Direct Oral Anticoagulants Versus Warfarin in Morbidly Obese Patients With Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-analysis

Mhanna, Mohammed; Beran, Azizullah; Al‐Abdouh, Ahmad; Sajdeya, Omar; Abdulsattar, Waleed; Srour, Omar; Ayesh, Hazem; Alom, Modar; Khuder, Sadik A.; Hamouda, Danae; Assaly, Ragheb

doi:10.1097/mjt.0000000000001403

Cited by 14 publications

(12 citation statements)

References 31 publications

(58 reference statements)

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Was not based on patients with AF (7); Duplicated studies (21). Finally, only 10 studies [11][12][13][14][15][16][17][18][19][20] were selected to be used for this meta-analysis.…”

Section: Searched Outcomesmentioning

confidence: 99%

Comparing the Clinical Outcomes Observed with Rivaroxaban Versus Warfarin for the Management of Obese Patients with Non-valvular Atrial Fibrillation: a Systematic Review and Meta-analysis

Zhuo

Wang

Shao

2022

Cardiovasc Drugs Ther

View full text Add to dashboard Cite

Background Atrial fibrillation (AF) is an irregular heart rhythm which is becoming more and more common in this new era. Obesity is a risk factor for cardiovascular events, and obese patients are more at risk for stroke. The Framingham Heart Study demonstrated an increase in the developmental risk of AF by 4% for every unit (kg/m2) increase in body mass index (BMI). An anticoagulant is often required for the management of such patients. In this analysis, we aimed to systematically compare the clinical outcomes which were associated with rivaroxaban versus warfarin for the treatment of obese patients with non-valvular AF. Methods PubMed, EMBASE, Web of Science, http://www.ClinicalTrials.gov, Google Scholar, and Cochrane Central were the searched databases. Clinical outcomes including stroke, systemic embolism, and major bleeding were the endpoints. In this study, dichotomous data were analyzed by the RevMan software version 5.4. Risk ratio (RR) with 95% confidence interval (CI) was used for result interpretation. Results Ten studies consisting of a total number of 168,081 obese participants were included whereby 81,332 participants were treated with rivaroxaban and 86,749 participants were treated with warfarin. The risks of ischemic (RR: 0.79, 95% CI: 0.74–0.84; P = 0.00001) and hemorrhagic stroke (RR: 0.61, 95% CI: 0.48–0.76; P = 0.0001) as well as systemic embolism (RR: 0.73, 95% CI: 0.62–0.87; P = 0.0004) were significantly lower with rivaroxaban compared to warfarin for the management of these obese patients with non-valvular AF. Rivaroxaban was also associated with a significantly lower risk of major bleeding (RR: 0.75, 95% CI: 0.65–0.87; P = 0.0001). Conclusion Based on this analysis, rivaroxaban seemed to be a better option in comparison to warfarin, due to its association with significantly lower risks of stroke and bleeding outcomes in obese patients with non-valvular AF. However, this hypothesis should further be confirmed in larger clinical trials.

show abstract

“…Was not based on patients with AF (7); Duplicated studies (21). Finally, only 10 studies [11][12][13][14][15][16][17][18][19][20] were selected to be used for this meta-analysis.…”

Section: Searched Outcomesmentioning

confidence: 99%

Comparing the Clinical Outcomes Observed with Rivaroxaban Versus Warfarin for the Management of Obese Patients with Non-valvular Atrial Fibrillation: a Systematic Review and Meta-analysis

Zhuo

Wang

Shao

2022

Cardiovasc Drugs Ther

View full text Add to dashboard Cite

show abstract

“…55 All of the other systematic reviews involving patients with varying degrees of obesity found DOACs to yield similar or better outcomes compared with warfarin in terms of VTE and major bleeding events. [56][57][58][59][60][61][62][63] However, as exemplified by one of the more recent systematic reviews, 63 the certainty of evidence underlying outcome comparisons was typically defined as low or very low, as the majority of included studies were observational or post hoc analyses of randomized trials. Detailed information related to specific DOACs and dosing regimens was not provided likely due to the lack of such data in the studies under review.…”

Section: Systematic Reviewsmentioning

confidence: 99%

Dilemmas Related to Direct-Acting Oral Anticoagulant Administration in Patients With Extreme Obesity

Erstad

Barletta

2022

Ann Pharmacother

View full text Add to dashboard Cite

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.

show abstract

“…Since that recommendation, several studies and post-hoc analyses have investigated the impact of BMI on the safety and effectiveness DOACs, including Dabigatran, Rivaroxaban, Apixaban, and Edoxaban [ 11 – 16 ]. A systemic review and meta-analysis including a total of 89,494 morbidly obese patients with non-valvular AF comparing DOACs to warfarin reported that DOAC was associated with significantly lower stroke or systemic embolism [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.62–0.81; P < 0.0001; I 2 = 0%] compared to warfarin [ 17 ]. In addition, DOACs had a significantly lower major bleeding compared to warfarin (OR: 0.60; 95% CI: 0.46–0.78; P < 0.0001; I 2 = 86%) [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

“…A systemic review and meta-analysis including a total of 89,494 morbidly obese patients with non-valvular AF comparing DOACs to warfarin reported that DOAC was associated with significantly lower stroke or systemic embolism [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.62–0.81; P < 0.0001; I 2 = 0%] compared to warfarin [ 17 ]. In addition, DOACs had a significantly lower major bleeding compared to warfarin (OR: 0.60; 95% CI: 0.46–0.78; P < 0.0001; I 2 = 86%) [ 17 ]. A sub-class analysis in that meta-analysis showed that apixaban and rivaroxaban were superior to warfarin in safety and efficacy [ 17 ].…”

Section: Introductionmentioning

confidence: 99%

“…In addition, DOACs had a significantly lower major bleeding compared to warfarin (OR: 0.60; 95% CI: 0.46–0.78; P < 0.0001; I 2 = 86%) [ 17 ]. A sub-class analysis in that meta-analysis showed that apixaban and rivaroxaban were superior to warfarin in safety and efficacy [ 17 ]. Although the results of several meta-analyses support the use of rivaroxaban and apixaban in morbidly obese patients with non-valvular AF, additional randomized clinical trials comparing the efficacy and safety of DOACs to warfarin in this patient population are needed before a strong recommendation can be made [ 17 , 18 ].…”

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

Evaluation of Apixaban safety and effectiveness in morbidly obese patients with atrial fibrillation: a retrospective cohort study

et al. 2022

View full text Add to dashboard Cite

Background The benefit of apixaban to reduce stroke risk in morbidly obese patients with nonvalvular atrial fibrillation (AF) is still undetermined. The International Society of Thrombosis and Hemostasis recommends avoiding the use of direct oral anticoagulants (DOAC)s in morbidly obese patients (body mass index > 40 or weight > 120 kg) because of limited clinical data. This exploratory study aims to evaluate the effectiveness and safety of using apixaban in morbidly obese (body mass index (BMI) ≥ 40) patients with AF. Methods An exploratory retrospective cohort study was conducted at a single-center, including adult patients with non-valvular AF using apixaban between 01/01/2016 and 31/12/2019. Patients were excluded if they were known to have liver cirrhosis Child-Pugh C, mechanical valve, serum creatinine > 1.5 mg/dL, follow up < 3 months, or using apixaban with a dose of ≤5 or > 10 mg/day. Included patients were categorized into two groups based on their BMI (BMI<40 Vs. BMI ≥ 40). The primary outcome was all thrombotic events, while the secondary outcomes were major and minor bleeding after apixaban initiation. Propensity score (PS) matching was used (1:1 ratio) based on the patient’s age, gender, and HAS-BLED score. Results A total of 722 patients were eligible; 254 patients were included after propensity score matching based on the selected criteria. The prevalence of all thrombotic events was similar between the two groups in the first year of apixaban initiation (OR (95%CI): 0.58 (0.13, 2.5), p-value = 0.46). In addition, the odds of developing major and minor bleeding were not statistically significant between the two groups (OR (95%CI): 0.39 (0.07, 2.03), p-value = 0.26 and OR (95%CI): 1.27 (0.56, 2.84), p-value = 0.40), respectively). Conclusion This exploratory study showed similar effectiveness and safety of apixaban use in both morbid and non-morbid obese patients with non-valvular AF. However, a larger randomized controlled trial with a longer follow-up period needs to confirm our findings.

show abstract

Direct Oral Anticoagulants Versus Warfarin in Morbidly Obese Patients With Nonvalvular Atrial Fibrillation: A Systematic Review and Meta-analysis

Cited by 14 publications

References 31 publications

Comparing the Clinical Outcomes Observed with Rivaroxaban Versus Warfarin for the Management of Obese Patients with Non-valvular Atrial Fibrillation: a Systematic Review and Meta-analysis

Comparing the Clinical Outcomes Observed with Rivaroxaban Versus Warfarin for the Management of Obese Patients with Non-valvular Atrial Fibrillation: a Systematic Review and Meta-analysis

Dilemmas Related to Direct-Acting Oral Anticoagulant Administration in Patients With Extreme Obesity

Evaluation of Apixaban safety and effectiveness in morbidly obese patients with atrial fibrillation: a retrospective cohort study

Contact Info

Product

Resources

About