Best Practices for the Use of Direct Oral Anticoagulants in Obesity - Episode 4
Practice Pearl #1 Definition of Obesity as Defined by CDC
Experts in cardiovascular disease review the definition of obesity and morbid obesity as stated by the CDC. They provide some insights on the management of thrombosis risks.
Jessica Kerr, PharmD, CDE: I want to switch gears a little just to bring in people in the world of obesity, especially when we’re talking about definitions. Dr Johnson, the CDC and the World Health Organization have published guidelines for obesity and clearly stated how they define that. Provide us with a little insight on the individual definitions for obesity between both of those establishments.
Matthew Johnson, MD: When looking at the definition of obesity, probably the best way to look at that is with body mass index. That is simply taking the weight in kilograms over the height in meters squared. The CDC breaks this down into different categories. But with a growing percentage of overweight or obese populations—we’re seeing it worldwide, but especially in the United States—this is becoming a very important and defining standard in most studies. Our reviews also duplicate here. But what we’re looking for is body mass index, and we’re looking for overweight in that 25-to-30 range. Sometimes that’s separated by the CDC as far as class of obesity: class 1 from 30 to 35, class 2 from 35 to 40, and then extreme obesity or what we consider morbid obesity over 40 for BMI.
Jessica Kerr, PharmD, CDE: I can imagine that just knowing that those simple definitions also helped to allow us to evaluate the clinical studies as inclusion and exclusion criteria as well. That’s good to have that as a background information. What are some of the key points to these guidance papers that can help a clinician to understand how it is important to consider obesity status in patients requiring anticoagulation.
Matthew Johnson, MD: It’s important as we go through and look how the inclusion criteria in these studies or analyses are performed. A lot of simplification goes into BMI, but it does really categorize those distinctions. as we go through reviews, whether post hoc analysis or randomized trials, as we go back and look at the data, we can really separate into those categories. Usually they’re broken down into very similar categories, with obesity being BMI over 30 and extreme obesity. We do have some reviews in that 30-to-40 range. But when we get to the extreme obesity or morbid obesity, greater than 40 BMI, there are very limited data out there to review.
Jessica Kerr, PharmD, CDE: According to medical literature, when you look at many acute and chronic disease states, patients who are obese maybe at a higher risk associated with the negative outcomes of the specific disease state that might be at hand. We know that it’s true for the risk of thrombosis in obese patients. Dr. Dobesh, share with us how clinicians can help manage the thrombosis risk in the obese patient population versus other comorbidities that they may be at risk for?
Paul Dobesh, PharmD, FCCP, BCPS: You know, it’s multifaceted, the role that obesity plays with other disease states. As you said, obesity in and of itself is a risk factor for venous thromboembolic disease. It contributes to coronary artery disease. There is a multifold risk of developing atrial fibrillation. Part of that is probably the obesity, but also we know that obesity is directly correlated to the development of diabetes from hyperinsulinemic and metabolic syndrome. We also know that obesity is directly related to hypertension. We know that hypertension and diabetes are both part of the CHA2DS2-VASc score. That’s a very multifaceted role that this place. As clinicians we have to realize that the obese patient is going to be higher risk. We have to really consider that we’re going to provide them an adequate dose of an anticoagulant to reduce that risk.