Direct-Acting Oral Anticoagulant Choice for Stroke Prevention in Obese Patients With Atrial Fibrillation |
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Affiliation: | 1. Center of Pharmacology, Therapeutic Drug Monitoring Unit, University Hospital of Cologne/Cologne, Germany;2. Department III of Internal Medicine, Heart Center/University Hospital of Cologne/ Cologne, Germany;1. Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom;2. Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark;3. Hospital Universitario La Paz, Universidad Europea, Madrid, Spain;4. Department of Hypertension, Medical University of Lodz, Lodz, Poland;5. Amsterdam UMC, University of Amsterdam, Heart Center, Department of Cardiology, Amsterdam, The Netherlands;6. Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany;7. Dell''Angelo Hospital, Venice-Mestre, Italy;8. Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy;9. Daiichi Sankyo, Inc., Basking Ridge, New Jersy;10. St. Vincenz-Hospital, Paderborn, Germany;11. Working Group: Molecular Electrophysiology, University Hospital Magdeburg, Magdeburg, Germany;1. Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health System, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, 130 E 77th St, New York, NY 10075, USA;2. Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ 08560, USA;3. Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt St Ste 7009, Durham, NC 27705, USA;1. Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905;2. Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota;3. Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota;4. Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota;5. Optum Labs, Cambridge, Minnesota;1. Department of Clinical Pharmacy, West Virginia University School of Pharmacy, Morgantown, West Virginia;2. Department of Pharmaceutics and Pharmacometrics, School of Pharmacy, Shujitsu University, Okayama, Japan;3. Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine, Tokyo, Japan;4. Division for Evaluation and Analysis of Drug Information, Faculty of Pharmacy, Keio University, Tokyo, Japan |
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Abstract: | Anticoagulation with direct-acting oral anticoagulants (DOACs) is recommended over warfarin for stroke prevention in patients with atrial fibrillation (AF). The efficacy of DOACs over warfarin in obese patients with AF is less defined and may carry the potential for subtherapeutic anticoagulation and reduced efficacy. The best available evidence to guide DOAC use in obese patients with AF is from analysis of obese subgroups of all the major landmark DOAC trials. From these subgroup analyses of the RE-LY, ARISTOTLE, ENGAGE-AF TIMI 48, and ROCKET-AF trials, DOAC use in obese patients demonstrated efficacy similar or superior to warfarin for stroke reduction. Major bleeding rates were similar or higher with DOACs compared with warfarin in these obese subgroup analyses. Meta-analysis of the above major clinical trials concluded that DOACs were more effective compared with warfarin for stroke prevention in obese patients (up to a body mass index [BMI] of 50 kg/m2) and had lower incidence of major bleeding. The totality of evidence supports that DOACs are as effective, if not superior, to warfarin in obese patients with AF. We propose an algorithm, based on the available evidence and current guidelines, to guide the use of DOACs based on severity of obesity. Any DOAC can be used in obese patients with BMI < 40 kg/m2. In patients with a BMI of 40-50 kg/m2, warfarin should be used, but apixaban or edoxaban can be considered. In obese patients with a BMI > 50 kg/m2, warfarin should be used. |
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