Why the study?
The efficacy and safety of DOACs in patients with high body weight or BMI has not been elucidated by randomized trials, despite 2016 guideline recommendations against their use in this group.
Are direct-acting oral anticoagulants safe and effective in patients with high body weight (>120 kg) or high BMI (>40 kg/m2)?
Are direct-acting oral anticoagulants safe and effective in patients with high body weight (>120 kg) or high BMI (>40 kg/m2)?
Current evidence suggests apixaban or rivaroxaban may be considered in patients with high body weight or BMI, while dabigatran should be avoided and edoxaban lacks sufficient data.
Cautions against routine DOAC use above BMI 40 kg/m²; leaves open optimal dosing pending dedicated prospective trials.
Objective: To review literature on the use of direct-acting oral anticoagulants (DOACs) in patients with high body weight (BW) and/or high body mass index (BMI) and to make recommendations regarding use in this patient population. Data Sources: A search using PubMed was conducted (inception to April 13, 2020) using the term DOAC AND the terms obesity OR body weight. A separate search was also conducted with individual DOACs (dabigatran, apixaban, rivaroxaban, edoxaban) and the aforementioned terms. Study Selection and Data Extraction: Studies included examined the effect of BW and/or BMI on DOAC pharmacokinetics, efficacy, or safety. Included studies had DOAC indications of prevention of stroke in nonvalvular atrial fibrillation, or treatment or long-term prevention of venous thromboembolism. Data Synthesis: The efficacy and safety of DOACs in patients with high BW/BMI has not yet been elucidated by randomized trials; however, 2016 international guidelines suggest avoiding their use in patients with a BW >120 kg or BMI >40 kg/m 2 . Since 2016, several studies have been published examining use of DOACs in this patient population. Relevance to Patient Care and Clinical Practice: This review thoroughly discusses the literature on DOACs in patients with a BW >120 kg or BMI >40 kg/m 2 pre-2016 and post-2016 guidelines. Conclusions: Evidence indicates that each DOAC may have differences in outcomes when used in patients with a high BW/BMI. Currently, low-quality data are available that support avoiding dabigatran and considering apixaban or rivaroxaban; lack of sufficient data preclude a recommendation for edoxaban use in this patient population.
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Sebaaly et al. (2020) studied this question.
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