Use of Direct Oral Anticoagulants in Morbidly Obese Patients

In 2016, the International Society on Thrombosis and Haemostasis (ISTH) published guidelines advising caution when using direct oral anticoagulants (DOACs) in patients with morbid obesity due to limited clinical efficacy and safety data supporting their use in this patient population. In this review, we analyzed published articles in the MEDLINE database (from inception through May 29, 2019), and the Cochrane Library, Google Scholar, and EMBASE databases (from inception through April 26, 2019) that evaluated morbidly obese patients with atrial fibrillation (AF) or venous thromboembolism (VTE) who received DOACs. A total of 19 studies, which included pharmacokinetic studies, original phase III trials for the DOACs, post hoc analyses of phase III trials, and retrospective cohort studies, were evaluated. Although currently available data do not indicate that using DOACs in the morbidly obese is problematic, DOAC-specific pharmacokinetic variations have been observed. Additionally, less data evaluating DOAC efficacy and safety exist for VTE treatment compared with the data for stroke prevention in patients with AF. The overall quality of the studies included in this review was low due to limited prospective randomized trial data, limiting the ability to form definitive judgments on efficacy and safety DOACs in the morbidly obese. Continued caution is recommended when considering DOAC use in the morbidly obese, particularly for those requiring anticoagulation for VTE treatment, until additional higher-quality data become available.