Although direct-acting oral anticoagulants (DOACs) have widespread first-line use for treatment and prevention of venous thromboembolism (VTE), uncertainty remains regarding their efficacy and safety in patients with obesity. We reviewed available data for use of DOACs for VTE treatment and prevention in patients with obesity, including phase 3, phase 4, meta-analyses, and pharmacokinetic and pharmacodynamics studies. In addition, we reviewed available data regarding DOACs in bariatric surgery.We provide updated guidance recommendations on using DOACs in patients with obesity for treatment and prevention of VTE, as well as following bariatric surgery.
Situations that ordinarily necessitate consideration of anticoagulation, such as arterial and venous thrombotic events and prevention of stroke in atrial fibrillation, become challenging in patients with inherited bleeding disorders such as hemophilia A, hemophilia B, and von Willebrand disease. There are no evidence-based guidelines to direct therapy in these patients, and management strategies that incorporate anticoagulation must weigh a treatment that carries a risk of hemorrhage in a patient who is already at heightened risk against the potential consequences of not treating the thrombotic event. In this paper, we review atherothrombotic disease, venous thrombotic disease, and atrial fibrillation in patients with inherited bleeding disorders, and discuss strategies for using anticoagulants in this population using cases to illustrate these considerations.
Background
Although historical trends before 1998 demonstrated improvements in mortality caused by pulmonary embolism (PE), contemporary estimates of mortality trends are unknown. Therefore, our objective is to describe trends in death rates caused by PE in the United States, overall and by sex‐race, regional, and age subgroups.
Methods and Results
We used nationwide death certificate data from Centers for Disease Control and Prevention Wide‐Ranging Online Data for Epidemiologic Research to calculate age‐adjusted mortality rates for PE as underlying cause of death from 1999 to 2018. We used the Joinpoint regression program to examine statistical trends and average annual percent change. Trends in PE mortality rates reversed after an inflection point in 2008, with an average annual percent change before 2008 of −4.4% (−5.7, −3.0,
P
<0.001), indicating reduction in age‐adjusted mortality rates of 4.4% per year between 1999 and 2008, versus average annual percent change after 2008 of +0.6% (0.2, 0.9,
P
<0.001). Black men and women had approximately 2‐fold higher age‐adjusted mortality rates compared with White men and women, respectively, before and after the inflection point. Similar trends were seen in geographical regions. Age‐adjusted mortality rates for younger adults (25–64 years) increased during the study period (average annual percent change 2.1% [1.6, 2.6]) and remained stable for older adults (>65 years).
Conclusions
Our study findings demonstrate that PE mortality has increased over the past decade and racial and geographic disparities persist. Identifying the underlying drivers of these changing mortality trends and persistently observed disparities is necessary to mitigate the burden of PE‐related mortality, particularly premature preventable PE deaths among younger adults (<65 years).
Bariatric surgery may alter the absorption, distribution, metabolism
and/or elimination (disposition) of orally administered drugs via changes to the
gastrointestinal tract anatomy, body weight, and adipose tissue composition. As
some patients who have undergone bariatric surgery will need therapeutic
anticoagulation for various indications, appropriate knowledge is needed
regarding anticoagulant drug disposition and resulting efficacy and safety in
this population. We review general considerations about oral drug disposition in
patients after bariatric surgery, as well as existing literature on oral
anticoagulation after bariatric surgery. Overall, available evidence on
therapeutic anticoagulation is very limited and individual drug studies are
necessary to learn how to safely and effectively use the direct oral
anticoagulants. Given the sparsity of presently available data, it appears most
prudent to use warfarin with INR monitoring, and not direct oral anticoagulants,
when full-dose anticoagulation is needed after bariatric surgery.
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