Practice Pearl #2 Challenges in Using DOACs in Obese Patients and Education

The panel of experts in cardiology discuss the barriers with treatment of obese patients with DOACs. They also discuss the importance of education of their peers.

Jessica Kerr, PharmD, CDE: Another question, Dr Johnson. We’ve talked about the heart data—the benefit is there, either equivalent or maybe superior in some of the risks that we would have come about with the DOACs, but what are some specific challenges that you recall making that treatment decision with DOACs in the obese population?

Matthew Johnson, MD: Well, the challenge was initially—I’m talking about a few years ago, as we get the extreme, especially the BMI of 40—the concern that maybe we haven’t studied enough and we don’t have enough data out there to safely use DOACs in that instance. The difficulty we have was with these patients—all the things we’ve talked about with diet interactions—is trying to maintain someone’s therapy range if they have all those variabilities. We get to the morbidly obese patient, and you have a lot of other drugs most of the time that these patients are taking and the interaction.

Clinically the difficulty I had was frustration from the patient and the practitioner, trying to keep someone anticoagulated with warfarin. Even early on, when we started to see the data coming out, with some of these BMIs in that 35-to-40 range and even above 40, clinically we started to get a comfort level, especially using rivaroxaban in those patients. Just as we were talking about with renal-insufficient patients, and we got more data with it, we were seeing the efficacy and safety in the data there. Just as Paul had mentioned earlier, that’s probably just as important or more important for the safety for these patients. The safety data continues to shine through.

Jessica Kerr, PharmD, CDE: Paul, can you talk about some of the newer data coming out or that have come out recently? With all the clinicians going in different ways with different responsibilities, how do we make our colleagues aware of these particular data? Have you found a trick to your trade to help on the education side, detailing those prescribing providers and even your pharmacists who are on the front lines with giving education to their own patients.

Paul Dobesh, PharmD, FCCP, BCPS: Sure. You hit on the term there: education, education, education. A lot of busy practitioners are really down deep in that patient care, so the luxury of my job is I have time to evaluate these trials and my job is to do this education. It’s things like you making sure you’re on the residents, periodically teaching grand rounds that happen, and you’re bringing these topics up there when you’re on service and then you’re more attuned. If you could put together a 1-page summary that maybe gets circulated around the pharmacy. I work a lot with the cardiology department, so maybe try to circulate stuff there. But things take time, right? Change doesn’t happen quickly. We know that. Whenever these drugs are out. They have been out now for, geez, 10 years, and just recently they have overcome warfarin. There are more people who get DOACs now than get started on warfarin. That just happened 2 years ago. Change happens slowly, and we just have to be advocates and keep at it and entertain good discussions like this. Creating educational materials like what we’re doing this afternoon. This has the ability to influence or educate thousands of people. These are great venues in which these types of messages can get out, and then people can just—bam, now we’re going to take better care of this group of patients.