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Anti-Xa Levels in Morbidly Obese Patients Using Apixaban or Rivaroxaban, Before and After Bariatric Surgery

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Abstract

Background

Despite limited evidence about the efficacy and safety of anticoagulation in patients post bariatric surgery, both vitamin K antagonists (VKA) and direct-acting oral anticoagulants (DOACs) are commonly prescribed.

Aim

To evaluate plasma anti-Xa levels of DOACs in morbidly obese (MO) patients before and after a Roux-en-Y gastric bypass (RYGB) procedure.

Patients and Methods

Retrospective, cross-sectional, and longitudinal study of anti-Xa activity of apixaban or rivaroxaban in MO patients (N = 41).

Results

Preoperative analysis of plasma anti-Xa levels were within the normal range in patients using apixaban (n = 29; body mass index [BMI] 44.5 ± 5.1 kg/m2) as well as those using rivaroxaban (n = 12; BMI 42.6 ± 5.9 kg/m2). Postoperative anti-Xa levels of apixaban were all within the therapeutic range, whereas anti-Xa levels of rivaroxaban were subtherapeutic in nine out of 14 (64%) patients. Perioperative longitudinal follow-up in patients using apixaban (n = 18) showed no significant change in anti-Xa levels after RYGB.

Conclusion

Plasma anti-Xa levels of apixaban in MO patients remained within the therapeutic range up to a body weight of 144 kg. In patients using rivaroxaban, no statistically significant relation between anti-Xa levels and bodyweight was found. After RYGB, plasma anti-Xa levels of apixaban were unaffected, whereas plasma anti-Xa levels of rivaroxaban tended to become subtherapeutic.

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Author information

Authors and Affiliations

  1. Department of Internal Medicine, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands

    Thom Kok, Hans de Boer, Marcel Hovens & Houshang Monajemi

  2. Department of Surgery, Rijnstate Hospital, Wagnerlaan 55, 6815 AD, Arnhem, The Netherlands

    Bart Witteman

  3. Department of Clinical Pharmacy, Division of Laboratory Medicine and Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands

    Matthijs van Luin

Authors
  1. Thom Kok
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  2. Hans de Boer
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  3. Bart Witteman
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  4. Marcel Hovens
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  5. Matthijs van Luin
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  6. Houshang Monajemi
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Contributions

Thom Kok conceived and designed the analysis; collected the data; contributed data or analysis tools; performed the analysis; and wrote the paper. Hans de Boer conceived and designed the analysis; contributed data or analysis tools; performed the analysis; and wrote the paper. Houshang Monajemi conceived and designed the analysis; contributed data or analysis tools; performed the analysis; and wrote the paper. Marcel Hovens wrote the paper. Bart Witteman wrote the paper. Matthijs van Luin wrote the paper.

Corresponding author

Correspondence to Thom Kok.

Ethics declarations

Ethics Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Conflict of Interest

The authors declare no competing interests.

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Key Points

- There is no evidence of safe use for DOACs in morbid obesity (MO) and after bariatric surgery (BS).

- We performed a retrospective, cross-sectional, and longitudinal study of anti-Xa levels for apixaban and rivaroxaban for patients with MO and after BS.

- Despite small numbers, apixaban and rivaroxaban appear to be safe in MO, while apixaban shows in range anti-Xa levels after BS.

- Further investigation is needed, but apixaban could be a possible safe medication to use in this category.

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Kok, T., de Boer, H., Witteman, B. et al. Anti-Xa Levels in Morbidly Obese Patients Using Apixaban or Rivaroxaban, Before and After Bariatric Surgery. OBES SURG 32, 607–614 (2022). https://doi.org/10.1007/s11695-021-05814-y

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  • DOI: https://doi.org/10.1007/s11695-021-05814-y

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