Previously, the 2016 guidance from the ISTH suggested not using DOACs in people with BMI >40 kg/m2 and weight >120 kg.
The new recommendations, presented at ISTH 2021 and published in the Journal of Thrombosis and Haemostasis, do not support use of dabigatran, edoxaban or betrixaban in patients with high BMI or body weight because of the limited clinical data.
For example, a sub-analysis of the EINSTEIN DVT/PE studies, showed that hazard ratios for rivaroxaban vs enoxaparin/VKA were similar in all bodyweight and BMI categories. A high BMI was not associated with an increased risk of recurrent VTE during anticoagulation.
A recently published study of apixaban versus warfarin has shown a significantly lower risk of recurrent VTE and major bleeding with the DOAC in obese and morbidly obese VTE patients.
In a meta-analysis of trials with extremely high body weight patients, DOACs were non-inferior compared to warfarin with respect to VTE recurrence (OR 1.07, 95% CI 0.93–1.23).
that small studies suggest obesity has no significant impact on peak and trough levels for apixaban and rivaroxaban although lower peak levels were seen with dabigatran.
Reference
ISTH
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