Best Practices for the Use of Direct Oral Anticoagulants in Obesity - Episode 6
Practice Pearl #1: Personal Insight and Implications ISTH Statement
The panel of experts in cardiology share their insights and the implications of the ISTH 2016 statement for DOACs.
Jessica Kerr, PharmD, CDE: Can either of you shed some light on how your collaborating practitioners, or you as a prescriber, follow this guidance? Can you give us some personal insight that you’re willing to share?
Paul Dobesh, PharmD, FCCP, BCPS: I’ll start and then hand it over to Matt. I work on a cardiology floor. I work with a lot of hospitalists. You know, ISTH recommendations don’t always titrate down to those specialists. Matt, correct me if I’m wrong here. People who focus on thrombosis, as I do, we’re well aware of it. My guess would be someplace between 40% and 60% are even aware of it. As far as your other question, do I follow it? Not anymore, and we’re going to get to why that is, because there have been evolving data. That statement came out in 2016, over 4 years ago. We’ve actually gained a fair amount of information about the use of DOACs in these obese patients. Matt, what’s your experience? Do you think a lot of the clinicians you work with are aware of this and follow it?
Matthew Johnson, MD: No, you’re probably spot on with the 40% to 60%. I correlate this back a few years ago, when there was a big discussion over renal insufficiency of these same drugs. As we sort through all the studies and information and now the obesity data that came out with a lot of reviews, this became a very hot topic about a year and a half ago. Things are settling down again, and as we’re applying a lot of what we’ve learned and the new information coming out, we’re finding the safety and efficacy in these morbidly obese patients.
Paul Dobesh, PharmD, FCCP, BCPS: Yeah, it’s interesting. Jess, you brought up low molecular weight. We had this exact conversation 15 years ago, about low molecular weight heparins. Low molecular weight heparins came out. They’re very commonly used. What do you do in renal? What do you do in obesity? Everyone had those questions. Now we’re in the realm of a new role, of new types of anticoagulants, dealing with the same questions. It just takes a while for this type of information to develop.
Jessica Kerr, PharmD, CDE: Matt, are there any other implications that this guidance from the International Society on Thrombosis and Haemostasis has created or that you are seeing, more than what we’ve already talked about?
Matthew Johnson, MD: No, it did cause an academic discussion. We see maybe 1 prescribed and the need to try to get through pharmacy, and then you’d get feedback: No, actually that’s not indicated here. A lot of partners came to me with questions regarding some of the data that are underlying those decisions.
Paul Dobesh, PharmD, FCCP, BCPS: At the University of Nebraska Medical Center, if you have a patient who is over 120 kg and gets a DOAC, that’s a flag. Those patients get flagged. Doesn’t mean they can’t do it right, but you have to override the flag and give some rationale. That pops up. I’m not a physician, so I don’t know if it pops up when the physician enters it. But I know it pops up when the pharmacist goes to verify the order, because I’ve had to verify those orders.