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Comparative Study
. 2024 Oct;29(5):543-552.
doi: 10.1177/1358863X241264478. Epub 2024 Aug 23.

Comparing DOAC and warfarin outcomes in an obese population using the 'real-world' Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry

Nelish Ardeshna  1   2 , Thane Feldeisen  3 , Xiaowen Kong  3   4 , Brian Haymart  4   5 , Scott Kaatz  4   6 , Mona Ali  4   7 , Geoffrey D Barnes  4   5 , James B Froehlich  4   5
Affiliations
Comparative Study

Comparing DOAC and warfarin outcomes in an obese population using the 'real-world' Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry

Nelish Ardeshna et al. Vasc Med. 2024 Oct.

Abstract

Introduction: Direct oral anticoagulants (DOACs) have overtaken warfarin in the treatment of nonvalvular atrial fibrillation (AF) and venous thromboembolism (VTE). Limited data explore the safety of DOACs in obesity.

Methods: This multicenter retrospective study between June 2015 and September 2019 uses the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) registry to compare DOACs and warfarin across weight classes (not obese: body mass index (BMI) ⩾ 18.5 and < 30; obese: BMI ⩾ 30 and < 40; severely obese: BMI ⩾ 40). Primary outcomes include major, clinically relevant nonmajor (CRNM), and minor bleeding events per 100 patient-years. Secondary outcomes include stroke, recurrent VTE, and all-cause mortality.

Results: DOACs were prescribed to 49% of the 4089 patients with AF and 46% of the 3162 patients with VTE. Compared to patients treated with warfarin, those treated with DOACs had a higher estimated glomerular filtration rate across BMI categories regardless of indication. In the AF population, severely obese patients treated with DOACs had more major (3.4 vs 1.8, p = 0.004), CRNM (8.6 vs 5.9, p = 0.019), and minor bleeding (11.4 vs 9.9, p = 0.001). There was no difference in stroke or all-cause mortality. In the VTE population, both CRNM (7.5 vs 6.7, p = 0.042) and minor bleeding (19.3 vs 10.5, p < 0.001) events occurred at higher rates in patients treated with DOACs. There was no difference in recurrent pulmonary embolism, stroke, or all-cause mortality.

Conclusion: There is a higher rate of bleeding in severely obese patients with VTE and AF treated with DOACs compared to warfarin, without a difference in secondary outcomes. Further studies to compare the anticoagulant classes and understand bleeding drivers in this population are needed.

Keywords: anticoagulation; bleeding; deep vein thrombosis (DVT); obesity; pulmonary embolism (PE); stroke; thrombosis; venous thromboembolism (VTE).

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Conflict of interest statement

Declaration of conflicting interestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr Geoffery Barnes reports research funding from Boston Scientific; consulting for Pfizer, Bristol-Myers Squibb (BMS), Janssen, Bayer, AstraZeneca, Sanofi, Anthos, Abbott Vascular, and Boston Scientific; and he serves on the Board of Directors for the Anticoagulation (AC) Forum. Dr Scott Kaatz reports research funding from Janssen, BMS, Osmosis Research, National Institutes of Health, and Bayer; consulting for Janssen, Pfizer, BMS, AstraZeneca, Gilead, Phase Bio, Boston Scientific, Inari, and Anthos; and Board membership for AC Forum, National Blood Clot Alliance Medical and Scientific Advisory Board, and PERT Consortium. Dr James Froelich reports research funding from Blue Cross Blue Shield of Michigan and FMD Society of America. The remaining authors have no conflicts of interest.

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