Direct oral anticoagulant therapy in patients with morbid obesity after intermediate- or high-risk pulmonary emboli

Abstract

BackgroundThere is little reported on the efficacy and safety of direct oral anticoagulants (DOAC) in morbid obesity after venous thromboembolism (VTE).MethodsThis was an observational study of patients after intermediate- or high- risk pulmonary embolus (PE) who followed up in the University of Rochester Pulmonary Hypertension Clinic 2–4 months after the initial event with echocardiogram and V/Q imaging regardless of symptoms. Rates of recurrent VTE, thrombus resolution, and development of chronic thromboembolic pulmonary hypertension (CTEPH) in patients with morbid obesity treated with a DOAC compared to vitamin K antagonists and non-morbidly obese patient after PE. Using the electronic medical record, recurrent events were assessed out to 12 months.Results107 patients (32, BMI>40; 39, BMI 30–39.9; and 36, BMI<30) followed up after treatment for PE. A DOAC was used in 70 patients (19, BMI>40; 27, BMI 30–39.9; and 24, BMI<30). There were no recurrent events within the first 12 months of initial diagnosis based on symptoms and imaging in any patient. There was no difference in rate of residual unmatched perfusion defect with DOAC or conventional anticoagulation, 49% versus 49%. This finding remained in the subset of morbidly obese patients at 47% versus 50%. For the overall cohort, there was no difference in the rate of CTEPH development based on anticoagulation with DOAC having a rate of 5% (versus 8% with warfarin). There were no major bleeding complications with DOAC.ConclusionDOAC therapy appears to be effective and safe in morbid obesity even after intermediate- or high- risk PE. ​

Left Ventricular Assist Device Pump Thrombosis in a Patient Treated with Apixaban

“…In 2016, the International Society of Hemostasis and Thrombosis recommended against the use of direct oral anticoagulants in patients with BMI >40 or a weight >120 kg due to the lack of solid supportive clinical data [ 13 ]. Since then, a few studies have shown apixaban to be safe in patients with such extremes of weight without any dose adjustments [ 14 , 15 ], while others advocated for the use of drug-specific peak and trough levels [ 16 ]. However, there has not been any revision of the guidelines as of yet.…”

Expert Recommendations on the Usage of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) from India: Current Perspective and Future Direction

“…In obese patients with acute VTE, there was no differences VTE recurrence (6.5 vs. 6.4%, p = 0.63), recurrence of PE (3.7 vs. 3.8%, p = 0.94), or DVT (3 vs. 3.5%, p = 0.56) between treatment with NOACs and warfarin. Bleeding was similar for both, NOAC and warfarin groups (1.7 vs. 1.2%, p = 0.31) [65]. Another observational study demonstrated NOAC to be effective and safe in morbid obese patients even after intermediate-or high-risk PE [65].…”

“…Bleeding was similar for both, NOAC and warfarin groups (1.7 vs. 1.2%, p = 0.31) [65]. Another observational study demonstrated NOAC to be effective and safe in morbid obese patients even after intermediate-or high-risk PE [65].…”

Use of direct oral anticoagulants for acute pulmonary embolisms in obesity: a propensity-matched, multicentre case–control study

“…[12] Recent evidence also suggests that's DOACs may have similar risks of long-term complications including chronic thromboembolic pulmonary hypertension compared to warfarin in morbidly obese patients with intermediate or high-risk PE. [14] This study has several limitations. INR monitoring and warfarin dose adjustments were carried out in the community in line with routine clinical practice, and we were therefore unable to account for the effect of sub-or supratherapeutic INR on outcome measures.…”

“…In a large registry based retrospective study of obese patients with all forms of VTE, S pyropoulos et al [ 12 ] also showed similar efficacy between rivaroxaban and warfarin with recurrent VTE rates of 16.8% and 15.9% at 12 months retrospectively. Recent evidence also suggests that's DOACs may have similar risks of long-term complications including chronic thromboembolic pulmonary hypertension compared to warfarin in morbidly obese patients with intermediate or high-risk PE [ 14 ].…”