Outcome of Morbidly Obese Patients with Acute Venous Thromboembolism Managed with Direct Oral Anticoagulants

Background.

Obesity is a major epidemic affecting all age groups in the USA. It has been associated with venous thromboembolism (VTE), which requires prolonged anticoagulation. Classic options (vitamin K antagonists, heparins) are increasingly replaced by direct oral anticoagulants (DOACs), which have not been well studied in patients with body mass index (BMI) > 40kg/m² or weight above 120 kg. Despite limited safety and efficacy data, patients and their caregivers often opted for this medication owing to its ease of administration, lack of requirement for frequent laboratory testing and for dietary restrictions.

Methods.

This is a retrospective study of all morbidly obese patients (BMI > 40kg/m²) diagnosed with acute VTE managed with DOACs at Beaumont hospital between January of 2018 and December of 2018. Data regarding demographics, specific DOAC, major bleeding (hemoglobin decrease by 2 g/dL) and new or progressive thrombosis were recorded during a sixty-day follow up. Data was analyzed using JMP statistical software.

Results

A total of 42 patients diagnosed with acute VTE received DOACs during the study period. Most were female (76%); the median BMI was 44 (IQR 42-60) and mean age was 57. Most patients had a BMI of 40-50 kg/m² (n=34, 81%) compared to BMI 50-60 kg/m² (n=6, 14%) and BMI >60kg/m² (n=6, 14%). Apixaban was the most frequently used DOAC (n=27, 65%). No clinically significant bleeding occurred during the study period. There were 2 thrombotic episodes (5% of patients) within 60 days of starting a DOAC; both occurred in patients receiving rivaroxaban. One event was present in the BMI 40-50kg/m² group and one in the >60kg/m² group.

Conclusions

DOACs appear to be safe and efficacious for the management of VTE in the morbidly obese population. Future studies may focus on the comparative efficacy of apixaban and rivaroxaban in the morbidly obese population.