Direct Oral Anticoagulants in Obesity: An Updated Literature Review.
Research article published in The Annals of pharmacotherapy (2020)
Abstract
OBJECTIVE: To review literature on the use of direct-acting oral anticoagulants (DOACs) in patients with high body weight (BW) and/or high body mass index (BMI) and to make recommendations regarding use in this patient population. DATA SOURCES: A search using PubMed was conducted (inception to April 13, 2020) using the term DOAC AND the terms obesity OR body weight. A separate search was also conducted with individual DOACs (dabigatran, apixaban, rivaroxaban, edoxaban) and the aforementioned terms. STUDY SELECTION AND DATA EXTRACTION: Studies included examined the effect of BW and/or BMI on DOAC pharmacokinetics, efficacy, or safety. Included studies had DOAC indications of prevention of stroke in nonvalvular atrial fibrillation, or treatment or long-term prevention of venous thromboembolism. DATA SYNTHESIS: The efficacy and safety of DOACs in patients with high BW/BMI has not yet been elucidated by randomized trials; however, 2016 international guidelines suggest avoiding their use in patients with a BW >120 kg or BMI >40 kg/m2. Since 2016, several studies have been published examining use of DOACs in this patient population. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: This review thoroughly discusses the literature on DOACs in patients with a BW >120 kg or BMI >40 kg/m2 pre-2016 and post-2016 guidelines. CONCLUSIONS: Evidence indicates that each DOAC may have differences in outcomes when used in patients with a high BW/BMI. Currently, low-quality data are available that support avoiding dabigatran and considering apixaban or rivaroxaban; lack of sufficient data preclude a recommendation for edoxaban use in this patient population.
Abstract sourced from PubMed (NCBI) for the cited record. See the original publication for the authoritative version.
Summary
Direct Oral Anticoagulants in Obesity: An Updated Literature Review.
Why This Matters for Hirudotherapy
This literature review surveyed PubMed evidence on direct-acting oral anticoagulants (DOACs: dabigatran, apixaban, rivaroxaban, edoxaban) in patients with high body weight (>120 kg) or BMI (>40 kg/m2), reporting that randomized efficacy/safety data in this group remain absent and that current low-quality evidence supports avoiding dabigatran while considering apixaban or rivaroxaban. For the medicinal-leech context, the paper is useful as a map of the modern systemic anticoagulant landscape that hirudotherapy sits alongside: leech-derived hirudin is a direct thrombin inhibitor, the same target class as the orally bioavailable small molecule dabigatran discussed here. It also illustrates that even well-studied synthetic anticoagulants carry real dosing uncertainty in special populations, which is the kind of unmet need that drives interest in alternative antithrombotic chemistries. Honest caveat: this is a narrative literature review of synthetic oral drugs with no leech or hirudotherapy content, and its recommendations are explicitly graded as low-quality, non-randomized evidence.
Citation
Direct Oral Anticoagulants in Obesity: An Updated Literature Review.
Sebaaly et al. · The Annals of pharmacotherapy, 2020
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