Wang TF, Carrier M, Fournier K, et al. Oral Anticoagulant Use in Patients with Morbid Obesity: A Systematic Review and Meta-Analysis. Thromb Haemost. 2021 Aug 16. doi: 10.1055/a-1588-9155. (Systematic review)

OBJECTIVES: Obesity is associated with increased risks of atrial fibrillation (AF) and venous thromboembolism (VTE) for which anticoagulation is commonly used. However, data on the efficacy and safety of oral anticoagulants in patients with morbid obesity are limited.

METHODS: We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) for AF or VTE in patients with morbid obesity.

RESULTS: We included three randomized controlled trials (5 studies) and 18 observational studies in adult patients with a body weight =120 kg, body mass index =40 kg/m2, or classified as morbid obesity who received DOACs or VKAs for AF or VTE (N = 77,687). The primary efficacy outcome was stroke/systemic embolism or recurrent VTE, and the primary safety outcome was major bleeding. DOACs were associated with a pooled incidence rate of stroke/systemic embolism of 1.16 per 100 person-years, compared to 1.18 with VKAs. The incidence of recurrent VTE on DOACs was 3.83 per 100 person-years, compared to 6.81 on VKAs. In both VTE and AF populations, DOACs were associated with lower risks of major bleeding compared to VKAs. However, all observational studies had moderate to serious risks of bias.

CONCLUSION: Patients with morbid obesity on DOACs had similar risks of stroke/systemic embolism, lower rates of recurrent VTE, and major bleeding events compared to those on VKAs. However, the certainty of evidence was low given that studies were mostly observational with high risk of confounding.

Discipline Area Score
Physician 5 / 7
Comments from MORE raters

Physician rater

This systematic review and meta-analysis shows that DOACs and VKAs have equivalent effectiveness and safety in morbidly obese patients with AF or VTE. The level of certainty of this conclusion is low based on the quality of studies included in the analysis. Since there is no "danger signal" in the individual studies nor in their aggregate, practitioners may prescribe DOACs in this patient population with a degree of confidence. This is buttressed by the current ISTH guidelines relating to the morbidly obese.
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