Department of Clinical Biochemistry, Thrombosis and Hemostasis Research Unit, Aarhus University Hospital, Aarhus, Denmark.
Semin Thromb Hemost. 2020 Nov;46(8):932-969. doi: 10.1055/s-0040-1718405. Epub 2020 Dec 23.
Anticoagulants are frequently used as thromboprophylaxis and in patients with atrial fibrillation (AF) or venous thromboembolism (VTE). While obesity rates are reaching epidemic proportions worldwide, the optimal dosage for obese patients has not been established for most anticoagulants, including low-molecular-weight heparin (LMWH), non-vitamin K antagonist oral anticoagulants (NOAC), and pentasaccharides (fondaparinux). The aim of the present systematic review was to summarize the current knowledge and provide recommendations on dosage of LMWH, NOAC, and fondaparinux in obese patients (body mass index [BMI] ≥ 30 kg/m or body weight ≥ 100 kg). Based on a systematic search in PubMed and Embase, a total of 72 studies were identified. For thromboprophylaxis with LMWH in bariatric surgery ( = 20 studies), enoxaparin 40 mg twice daily, dalteparin 5,000 IE twice daily, or tinzaparin 75 IU/kg once daily should be considered for patients with BMI ≥ 40 kg/m. For thromboprophylaxis with LMWH in nonbariatric surgery and in medical inpatients ( = 8 studies), enoxaparin 0.5 mg/kg once or twice daily or tinzaparin 75 IU/kg once daily may be considered in obese patients. For treatment with LMWH ( = 18 studies), a reduced weight-based dose of enoxaparin 0.8 mg/kg twice daily should be considered in patients with BMI ≥ 40 kg/m, and no dose capping of dalteparin and tinzaparin should be applied for body weight < 140 kg. As regards NOAC, rivaroxaban, apixaban, or dabigatran may be used as thromboprophylaxis in patients with BMI < 40 kg/m ( = 4 studies), whereas rivaroxaban and apixaban may be administered to obese patients with VTE or AF, including BMI > 40 kg/m, at standard fixed-dose ( = 20 studies). The limited available evidence on fondaparinux ( = 3 studies) indicated that the treatment dose should be increased to 10 mg once daily in patients weighing > 100 kg.
抗凝剂常被用于血栓预防，以及房颤（AF）或静脉血栓栓塞（VTE）患者的治疗。目前，肥胖率在全球范围内呈流行趋势，但大多数抗凝剂（包括低分子量肝素（LMWH）、非维生素 K 拮抗剂口服抗凝剂（NOAC）和戊糖（磺达肝癸钠））在肥胖患者中的最佳剂量尚未确定，这些患者的体质量指数（BMI）≥30kg/m2 或体重大于 100kg。本系统综述旨在总结目前的相关知识，并为肥胖患者（BMI≥30kg/m2 或体重大于 100kg）使用 LMWH、NOAC 和磺达肝癸钠的剂量提供建议。基于对 PubMed 和 Embase 的系统检索，共确定了 72 项研究。对于肥胖患者接受 LMWH 进行减重手术（=20 项研究）的血栓预防，对于 BMI≥40kg/m2 的患者，应考虑每日两次给予依诺肝素 40mg、达肝素 5000IE 两次、或每日一次亭扎肝素 75IU/kg。对于肥胖患者接受 LMWH 进行非减重手术和内科住院患者的血栓预防（=8 项研究），可以考虑每日一次或两次给予依诺肝素 0.5mg/kg 或每日一次给予亭扎肝素 75IU/kg。对于 LMWH 的治疗（=18 项研究），对于 BMI≥40kg/m2 的患者，应考虑使用依诺肝素的低体重剂量 0.8mg/kg 每日两次，并且对于体重<140kg 的患者，不应限制达肝素和亭扎肝素的剂量。对于 NOAC，利伐沙班、阿哌沙班或达比加群可用于 BMI<40kg/m2 的患者（=4 项研究），而对于 VTE 或 AF 肥胖患者（包括 BMI>40kg/m2 的患者），可以给予标准固定剂量的利伐沙班和阿哌沙班（=20 项研究）。磺达肝癸钠的可用证据有限（=3 项研究）表明，对于体重>100kg 的患者，治疗剂量应增加至每日一次 10mg。
