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Safety and Pharmacokinetics of Direct Oral Anticoagulants after Bariatric Surgery: A Systematic Review

R. Leong1, D.K Chu2,3, M.A Crowther2, S. Mithoowani2

1McMaster University, Faculty of Health Sciences, Hamilton, Canada, 2McMaster University, Department of Medicine, Hamilton, Canada, 3McMaster University, Department of Health Research Methods, Evidence and Impact, Hamilton, Canada

Abstract Number: LPB0002

Meeting: ISTH 2021 Congress

Theme: Arterial Thromboembolism » Cerebrovascular Disorders

Background: Bariatric surgery likely impairs the absorption of direct oral anticoagulants (DOACs). The optimal DOAC after bariatric surgery is unclear.

Aims: To report on the safety and pharmacokinetics of DOACs after bariatric surgery in adults.

Methods: We systematically searched MEDLINE, EMBASE, Cochrane Library, CINAHL and ClinicalTrials.gov from Jan 2000-Jul 2020 for randomized and non-randomized studies. Two reviewers independently screened titles, abstracts and full-text articles. We used the Newcastle-Ottawa scale to assess risk of bias in non-randomized studies excluding case reports. This review was registered with PROSPERO (CRD42020202636).

Results: We screened 2,086 titles and abstracts and included 19 records (n=2,233 patients): no randomized trials, seven cohort studies, two case series, and ten case reports. Patients were taking DOACs for a variety of indications. Most studies had a moderate-high risk of bias. Of 2,123 patients taking apixaban, two (0.1%) developed venous thromboembolism (VTE) and six (0.3%) had major bleeding. Peak apixaban levels were measured in 13 patients (mean 182 ng/mL, 95% confidence interval [CI] 142-223 ng/mL); none were outside the therapeutic range seen in phase II studies. Of 94 patients taking rivaroxaban, two developed VTE (2.1%) and five (5.3%) had major bleeding. Peak rivaroxaban levels were measured in 17 patients (mean 249 ng/mL, 95% CI 162-336 ng/mL); eight (47%) were below and one (5.9%) was above the therapeutic range. Of 16 patients taking dabigatran, one patient (6.3%) each developed VTE, stroke and major bleeding. Peak dabigatran levels were measured in 12 patients (mean 57 ng/mL, 95% CI 22-91 ng/mL); nine (75%) were below and none were above the therapeutic range.

Conclusions: The preferred DOAC after bariatric surgery is uncertain. Additional cohort and registry studies are warranted given how frequently such patients require anticoagulant therapy.

To cite this abstract in AMA style:

Leong R, K Chu D, A Crowther M, Mithoowani S. Safety and Pharmacokinetics of Direct Oral Anticoagulants after Bariatric Surgery: A Systematic Review [abstract]. Res Pract Thromb Haemost. 2021; 5 (Suppl 2). https://abstracts.isth.org/abstract/safety-and-pharmacokinetics-of-direct-oral-anticoagulants-after-bariatric-surgery-a-systematic-review/. Accessed May 20, 2022.

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