Weighing in on Direct Oral Anticoagulant Dosing in Patients With Obesity

In recent years there has been a significant increase in the prevalence of both obesity and atrial fibrillation (AF), with up to about 40% of the US population now being considered obese. 1 Hales CM Carroll MD Fryar CD Ogden CL Prevalence of obesity and severe obesity among adults: United States, 2017-2018. NCHS Data Brief. 2020; : 1-8 Google Scholar During this same period the use of direct oral anticoagulants (DOACs) to reduce the risk of embolic events associated with nonvalvular AF has expanded dramatically. 2 January CT Wann LS Calkins H Chen LY Cigarroa JE Cleveland Jr, JC Ellinor PT Ezekowitz MD Field ME Furie KL Heidenreich PA Murray KT Shea JB Tracy CM Yancy CW 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in collaboration with the Society of Thoracic Surgeons [published correction appears in Circulation 2019;140:e285]. Circulation. 2019; 140: e125-e151 Crossref PubMed Scopus (1579) Google Scholar The overall enhanced safety and efficacy of these drugs when compared with vitamin K antagonists has been established in multiple landmark studies and is contributed to by their fewer interactions with diet or other drugs, lack of requirement for routine monitoring, and, importantly, that they are usually given in a fixed dose schedule. However, does one dose fit all patients, especially large or obese patients?