Weighing Options: Comparing Oral Anticoagulants for Patients at Various BMIs

Authors:
Taylor M. Benavides, PharmD, BCPS
Elizabeth B. Hearn, PharmD, BCACP

Reviewers:
Megan Supple, PharmD, BCACP, CPP
Katie Kiser, PharmD, BCACP

Citation:
Patel SM, Braunwald E, Steffel J, et al. Efficacy and Safety of Non-Vitamin-K Antagonist Oral Anticoagulants Versus Warfarin Across the Spectrum of Body Mass Index and Body Weight: An Individual Patient Data Meta-Analysis of 4 Randomized Clinical Trials of Patients with Atrial Fibrillation. Circulation. 2024;149(12):932-943.

The Problem

Direct oral anticoagulants (DOACs) are the standard of care for stroke prevention in most patients with nonvalvular atrial fibrillation (NVAF).¹ That is, except for patients with BMI >40.  In these patients there is a concern that drug concentrations might be lower and thereby, reducing the efficacy of DOACs. Data on the safety and efficacy of DOACS in patients with obesity are limited and, at times, contradictory.^2,3 What would you recommend for a patient with a BMI>40: warfarin, which requires periodic monitoring and dose adjustments, or a DOAC, which may not be as effective?