Final Thoughts on DOACs in Obese Patients

Matthew Johnson, MD, and Paul Dobesh, PharmD, FCCP, BCPS, share some final thoughts on the dosing of DOACs in obese patients.

Jessica Kerr, PharmD, CDE: Thank you both for this rich amount of information and the discussion that we’ve been able to have today. Before we conclude, can I get your final thoughts on the topics that we’ve discussed today? Paul, we’ll start with you.

Paul Dobesh, PharmD, FCCP, BCPS: Overall, direct oral anticoagulants have been a blessing to patients and practitioners in dealing with anticoagulation. They overcome most of the limitations of warfarin, and they’re safe and effective in multiple populations. It varies a little based on drug, about indications. These are definitely really good drugs for patients who need anticoagulation in the prevention or treatment of thrombotic disease. As we said, going back to the same discussions we had 15 years ago with low molecular heparin, we’re still learning. Here’s what we know for most patients, but what about those “special” populations? Today our focus is on obesity. Is there enough drug to cover using standard doses, fixed doses, in these heavier patients, even really heavy patients? The data with rivaroxaban is very consistent there. Other DOACs have a little bit of a drop-off there. The impact on patient outcomes has yet to be fully determined. We’re in a place where, at least for some of the DOACs, obesity is not a reason not to use a DOAC.

Jessica Kerr, PharmD, CDE: Dr Johnson, do you want to share anything?

Matthew Johnson, MD: I agree. Change is probably the biggest thing, and we’re just reluctant to change things. We used to call them novel agents—they are not novel anymore; they’ve been around for a long time and our comfort level using them has grown quite a bit. I think back over the years when we’re all afraid possibly to make the transition until there is reversal agent. We don’t hear that discussion anymore, but everybody was reluctant for the change. As things developed, we got more studies to think about, patients studied with all these agents, and a stack of journals that we have acquired over the last 10 years using these agents.

The indications, especially for rivaroxaban, continue to grow. Not just VTE or A-fib, but we’re talking about chronic management of coronary disease and PAD and those things. To keep people engaged with this, information continues to grow. It takes discussions like this to review these topics and bring new food for thought in these categories.

Jessica Kerr, PharmD, CDE: Great. Well, definitely from a patient perspective, when these agents first came out, the cost was a concern, whether it was on the formulary and stuff. We’re just not needing to go through so many nonformulary approvals anymore, and I think that’s been a beneficial effect for the class as well. I would like to thank you both again. To our viewing audience, we hope you have found this Pharmacy Times® Practice Pearls discussion to be useful and informative.