficacy, and Safety of Direct Oral Anticoagulants in Patients Undergoing Bariatric Surgery

The role of direct oral anticoagulants (DOACs) for prevention of venous thromboembolism (VTE) in bariatric surgery has been unclear. Current clinical guidelines recommend against DOAC use in bariatric surgery, but lack the inclusion of recent prospective trials. This article reviews data on the pharmacokinetics/pharmacodynamics and efficacy/safety of rivaroxaban or apixaban prophylaxis in this setting. Targeted literature reviews identified prospective studies of rivaroxaban (n=4) or apixaban (n=2) and retrospective studies (n=7) on VTE prophylaxis in bariatric surgery. Single dose 10 mg rivaroxaban produced comparable systemic exposure pre- and postsurgery, regardless of procedure type. In a randomized clinical trial, no cases of clinically overt VTE occurred with 7-day or 28-day administration of prophylactic rivaroxaban postsurgery, with low rates of relevant bleeding (1.9%). A noncontrolled, nonrandomized trial with risk-adapted dosing of rivaroxaban showed no thrombosis and a low bleeding risk (0.9%). Single-doses of 5 mg apixaban at 1, 6 and 12 months resulted in no clinically significant changes in pharmacokinetic and pharmacodynamic parameters. A randomized controlled trial in sleeve gastrectomy patients with twice-daily prophylactic apixaban or low molecular weight heparin resulted in no VTE and low rates of bleeding events (2%). Retrospective studies support the effectiveness/safety of rivaroxaban or apixaban in bariatric surgery patients; however, their findings are limited by study design, inconsistent dosing information, and heterogeneity of patient populations. Available evidence suggests that rivaroxaban and apixaban may be feasible options for thromboprophylaxis after bariatric surgery, although additional prospective studies are needed to confirm efficacy and safety.