Non-Vitamin K Antagonist Oral Anticoagulant for Atrial Fibrillation in Obese Patients

Wang, Stephen Y; Giugliano, Robert P.

doi:10.1016/j.amjcard.2020.04.016

Cited by 18 publications

(20 citation statements)

References 24 publications

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“…However, PK data from populations with obesity, when available, are reassuring about drug exposure [ 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 ]. Moreover, the outcome is always at least equal, if not better, in large retrospective and observational studies [ 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 ]. BMI is not a relevant covariate when tested [ 43 , 44 , 47 , 48 , 70 ].…”

Section: Discussionmentioning

confidence: 99%

“…In metanalyses including data from RCTs only, DOAC treatment resulted in efficacy and safety at least comparable to warfarin in overweight and obese patients [ 58 , 59 , 65 , 66 ].…”

Section: Metanalysesmentioning

confidence: 99%

“…Both Wang et al [ 66 ] and Zhou et al [ 59 ] analyzed efficacy and safety in different BMI classes (by using different cut-offs), confirming a significantly better efficacy profile of DOACs compared to warfarin, without differences in major bleeding.…”

Section: Metanalysesmentioning

confidence: 99%

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Direct Oral Anticoagulants in Patients with Obesity and Atrial Fibrillation: Position Paper of Italian National Association of Hospital Cardiologists (ANMCO)

Mocini

Fusco

Mocini

et al. 2021

JCM

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The use of the direct oral anticoagulants dabigatran, rivaroxaban, apixaban and edoxaban (DOACs) offers some major advantages over warfarin and other vitamin K antagonists (VKAs). One advantage is the possibility to use a fixed dose in normal-weight patients, overweight patients and patients with obesity. However, the “one size fits all” strategy raised a concern regarding the possibility to undertreat patients with a high body mass index. No randomized controlled trials (RCTs) have ever compared VKAs and DOACs in this population. We analyzed data from the literature on DOAC pharmacokinetics and pharmacodynamics, results from the four pivotal phase III trials on non-valvular atrial fibrillation, retrospective observational studies and metanalyses. While we are aware of the limitation imposed by the absence of specific RCTs, we propose the position of the Italian Association of Hospital Cardiologists (ANMCO) on the use of DOACs in patients with obesity based on the existing evidence.

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Section: Discussionmentioning

confidence: 99%

“…In metanalyses including data from RCTs only, DOAC treatment resulted in efficacy and safety at least comparable to warfarin in overweight and obese patients [ 58 , 59 , 65 , 66 ].…”

Section: Metanalysesmentioning

confidence: 99%

See 1 more Smart Citation

Direct Oral Anticoagulants in Patients with Obesity and Atrial Fibrillation: Position Paper of Italian National Association of Hospital Cardiologists (ANMCO)

Mocini

Fusco

Mocini

et al. 2021

JCM

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“…However, data are also emerging on the use of NOACs in these patients suggesting that NOACs may be a safe and effective alternative to warfarin for prevention of stroke or SEE in morbidly obese patients [37,40,41]. Recent analyses of the four pivotal NOAC trials (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE AF-TIMI 48) stratified by BMI showed preserved efficacy with NOACs compared with warfarin in obese patients, with a similar risk of major bleeding [42]. Although the data for class III obese patients (BMI ≥40 kg/m 2 ) are limited, apixaban and edoxaban demonstrated similar efficacy and safety to warfarin in patients with BMI 40-50 kg/m 2 .…”

Section: Discussionmentioning

confidence: 99%

Impact of Weight on Clinical Outcomes of Edoxaban Therapy in Atrial Fibrillation Patients Included in the ETNA-AF-Europe Registry

Boriani

Caterina

Manu

et al. 2021

JCM

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Background: Extremes of body weight may alter exposure to non-vitamin K antagonist oral anticoagulants and thereby impact clinical outcomes. This ETNA-AF-Europe sub-analysis assessed 1-year outcomes in routine care patients with atrial fibrillation across a range of body weight groups treated with edoxaban. Methods: ETNA-AF-Europe is a multinational, multicentre, observational study conducted in 825 sites in 10 European countries. Overall, 1310, 5565, 4346 and 1446 enrolled patients were categorised into ≤60 kg, >60–≤80 kg (reference weight group), >80–≤100 kg and >100 kg groups. Results: Patients weighing ≤60 kg were older, more frail and had a higher CHA2DS2-VASc score vs. the other weight groups. The rates of stroke/systemic embolism, major bleeding and ICH were low at 1 year (0.82, 1.05 and 0.24%/year), with no significant differences among weight groups. The annualised event rates of all-cause death were 3.50%/year in the overall population. After adjustment for eGFR and CHA2DS2-VASc score, the risk of all-cause death was significantly higher in extreme weight groups vs. the reference group. Conclusions: Low rates of stroke and bleeding were reported with edoxaban, independent of weight. The risk of all-cause death was higher in extremes of weight vs. the reference group after adjustment for important risk modifiers, thus no obesity paradox was observed.

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“…5 Similarly, consistent benefits of DOACs have been reported from the ARISTOTLE trial comparing apixaban with warfarin for stroke prevention in patients with AF and body weight >120 kg, 9 as well as in a meta-analysis of AF trials examining outcomes with DOACs compared with warfarin according to BMI. 10 Despite the overall reassuring results from the analyses by Martin et al and Boriani et al with the use of DOACs in patients with high body weights, several caveats should be considered. First, drug levels are poorly validated as a surrogate for clinical outcomes.…”

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confidence: 99%

Direct Oral Anticoagulant Dosing in Extremes of Body Weight: Time to Revisit the Guidelines?

Pandey

Eikelboom

2020

Thromb Haemost

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Non-Vitamin K Antagonist Oral Anticoagulant for Atrial Fibrillation in Obese Patients

Cited by 18 publications

References 24 publications

Direct Oral Anticoagulants in Patients with Obesity and Atrial Fibrillation: Position Paper of Italian National Association of Hospital Cardiologists (ANMCO)

Direct Oral Anticoagulants in Patients with Obesity and Atrial Fibrillation: Position Paper of Italian National Association of Hospital Cardiologists (ANMCO)

Impact of Weight on Clinical Outcomes of Edoxaban Therapy in Atrial Fibrillation Patients Included in the ETNA-AF-Europe Registry

Direct Oral Anticoagulant Dosing in Extremes of Body Weight: Time to Revisit the Guidelines?

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