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Venous Thromboembolism Treatment by Body Size
Quick Takes
- Many severely obese patients with acute VTE are receiving DOAC therapy.
- DOAC therapy was associated with similar rates of bleeding and recurrent VTE as warfarin therapy in severely obese patients.
- DOAC medications can be used safely in severely obese patients with acute and chronic VTE.
Study Questions:
What is the use and associated outcomes from direct oral anticoagulant (DOAC) use for venous thromboembolism (VTE) across weight and body mass index (BMI)?
Methods:
The authors performed a retrospective cohort study of patients with first-time VTE between 2013–2018, who were treated with a DOAC or warfarin in the Veterans Health Administration. Patients were stratified by weight and BMI to assess for associations with outcomes by drug selection and weight/BMI. Outcomes of interest include major bleeding, clinically relevant nonmajor bleeding, and recurrent VTE.
Results:
The analysis cohort included 51,871 patients prescribed either DOAC or warfarin within 30 days of an index VTE, age 64.5 ± 13.1 years, 6.0% female. The median weight was 93.4 kg (interquartile range, 80.5-108.6 kg). Among the 6,934 patients with weight ≥120 kg, 38.4% were treated with DOAC medications. DOAC prescription was not associated with major bleeding (adjusted hazard ratio [aHR], 0.78; 95% confidence interval [CI], 0.32-1.92), clinically relevant nonmajor bleeding (aHR, 1.12; 95% CI, 0.76-1.64), or recurrent VTE risk (aHR, 1.31; 95% CI, 0.59-2.98) in patients with higher weight or BMI category compared to patients receiving warfarin therapy.
Conclusions:
The authors concluded that severely obese patients with VTE are frequently prescribed DOAC therapy without an increase in the risk of bleeding or recurrent VTE as compared to warfarin therapy.
Perspective:
Due to the one-size-fits-all dosing strategy of DOAC patients based largely on age and renal function, concerns have been raised about the safety of DOAC medication use given a relatively larger volume of drug distribution. This led to a recommendation in 2016 from the International Society on Thrombosis and Haemostasis (ISTH; DOI: 10.1111/jth.13323) to avoid DOAC use in patients with BMI >40 kg/m2 or weight >120 kg. However, this study adds to a growing body of literature supporting the safety and efficacy of DOAC use in severely obese patients. In response, the ISTH has updated their guidance to now support the use of DOACs in patients with BMI >40 kg/m2 or weight >120 kg (DOI: 10.1111/jth.15358).
Clinical Topics: Anticoagulation Management, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Anticoagulation Management and Venothromboembolism
Keywords: Anticoagulants, Body Mass Index, Hemorrhage, Obesity, Obesity, Morbid, Overweight, Pharmaceutical Preparations, Primary Prevention, Thrombosis, Treatment Outcome, Vascular Diseases, Venous Thromboembolism, Veterans Health, Warfarin
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