Practices, beliefs, and attitudes of clinicians in prescribing direct oral anticoagulants for obese adults with atrial fibrillation: a qualitative study

Abstract

Background Atrial fibrillation (AF) and obesity affect over 60 and 650 million people, respectively. Aim This study aimed to explore clinician practices, beliefs, and attitudes towards the use of direct oral anticoagulants (DOACs) in obese adults (BMI ≥ 30 kg/m2) with AF. Method Semi-structured interviews via video conference were conducted with multidisciplinary clinicians from across Australia, with expertise in DOAC use in adults with AF. Clinicians were invited to participate using purposive and snowball sampling techniques. Data were analysed in NVIVO using thematic analysis. Results Fifteen clinicians including cardiologists (n = 5), hospital and academic pharmacists (n = 5), general practitioners (n = 2), a haematologist, a neurologist and a clinical pharmacologist participated. Interviews were on average 31 ± 9 min. Key themes identified were: Health system factors in decision-making Disparities between rural and metropolitan geographic areas, availability of health services, and time limitations for in-patient decision-making, were described; Condition-related factors in decision-making Clinicians questioned the significance of obesity as part of decision-making due to the practical limitations of dose modification, and the rarity of the extremely obese cohort; Decision-making in the context of uncertainty Clinicians reported limited availability, reliability and awareness of primary evidence including limited guidance from clinical guidelines for DOAC use in obesity. Conclusion This study highlights the complexity of decision-making for clinicians, due to the limited availability, reliability and awareness of evidence, the intrinsic complexity of the obese cohort and limited guidance from clinical guidelines. This highlights the urgent need for contemporary research to improve the quality of evidence to guide informed shared decision-making.

Trends in prescribing and outcomes in obese versus non-obese patients receiving rivaroxaban therapy: an observational study using real-world data

“…This distinction in the trend of rivaroxaban prescribing in obese vs. non-obese populations may reflect clinicians' hesitance in prescribing rivaroxaban for obese population in light of the emerging and conflicting evidence and/or recommendations in recent years [35][36][37][38][39]. Such key recommendations were reported in the ISTH position statement "we suggest that DOACs should not be used in patients with a BMI of > 40 kg/m 2 or a weight of > 120 kg, because there are limited clinical data available for patients at the extreme of weight, and the available PK/ PD evidence suggests that decreased drug exposures, reduced peak concentrations and shorter half-lives occur with increasing weight, which raises concerns about underdosing in the population at the extreme of weight", which emphasizes the usefulness of exploring such prescription trends of rivaroxaban in real-world practice [40][41][42].…”