Department of Pharmacy, Houston Methodist Hospital, Houston, Texas.
University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.
Tex Heart Inst J. 2024 May 15;51(1). doi: 10.14503/THIJ-23-8260.
Current venous thromboembolism guidelines recommend using direct oral anticoagulants (DOACs) over warfarin regardless of obesity status; however, evidence remains limited for the safety and efficacy of DOAC use in patients with obesity. This retrospective analysis sought to demonstrate the safety and efficacy of DOACs compared with warfarin in a diverse population of patients with obesity in light of current prescribing practices.
A retrospective cohort study was conducted at a large academic health system between July 2014 and September 2019. Adults with an admission diagnosis of deep vein thrombosis (DVT) or pulmonary embolism, with weight greater than 120 kg or a body mass index greater than 40, and who were discharged on an oral anticoagulant were included. Outcomes included occurrence of a thromboembolic event (DVT, pulmonary embolism, or ischemic stroke), bleeding event requiring hospitalization, and all-cause mortality within 12 months following index admission.
Out of 787 patients included, 520 were in the DOAC group and 267 were in the warfarin group. Within 12 months of index hospitalization, thromboembolic events occurred in 4.23% of patients in the DOAC group vs 7.12% of patients in the warfarin group (hazard ratio, 0.6 [95% CI, 0.32-1.1]; P = .082). Bleeding events requiring hospitalization occurred in 8.85% of DOAC patients vs 10.1% of warfarin patients (hazard ratio, 0.93 [95% CI, 0.57-1.5]; P = .82). A DVT occurred in 1.7% and 4.9% of patients in the DOAC and warfarin groups, respectively (hazard ratio, 0.35 [95% CI, 0.15-0.84]; P = .046).
No significant differences could be determined between DOACs and warfarin for cumulative thromboembolic or bleeding events, pulmonary embolism, ischemic stroke, or all-cause mortality. The risk of DVT was lower with apixaban and rivaroxaban. Regardless of patient weight or body mass index, physicians prescribed DOACs more commonly than warfarin.
目前的静脉血栓栓塞症指南建议无论肥胖状况如何，都应使用直接口服抗凝剂（DOACs）替代华法林；然而，关于肥胖患者使用 DOAC 的安全性和疗效的证据仍然有限。本回顾性分析旨在根据当前的处方实践，证明 DOAC 在肥胖患者这一多样化人群中的安全性和疗效优于华法林。
在 2014 年 7 月至 2019 年 9 月期间，在一家大型学术医疗系统进行了一项回顾性队列研究。纳入标准为：因深静脉血栓形成（DVT）或肺栓塞入院诊断、体重>120kg 或体重指数>40、出院时接受口服抗凝剂治疗的成年人。主要转归包括血栓栓塞事件（DVT、肺栓塞或缺血性脑卒中）、需要住院治疗的出血事件以及索引入院后 12 个月内的全因死亡率。
在 787 例患者中，520 例患者接受 DOAC 治疗，267 例患者接受华法林治疗。在索引住院后 12 个月内，DOAC 组患者中有 4.23%发生血栓栓塞事件，华法林组患者中有 7.12%发生血栓栓塞事件（风险比，0.6 [95%CI，0.32-1.1]；P=0.082）。需要住院治疗的出血事件在 DOAC 组患者中的发生率为 8.85%，在华法林组患者中的发生率为 10.1%（风险比，0.93 [95%CI，0.57-1.5]；P=0.82）。DOAC 组和华法林组患者分别有 1.7%和 4.9%发生 DVT（风险比，0.35 [95%CI，0.15-0.84]；P=0.046）。
在累积血栓栓塞或出血事件、肺栓塞、缺血性脑卒中或全因死亡率方面，DOAC 与华法林之间未发现显著差异。阿哌沙班和利伐沙班的 DVT 风险较低。无论患者体重或体重指数如何，医生更常开具 DOAC 而非华法林。
