Introduction Venous thromboembolism (VTE) is a leading cause of morbidity and mortality globally. The direct oral anticoagulants, including rivaroxaban, are relatively novel therapeutic options in the treatment and prevention of VTE. There is a conflicting and inconclusive evidence surrounding the pharmacokinetics (PK) of rivaroxaban in patients with VTE who are obese. Objectives We conducted a systematic review to provide an overview, and to synthesize the available evidence in the current literature pertaining to rivaroxaban PK in obese subjects who are healthy or diseased. Methods The PubMed, Embase, ScienceDirect, Rayyan, and Cochrane Library databases were systematically searched from 1 May 2021 through 28 February 2022. Studies investigating rivaroxaban PK in adult obese subjects were included in the review. Pertinent data, including anthropometric parameters, rivaroxaban dosage regimen, PK parameters, PK model, and outcome measures were extracted. Reference values of rivaroxaban PK parameters in the general population were used for comparison purposes. The review protocol was registered in the PROSPERO database (CRD42020177770). Results In the 11 studies included in this systematic review, over 7140 healthy or diseased subjects received rivaroxaban therapy, with varying clinical indications in the diseased population. The reported PK parameters of rivaroxaban in obese subjects compared with reference values in the general population were variable. The reported values of the volume of distribution (V d ) among obese subjects (73.4-82.8 L) fell within the range of values reported/calculated for the general population (59.4-104 L), assuming complete bioavailability. However, some of the reported values of clearance (CL) in obese subjects (7.86-16.8 L.h −1 ) do not fall within the range of values reported/calculated for the general population (5.57-11.3 L.h −1 ). The reported maximum plasma concentrations in obese subjects versus the general population following a 10 mg dose were 149 vs. 143-180 µg.L −1 , and following a 20 mg dose were 214-305 vs. 299-360 µg.L −1 , respectively. The area under the plasma concentration versus time curves (AUC) over different intervals in obese subjects versus the general population following a 10 mg dose were 1155 (AUC from time zero to infinity [AUC ∞ ]) vs. 1029 (AUC ∞ ) µg.h.L −1 ; and 1204-2800 (AUC from time zero to 24 h [AUC 24 ]) vs. 3200 (AUC 24 ) µg.h.L −1 , respectively, following a 20 mg dose. The reported values of half-life and time to reach the maximum plasma concentration in obese subjects versus the general population were not consistent across studies. Conclusion Variable changes and inconsistencies in different rivaroxaban PK parameters were reported in obese subjects. Further well-designed studies are warranted to better characterize the PK and clinical outcomes of rivaroxaban in subjects with obesity.

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Background Syrian refugees living in Jordan have many chronic conditions and use many medications. Pharmacists delivering the Medication Management Review (MMR) service can have a role in improving this growing global refugees’ problem. Objectives To assess the effect of the MMR service on adherence to treatment therapy and knowledge of chronic medications for Syrian refugees residing in Jordan. Methods This randomized intervention control single-blinded study was conducted in Jordan. Syrian refugees were recruited and randomized into intervention and control groups. Two home visits were delivered to each participant, at baseline and three months later. All participants completed questionnaires regarding adherence and knowledge. As a part of the MMR service, treatment-related problems (TRPs) were recognized for all patients; recommendations to resolve these TRPs were only delivered to intervention group refugees’ physicians; TRPs were corrected. At follow-up, TRPs assessment, adherence and medication knowledge were assessed for all refugee participants. Results Participants (n = 106; intervention n = 53, control n = 53) had a number of medications and diagnosed chronic diseases of 5.8 ± 2.1 and 2.97 ± 1.16 per participant respectively. A significant improvement in the adherence and knowledge scores were noted in the intervention (P < 0.001 for both) but not the control group (P = 0.229, P = 0.07 respectively). Conclusion The MMR service can significantly improve refugees’ TRPs, adherence to therapy and knowledge of chronic medications. If this approach was extended to the large scale, many refugees in need would be able to access a quality essential health-care service; a step towards achieving universal health coverage. Trial registration Registry: ClinicalTrials.gov Identifier: NCT04554810.