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Grange C, Rioufol C, Souquet PJ, Assaad S. Anti-coagulant Treatment of Cancer-Associated Thrombosis in Frail Patients: Impact of Frailties on the Management of Drug-Drug Interactions. Clin Pharmacokinet 2023; 62:1523-1531. [PMID: 37824026 PMCID: PMC10582124 DOI: 10.1007/s40262-023-01298-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 10/13/2023]
Abstract
Low molecular weight heparins (LMWH) and anti-Xa direct oral anti-coagulants (DOACs) are recommended for the long-term treatment of cancer-associated thrombosis (CAT) based on well-documented randomised controlled trials. Anti-Xa DOACs are viewed as a first choice for the treatment of patients with CAT. A large number of drug-drug interactions have been reported between DOACs and chemotherapy drugs, modifying circulating levels of DOAC leading to fears of increased bleeding risks or thrombotic recurrence. Progresses in anti-neoplastic therapies have improved the prognosis and the survival, thus increasing the prevalence of frail patients with cancer. However, since frailties tend to be excluded from large trials due to multiple co-morbidities, current guidelines are not fully applicable to this population. The management of these frail patients with CAT is particularly complex and requires a risk assessment on a case-by-case basis with specific focus on cancer, patient-related risk factors and drug-drug interactions. In this brief review we have identified age, co-morbidities and co-medications as key factors of frailty that require careful attention and we have developed a therapeutic decision algorithm to help clinicians optimising the use of anti-coagulants in patients with cancer with CAT, especially in case of anti-Xa DOACs concomitant medications. With the evaluation of the bleeding risk according to the type of cancer, and anticipating drug-drug interactions intensity, taking into account patient frailties allows the optimisation of the anti-coagulant choice. A systematic collaboration between oncologists, vascular pathology specialists and pharmacists is warranted to ensure an optimal patient management. Clinical studies are needed to determine the real impact of these interactions.
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Affiliation(s)
- Claire Grange
- Service de Médecine Interne-Médecine Vasculaire, Hospices Civils de Lyon, CH Lyon Sud, Lyon, France.
| | - Catherine Rioufol
- Hospices Civils de Lyon, CH Lyon Sud, Service de Pharmacie, UCBL1-EA 3738 CICLY, Lyon, France
| | - Pierre-Jean Souquet
- Service de Pneumologie et Oncologie Thoracique, Hospices Civils de Lyon, CH Lyon Sud, Lyon, France
| | - Souad Assaad
- Département d'Oncologie Médicale, Centre Léon Bérard, Lyon, France
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2
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Guarascio M, Bertù L, Donadini MP, Antonucci E, Palareti G, Ageno W. DOACs use in extreme body-weighted patients: results from the prospective START-register. Intern Emerg Med 2023; 18:1681-1687. [PMID: 37301770 DOI: 10.1007/s11739-023-03334-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely used for the treatment of venous thromboembolism (VTE) and for stroke prevention in atrial fibrillation (AF). However, evidence in obese and underweight patients is limited. We assessed the safety and effectiveness of DOACs and vitamin K antagonists (VKAs) in patients ≥ 120 kg or ≤ 50 kg enrolled in an observational prospective cohort study, the START-Register. METHODS Adult patients started on anticoagulant therapy were followed up for a median of 1.5 years (IQR 0.6-2.8). Primary efficacy outcome was the occurrence of VTE recurrence, stroke and systemic embolism. Primary safety outcome was major bleeding (MB). RESULTS 10,080 AF and VTE patients were enrolled between March 2011 and June 2021, 295 patients weighted ≤ 50 kg and 82 patients ≥ 120 kg. Obese patients were significantly younger than underweight patients. Rates of thrombotic events were low and similar between DOACs and VKAs in underweight patients (1 event on DOACs therapy [0.9% 95% CI 0.11-5.39] and 2 on VKAs [1.1% 95% CI 0.01-47.68]) and in overweight patients (0 events on DOACs, 1 on VKAs [1.6%, 95% CI 0.11-5.79]. Two MB events occurred on DOACs (1.9%, 95% CI 0.38-6.00) and 3 on VKAs (1.6%, 95% CI 0.04-22.06) in the underweight group; 1 MB on DOACs (5.3% 95% CI 0.33-16.68) and 2 on VKAs (3.3%, 95% CI 0.02-130.77) in the overweight group. CONCLUSIONS DOACs seem to be effective and safe also for the treatment of patients with extreme body weights, both underweight and overweight. Further prospective studies are needed to support these findings.
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Affiliation(s)
| | - Lorenza Bertù
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese, Italy
| | - Marco Paolo Donadini
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese, Italy
- Emergency Medicine and Thrombosis and Haemostasis Center, ASST Sette Laghi, Varese, Italy
| | | | | | - Walter Ageno
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, Varese, Italy
- Emergency Medicine and Thrombosis and Haemostasis Center, ASST Sette Laghi, Varese, Italy
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3
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Falco L, Tessitore V, Ciccarelli G, Malvezzi M, D'Andrea A, Imbalzano E, Golino P, Russo V. Antioxidant Properties of Oral Antithrombotic Therapies in Atherosclerotic Disease and Atrial Fibrillation. Antioxidants (Basel) 2023; 12:1185. [PMID: 37371915 DOI: 10.3390/antiox12061185] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 05/22/2023] [Accepted: 05/29/2023] [Indexed: 06/29/2023] Open
Abstract
The thrombosis-related diseases are one of the leading causes of illness and death in the general population, and despite significant improvements in long-term survival due to remarkable advances in pharmacologic therapy, they continue to pose a tremendous burden on healthcare systems. The oxidative stress plays a role of pivotal importance in thrombosis pathophysiology. The anticoagulant and antiplatelet drugs commonly used in the management of thrombosis-related diseases show several pleiotropic effects, beyond the antithrombotic effects. The present review aims to describe the current evidence about the antioxidant effects of the oral antithrombotic therapies in patients with atherosclerotic disease and atrial fibrillation.
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Affiliation(s)
- Luigi Falco
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Viviana Tessitore
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Giovanni Ciccarelli
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Marco Malvezzi
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | | | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, 98122 Messina, Italy
| | - Paolo Golino
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
| | - Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Science, University of Campania "Luigi Vanvitelli"-Monaldi Hospital, 80126 Naples, Italy
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Rosovsky RP, Kline-Rogers E, Lake L, Minichiello T, Piazza G, Ragheb B, Waldron B, Witt DM, Moll S. Direct Oral Anticoagulants in Obese Patients with Venous Thromboembolism: Results of an Expert Consensus Panel. Am J Med 2023; 136:523-533. [PMID: 36803697 DOI: 10.1016/j.amjmed.2023.01.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 02/18/2023]
Abstract
In clinical practice, direct oral anticoagulants (DOACs) are increasingly used for venous thromboembolism treatment and prevention. A substantial proportion of patients with venous thromboembolism are also obese. International guidance published in 2016 stated that DOACs could be used in standard doses in patients with obesity up to a body mass index [BMI] of 40 kg/m2, but should not be used in those with severe obesity (BMI > 40 kg/m2) owing to limited supporting data at the time. Although updated guidance in 2021 removed this limitation, some healthcare providers still avoid DOACs even in patients with lower levels of obesity. Furthermore, there are still evidence gaps regarding treatment of severe obesity, the role of peak and trough DOAC levels in these patients, use of DOACs after bariatric surgery, and appropriateness of DOAC dose reduction in the setting of secondary venous thromboembolism prevention. This document describes proceedings and outcomes of a multidisciplinary panel convened to review these and other key issues regarding DOAC use for treatment or prevention of venous thromboembolism in individuals with obesity.
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Affiliation(s)
- Rachel P Rosovsky
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Eva Kline-Rogers
- University of Michigan, Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Leslie Lake
- National Blood Clot Alliance, Philadelphia, Pennsylvania
| | - Tracy Minichiello
- University of California, Department of Veterans Affairs, San Francisco, California
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bishoy Ragheb
- Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee
| | | | - Daniel M Witt
- University of Utah College of Pharmacy, Department of Pharmacotherapy, Salt Lake City, Utah
| | - Stephan Moll
- Department of Medicine, UNC School of Medicine, Chapel Hill, North Carolina
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Wee B, Lui B, Lai J, Khattak Z, Kwok A, Donarelli C, Ho P, Lim HY. Management of venous thromboembolism in morbidly obese patients: a 10-year review. J Thromb Thrombolysis 2023; 55:304-11. [PMID: 36526867 DOI: 10.1007/s11239-022-02738-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Abstract
Obesity is a known risk factor for venous thromboembolism (VTE) and poses a unique set of challenges in anticoagulation management. We report a 10-year experience of VTE management in morbidly obese patients. We conducted a retrospective analysis of VTE presentations to Northern Health, Victoria, Australia, from January 2011 to December 2020, with median follow-up of 44 months. Morbidly obese patients (defined as weighing > 120 kg) were compared to those ≤ 120 kg. Patients with active malignancy were excluded. 194 VTE cases with weight > 120 kg were compared to 2168 cases weighing ≤ 120 kg. Patients > 120 kg were more likely to present with unprovoked VTE (59.3% vs. 45.2%, p < 0.001) and major VTE (74.7% vs. 67.4%, p = 0.028). Overall, patients > 120 kg were more likely to develop VTE recurrence after anticoagulation cessation (7.80 vs. 3.92 per 100-patient-years, HR 1.97, 95%CI 1.29-3.00), while there were no significant differences in major bleeding or 30-day all-cause mortality. There were no significant differences in outcomes in patients > 120 kg treated with warfarin compared to direct oral anticoagulants (DOAC), or when comparing those treated with an uncapped (1 mg/kg BD) vs. capped (< 1 mg/kg) enoxaparin dosing regimen. Morbid obesity is associated with increased clot burden at presentation and VTE recurrence following anticoagulation cessation, without significant differences in bleeding compared to those ≤ 120 kg. There were no significant differences in morbidly obese patients' outcomes when treated with warfarin or DOAC, or when treated with an uncapped or capped enoxaparin dosing strategy. Larger randomised controlled trials evaluating the safety of DOACs and different enoxaparin dosing strategies in patients > 120 kg are warranted.
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Liu J, Qiao X, Wu M, Wang H, Luo H, Zhang H, Chen Y, Sun J, Tang B. Strategies involving low-molecular-weight heparin for the treatment and prevention of venous thromboembolism in patients with obesity: A systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1084511. [PMID: 36967796 PMCID: PMC10031025 DOI: 10.3389/fendo.2023.1084511] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/13/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION Recent studies have indicated that the dosage of LMWH in patients with specific weights may be controversial. Therefore, we conducted a meta-analysis to explore an appropriate dosage of LMWH for the prevention and treatment of venous thromboembolism (VTE) in patients with obesity. MATERIALS AND METHODS We searched the PubMed, EMBASE, and Cochrane Library databases up to July 23, 2022. Study selection, bias analysis, and information extraction were performed by three independent reviewers. The occurrence or recurrence of VTE and bleeding events were the primary outcomes we assessed. RESULTS Eleven studies (a total of 6266 patients) were included in the prevention group, and 6 studies (a total of 3225 patients) were included in the treatment group. For VTE prophylaxis, compared with the standard-dosage group, the high-dosage group had a lower incidence of VTE (OR: 0.47, 95% CI: 0.27-0.82, P=0.007) and a similar incidence of bleeding events (OR: 0.86, 95% CI: 0.69-1.08, P=0.020). For VTE therapy, compared to the standard-dosage group, the reduced-dosage group had a similar incidence of VTE recurrence (OR: 0.86, 95% CI: 0.11-6.84, P=0.89) but a lower incidence of bleeding events (OR: 0.30, 95% CI: 0.10-0.89, P=0.03). CONCLUSION In patients with obesity, increasing the dosage of LMWH is a more appropriate option for the prevention of VTE. Due to the limited evidence, reducing the therapeutic dosage of LMWH requires careful consideration. Larger-scale, well-designed randomized controlled trials are necessary. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?, identifier ID=CRD42022298128.
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Affiliation(s)
- Junjie Liu
- Vascular, Abdominal & Hernia Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xi Qiao
- Department of Clinical Medicine, The Second Clinical Medical College, Chongqing Medical University, Chongqing, China
| | - Mingdong Wu
- Vascular, Abdominal & Hernia Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyang Wang
- Vascular, Abdominal & Hernia Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Vascular, Abdominal & Hernia Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haolong Zhang
- Vascular, Abdominal & Hernia Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yikuan Chen
- Vascular, Abdominal & Hernia Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jianming Sun
- Vascular, Abdominal & Hernia Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tang
- Vascular, Abdominal & Hernia Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
- *Correspondence: Bo Tang,
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Wang TF. The 5 most frequently asked questions about factor Xa inhibitors. Hematology Am Soc Hematol Educ Program 2022; 2022:515-521. [PMID: 36485108 PMCID: PMC9821165 DOI: 10.1182/hematology.2022000385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Direct oral anticoagulants (DOACs) are commonly used oral factor Xa inhibitors in recent years. However, in some special clinical situations, the appropriate use of these anticoagulants may be of concern. In this article, we address the 5 commonly asked questions regarding their use for the treatment of venous thromboembolism, including in the setting of obesity, renal impairment, gastrointestinal (GI) malignancy, catheter-related thrombosis, and drug-drug interactions. Data on the use of DOACs in the presence of significant obesity or renal failure are mainly observational. Some DOACs are shown to have an increased risk of bleeding in patients with unresected luminal GI malignancy but not others, so selection of appropriate patients is the key. Furthermore, literature on the use of DOACs for catheter-related thrombosis or when drug-drug interactions are of concern is limited, and more research is welcome.
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Affiliation(s)
- Tzu-Fei Wang
- Correspondence Tzu-Fei Wang, The Ottawa Hospital, General Campus, 501 Smyth Road, Box 201A, Ottawa, ON K1H 8L6, Canada; e-mail:
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Erstad BL, Barletta JF. Dilemmas Related to Direct-Acting Oral Anticoagulant Administration in Patients With Extreme Obesity. Ann Pharmacother 2022; 57:727-737. [PMID: 36258660 DOI: 10.1177/10600280221130456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The objective of the study was to discuss the controversies surrounding the use and dosing of direct-acting oral anticoagulants (DOACs) in obese patients recognizing the limitations of the existing evidence base that preclude strong recommendations. DATA SOURCES A literature search of MEDLINE was performed (2020 to end August 2022) subsequent to recent guidelines using the following search terms: direct acting anticoagulants, obesity, rivaroxaban, apixaban, edoxaban, dabigatran, dabigatran etexilate, and clinical practice guidelines. STUDY SELECTION AND DATA ABSTRACTION English-language studies and those conducted in adults were selected. DATA SYNTHESIS The available randomized studies evaluating DOACs had relatively small numbers of patients with more extreme forms of obesity (body mass index [BMI] > 40 kg/m2) and none of the larger studies had a specific focus on dosing DOACs in obese patients. Recent guidelines by the International Society on Thrombosis and Haemostasis (ISTH) have specific recommendations for dosing DOACs in obesity. There are pharmacokinetic/pharmacodynamic and observational studies published before and after the ISTH guidelines with a focus on DOAC dosing in obese patients that generally support the recommendations in the guidelines, but most involved small numbers of patients usually with BMIs <45 kg/m2. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review discusses DOAC dosing in obesity with important considerations for clinicians related to DOAC choice and dosing. CONCLUSIONS Dosing alterations of DOACs do not appear to be necessary when used for either prophylaxis or treatment in patients with BMIs up to approximately 45 to 50 kg/m2, but research is needed for BMIs >50 kg/m2.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, The University of Arizona, Tucson, AZ, USA
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy-Glendale Campus, Midwestern University, Glendale, AZ, USA
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Russo V, Fabiani D. Put out the fire: The pleiotropic anti-inflammatory action of non-vitamin K oral anticoagulants. Pharmacol Res 2022; 182:106335. [PMID: 35781059 DOI: 10.1016/j.phrs.2022.106335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/15/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) should be the preferred anticoagulant strategy for preventing ischemic stroke in patients with atrial fibrillation (AF) at increased thromboembolic risk and for treating deep venous thromboembolism (DVT) in the general population. Beyond their inhibiting action on the activated factor X (FXa) or thrombin (FIIa), NOACs showed some pleiotropic anti-inflammatory effects. The present review aimed to describe the role of FXa and FIIa in the inflammation pathway and the potential anti-inflammatory effects of NOACs.
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Affiliation(s)
- Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy.
| | - Dario Fabiani
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, Naples, Italy
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10
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Jamieson MJ, Byon W, Dettloff RW, Crawford M, Gargalovic PS, Merali SJ, Onorato J, Quintero AJ, Russ C. Apixaban Use in Obese Patients: A Review of the Pharmacokinetic, Interventional, and Observational Study Data. Am J Cardiovasc Drugs 2022; 22:615-631. [PMID: 35570249 PMCID: PMC9618533 DOI: 10.1007/s40256-022-00524-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2022] [Indexed: 11/30/2022]
Abstract
Abstract Relatively little is known about the influence of extreme body weight on the pharmacokinetics (PK), pharmacodynamics (PD), efficacy, and safety of drugs used in many disease states. While direct oral anticoagulants (DOACs) have an advantage over warfarin in that they do not require routine drug monitoring, some may regard this convenience as less compelling in obese patients. Some consensus guidelines discourage using DOACs in patients weighing > 120 kg or with a body mass index > 35–40 kg/m2, given a sparsity of available data in this population and the concern that fixed dosing in obese patients might lead to decreased drug exposure and lower efficacy. Per the prescribing information, apixaban does not require dose adjustment in patients weighing above a certain threshold (e.g., ≥ 120 kg). Data from healthy volunteers and patients with nonvalvular atrial fibrillation (NVAF) or venous thromboembolism (VTE) have shown that increased body weight has a modest effect on apixaban’s PK. However, the paucity of exposure data in individuals > 120 kg and the lack of guideline consensus on DOAC use in obese patients continue to raise concerns about potential decreased drug exposure at extreme weight. This article is the first to comprehensively review the available PK data in obese individuals without NVAF or VTE, and PK, PD, efficacy, effectiveness, and safety data for apixaban in obese patients with either NVAF or VTE, including subgroup analyses across randomized controlled trials and observational (real-world) studies. These data suggest that obesity does not substantially influence the efficacy, effectiveness, or safety of apixaban in these patients. Trial Registration ARISTOTLE: NCT00412984; AVERROES: NCT00496769; AMPLIFY: NCT00643201; AMPLIFY-EXT: NCT00633893; ADVANCE-1: NCT00371683; ADVANCE-2: NCT00452530; ADVANCE-3: NCT00423319 Video abstract Apixaban Use in Obese Patients: A Review of the Pharmacokinetic, Interventional, and Observational Study Data (MP4 161.22 MB)
Supplementary Information The online version contains supplementary material available at 10.1007/s40256-022-00524-x.
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Affiliation(s)
| | - Wonkyung Byon
- Global Product Development, Clinical Pharmacology, Pfizer, Groton, CT, 06340, USA
| | | | - Matthew Crawford
- Worldwide Research and Development, Computational Sciences, Pfizer, New York, NY, 10017, USA
| | - Peter S Gargalovic
- US Medical Cardiovascular, Bristol Myers Squibb, Princeton, NJ, 08648, USA
| | - Samira J Merali
- Clinical Pharmacology and Pharmacometrics, Bristol Myers Squibb, Princeton, NJ, 08648, USA
| | - Joelle Onorato
- US Medical Cardiovascular, Bristol Myers Squibb, Princeton, NJ, 08648, USA
| | - Andres J Quintero
- Internal Medicine, Medical Affairs, Medical Innovation and Effectiveness, Pfizer, New York, NY, 10017, USA
| | - Cristina Russ
- Internal Medicine, Medical affairs, Pfizer, New York, NY, 10017, USA
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11
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Wang TF, Carrier M, Fournier K, Siegal DM, Le Gal G, Delluc A. Oral anticoagulant use in patients with morbid obesity: A systematic review and meta-analysis. Thromb Haemost 2021; 122:830-841. [PMID: 34399433 DOI: 10.1055/a-1588-9155] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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 3 randomized controlled trials (5 studies) and 18 observational studies in adult patients with a body weight ≥ 120 kg, body mass index (BMI) ≥ 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. CONCLUSIONS 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.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine. University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Deborah M Siegal
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
| | - Grégoire Le Gal
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Canada.,Université de Bretagne Occidentale, Brest, France.,INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, Saint Etienne, France
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12
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Zhuang Y, Dai LF, Chen MQ. Efficacy and safety of non-vitamin K antagonist oral anticoagulants for venous thromboembolism: a meta-analysis. JRSM Open 2021; 12:20542704211010686. [PMID: 34178359 PMCID: PMC8207293 DOI: 10.1177/20542704211010686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Several trials had compared the efficacy and safety between non-vitamin K antagonist oral anticoagulants and warfarin for acute venous thromboembolism, but the results were incomplete. This updated review comprehensively assessed the efficacy and safety of non-vitamin K antagonist oral anticoagulants for venous thromboembolism. Design Meta-analysis of randomised control trials. Six databases were searched from January 2000 to December 2018. Setting Adult patients had got non-vitamin K antagonist oral anticoagulants or warfarin for venous thromboembolism. Participants Randomised control trials that compared the efficacy and safety between non-vitamin K antagonist oral anticoagulants and warfarin. Main outcome measures The efficacy and safety of non-vitamin K antagonist oral anticoagulants . Results Seven studies involving 29,879 cases were included, among which 14,943 cases were assigned to non-vitamin K antagonist oral anticoagulants group and 14,936 cases to warfarin group. Meta-analysis showed that compared with warfarin, recurrent venous thromboembolism (odds ratio 0.94 [95% confidence interval 0.81 to 1.11]), death related to venous thromboembolism or fatal pulmonary embolism (odds ratio 1.00 [95% confidence interval 0.63 to 1.60]), symptomatic deep-vein thrombosis (odds ratio 0.88 [95% confidence interval 0.72 to 1.09]), symptomatic nonfatal pulmonary embolism (odds ratio 1.03 [(95% confidence interval 0.82 to 1.30]) and all deaths (odds ratio 0.92 [95% confidence interval 0.76 to 1.12]) are similar in non-vitamin K antagonist oral anticoagulants group, but major bleeding event (odds ratio 0.61 [95% confidence interval 0.50 to 0.75]) and clinically relevant non-major bleeding event (odds ratio [95% confidence interval 0.53 to 0.85]) are less in non-vitamin K antagonist oral anticoagulants group. . Conclusions For the treatment of venous thromboembolism, non-vitamin K antagonist oral anticoagulants is as effective as warfarin, and has a better safety profile than warfarin.
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Affiliation(s)
- Yan Zhuang
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
| | - Lin-Feng Dai
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
| | - Ming-Qi Chen
- Department of Critical Care Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, Nanjing 210029 China
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Lamarche MC, Alrajhi E, Wells PS. Direct oral anticoagulant use in special populations. Curr Opin Pulm Med 2021; 27:311-8. [PMID: 34115699 DOI: 10.1097/MCP.0000000000000787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The pivotal phase III trials demonstrating efficacy and safety of direct oral anticoagulants (DOACs) in the treatment of venous thromboembolism (VTE) or nonvalvular atrial fibrillation (NVAF) excluded patients with important and common comorbidities, including obesity, advanced chronic kidney disease, cirrhosis, cancer and antiphospholipid antibody syndrome. Despite the lack of large prospective randomized control trials in these patient populations, the use of DOACs has led to a wealth of efficacy and safety data within these groups. RECENT FINDINGS Retrospective studies, meta-analyses, national databases and pharmacokinetic data have shed light on the efficacy and safety of DOACs in these patient populations. Although DOACs should be avoided in those with high-risk triple positive antiphospholipid antibody syndrome, advanced cirrhosis, advanced kidney disease and intact gastrointestinal cancers, and used with caution in genitourinary cancers, their use extends beyond the inclusion criteria of the initial randomized control trials. SUMMARY DOACs have revolutionized anticoagulant management and have become the cornerstone for VTE treatment and stroke prevention in NVAF. The decision to use DOACs must be individualized. Patient preference, underlying comorbidities and informed consent must always be considered when selecting the most appropriate anticoagulant.
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